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Anorexia Nervosa (Review) : BMJ (Online) May 2007
Anorexia Nervosa (Review) : BMJ (Online) May 2007
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Anorexia nervosa
Jane Morris, Sara Twaddle
Royal Edinburgh Hospital, Anorexia nervosa has the highest mortality of any psy- psychotherapy for adults with the disorder.7 The
Edinburgh EH10 5HF chiatric disorder.1 It has a prevalence of about 0.3% in reviews are based on only seven and six small studies,
Correspondence to: J Morris young women. It is more than twice as common in respectively, all of which had major methodological
ejanemorris@talk21.com limitations. A further electronic and hand search of
teenage girls, with an average age of onset of
BMJ 2007;334:894-8 15 years; 80-90% of patients with anorexia are female. papers published more recently is supplemented by
doi: 10.1136/bmj.39171.616840.BE Anorexia is the most common cause of weight loss in work in press, conference presentations, and some per-
young women and of admission to child and adoles- sonal communications with the relatively small group
cent hospital services. Most primary care practitioners of international experts in the field.
encounter few cases of severe anorexia nervosa, but
these cause immense distress and frustration in carers What are the hallmarks of anorexia nervosa?
and professionals. We describe the clinical features of The core psychological feature of anorexia nervosa is
anorexia nervosa and review the current evidence on the extreme overvaluation of shape and weight. People
treatment and management. with anorexia also have the physical capacity to toler-
ate extreme self imposed weight loss. Food restriction
How good is the evidence for managing anorexia is only one aspect of the practices used to lose weight.
nervosa? Many people with anorexia use overexercise and over-
Ironically, this most lethal of psychiatric disorders is activity to burn calories. They often choose to stand
the Cinderella of research. It is hard to engage patients rather than sit; generate opportunities to be physically
with anorexia for treatment, let alone research. active; and are drawn to sport, athletics, and dance.
Furthermore, the complexity of coordinated Purging practices include self induced vomiting,
approaches used in most specialist centres may over- together with misuse of laxatives, diuretics, and “slim-
whelm conventional research methods. ming medicines.” Patients may also practise “body
High quality evidence on the effects of starvation on checking,” which involves repeated weighing, measur-
the body is available to guide physical aspects of care.2 ing, mirror gazing, and other obsessive behaviour to
Genetic studies, including twin and family studies,3 reassure themselves that they are still thin (box 1).
and more recently gene analysis, have shed some
light on causes, but few randomised controlled trials
of treatment exist. In contrast, many randomised con-
What is it like to experience anorexia nervosa?
trolled trials are found on the management of normal
weight bulimia nervosa.4 Unfortunately, these inter- At first I believed my thoughts were normal when I
looked in the mirror—you don’t expect your eyes to lie. I
ventions have a poor response in anorexia nervosa.
felt such self loathing that I drastically reduced my food
This review is based on searches in PubMed, Med- intake and did a lot of exercise. I felt better about myself
line, and PsycLIT for treatment of anorexia nervosa and decided that once I’d lost a pound or two I would eat
and related eating disorders, and the National Institute normally again. When it came to it I was too scared. It
for Health and Clinical Excellence (NICE) clinical felt good to lose a couple of pounds but it became
guideline.5 We found no category A evidence (at least addictive. If I did a certain amount of exercise one day,
one randomised controlled trial as part of a high qual- the next day I had to do at least the same amount. I
ended up feeling physically rubbish, but my mind said
ity and consistent body of literature (evidence level 1)), I’m a horrible person who deserves pain.
and only family interventions met category B criteria Paranoia sets in. You’re convinced people think you are
(well conducted clinical studies but no randomised fat even when they say you are not. Your mind tells you
controlled trials (evidence levels 2 and 3) or extra- they are lying, until you find you can’t trust anyone.
polated from level I evidence). NICE uses category C Living with anorexia is a constant battle between two
recommendations (expert committee reports or clini- evils. On one hand eating feels like an evil thing, but
cal experience of respected authorities (evidence level other people see that very belief as the evil. When I feel I
really must starve or exercise I get angry with the nurses.
4) or extrapolation from level 2 or 3) to provide gui- Other times it’s a relief though, because at least they
dance where high quality formal evidence is absent. take the responsibility away from me.
Two Cochrane reviews cover antidepressant treat- S, aged 17
ment for anorexia nervosa6 and individual
such as role conflict, transition, or loss—and works to generate new ways to deal with
distress
Motivational enhancement therapy Without this, the risk of repeated cycles of detention
This psychotherapy uses interviewing techniques derived from work with substance and relapse exists. In practice, patients in extremis can
misuse to reframe “resistance” to change as “ambivalence” about change, and to often be treated with their consent. Voluntary treatment
nurture and amplify healthy impulses is more likely when the clinician is experienced at
Dynamically informed therapies managing anorexia and can confidently assess and
These therapies may also result in weight gain and recovery provided the patient is
tolerate fairly high levels of risk in the interests of
aware of the risk of irreversible physical damage or death and acknowledges that
certain boundaries (for example, that they must be weighed weekly, examined
collaborative therapeutic relationships, rather than
monthly by a doctor, and admitted to hospital if weight continues on a downward coerce patients. Even legal measures of compulsion
trend) are observed. The therapies involve talking, art, music, and movement may be used in a helpful therapeutic way, though, and
Group therapy should not be avoided at all costs.
