Update on Anorexia Treatment and Research

It's the deadliest mental illness. What's being done about it?

Anorexia nervosa (AN) affects approximately 1% of women in the US, and the incidence has increased every decade since 1930. Despite the relatively low percentage of individuals affected, AN has the highest mortality rate of any mental illness, and 1 in 5 related deaths is by suicide.1,2 There have been few developments in terms of treatment approaches in recent years, though emerging research shows promise in elucidating various aspects of the disease that could ultimately improve understanding of AN and inform treatment.

“It remains the case that treatment has to be broad and flexible,” said Michael A. Strober, PhD, the Resnick Chair