There is little evidence that therapy for patients with anorexia benefits from being The best place to admit patients with life threatening
delivered in group sessions rather than individual sessions; in fact, group therapy anorexia is not always obvious. An acute medical ward
may even worsen the problem. However, dialectical behaviour therapy offers —especially one that specialises in endocrinology,
structured groups in parallel with individual sessions. This therapy teaches skills that gastroenterology, or diabetes—is usually better than a
help patients to tolerate distress, soothe their feelings, and manage interpersonal general psychiatric ward. Some non-specialist medical
relationships wards have nurse specialists, who are experienced in
Family work managing patients with eating disorders. These nurses
The term “family work” covers any intervention that harnesses the strengths of the
can help translate recommendations into practice and
family in tackling the patient’s disorder or that tries to deal with the family’s stress in “troubleshoot” for the furtive compulsions of anorexia.
the face of it. It includes family therapies, support groups, and psychoeducational
input
Conjoint therapy What is the currently accepted best management?
Evidence points to the effectiveness of the Maudsley model of family therapy and Anorexia takes an average of five or six years from
similar interventions focused on eating disorders. Whole families—or at least the diagnosis to recovery. Up to 30% of patients do not
parents and the patient—attend counselling sessions together, which can cause recover.11 12 This makes meaningful follow-up of inter-
intolerable emotional stress ventions crucial but difficult. Coercive approaches
Separated family therapy may result in impressive short term weight gain but
The patient and the parents attend separate meetings, sometimes with two different
make patients more likely to identify with and cling
therapists. This form of therapy seems to be as effective as conjoint therapy,
particularly for older patients, and involves lower levels of expressed emotion on to the behaviour associated with anorexia.
Multifamily groups Overall prognosis for patients with eating disorders is
Such groups provide a novel way of empowering parents by means of peer support independent of whether treatment is received or not.13
and help from a therapist. Several families, including the patients, meet together for Discredited behavioural regimens for anorexia involved
intensive sessions that often last the whole day and include eating together incarceration in hospital, with removal of all “privileges”
Relatives’ and carers’ support groups (visitors, television, independent use of bathroom),
These groups range from self help meetings to highly structured sessions led by a
which were given back as a reward for weight gain.
therapist that aim to teach psychosocial and practical skills to help patients with
anorexia to recover while avoiding unnecessary conflict. Most encompass at least Hospital admission is still strongly correlated with
some educational input about the nature of anorexia poor outcome.14 Long term prognosis is worse for
patients compulsorily detained in an inpatient facility
than for those treated voluntarily in the same unit, with medical professionals. The guiding principle of moti-
more deaths in the first group.10 The use of brief hospi- vational enhancement is to acknowledge and explore
tal admissions to acute medical wards at times of life rather than fight the patient’s ambivalence about
threatening crisis or after overdose may be associated recovery. Treatment is more effective when the thera-
with lower mortality.9 12 pist and the patient work together against the anorexia.
Such a relationship may allow the patient to be treated
How is weight gain achieved? without having to invoke the Mental Health Act. Moti-
In countries where all treatment is given in hospital, vation is not an all or nothing battle to be won before
refeeding is an early intervention. Subsequent treat- treatment can start—it must be actively engendered
ment helps patients tolerate, maintain, or regain throughout the treatment.
normal weight. This may also be the preferred Family work is the only well researched intervention
approach for children and young adolescents, where that has a beneficial impact.19 Family work teaches the
long periods at low weight are detrimental to growth family and patient to be aware of the perpetuating fea-
and development. Hospital refeeding needs tures of the disorder. Fury, anger, and fighting lead to
physiological fine tuning and may expose the patient entrenched symptoms but too much permissiveness
to iatrogenic complications such as infections, the encourages the illness by allowing it to become an
sequelae of passing tubes, and the effects of being accepted response to stress, or—if the family will do
exposed to a “proanorexia” culture (by mixing with anything to encourage the patient to eat—a route to
other patients who have anorexia). providing “secondary gain” from the illness. Support
A second approach temporarily accepts low weight, of carers is essential to maintain the firm but sympa-
if weight is stable and regularly monitored, while thetic boundaries conducive to recovery
patients or their families take responsibility for refeed- Early studies on teenagers with relatively recent
ing. It is helpful to provide dietetic expertise separately onset anorexia showed that therapy involving the
from psychotherapy. One study found that unsup- whole family was superior to treating just the patient.
ported dietetic advice without parallel interventions Further studies showed that, if tolerated, sessions invol-
had a 100% dropout rate.15 Weight gain is slower ving the family and patient together gave the best
with this second approach, but it is more likely to be
maintained. This approach avoids many iatrogenic
risks. However, clinicians still need access to medical ADDITIONAL EDUCATIONAL RESOURCES
wards for physical emergencies. Resources for healthcare professionals
National Institute for Health and Clinical Excellence
complex treatments using psychodynamic under- families, friends and sufferers. Hove: Psychology
standing, systemic principles, and techniques bor- Press, 1997
rowed from motivational enhancement therapy and Resources for patients and carers
dialectical behavioural therapy (box 2). These treat- Beating Eating Disorders (www.edauk.com)—The
ments should be delivered in various settings that Eating Disorders Association site has good
cater for the level of intensity and degree of medical information about the eating disorders network in the
monitoring and care needed. The coordinated work- United Kingdom, resource lists, and details of local
self help and support groups
ing of a wide range of medical and psychiatric services
National Institute for Health and Clinical Excellence
that do not usually work together will be needed.
(www.nice.org.uk)—This site also contains a patient
Because of the age group affected, and the time span and carer version of the NICE guidelines
involved, patients’ care often undergoes many Bloomfield S. Eating disorders: helping your child
transitions. These are peak times for relapse and recover. Norwich: Eating Disorders Association, 2006
decompensation. Bryant-Waugh R, Lask B. Eating disorders: a parents’
Early on, especially in younger patients, motivation guide. Revised ed. Hove: Brunner-Routledge, 2004
for treatment lies with parents, schoolteachers, or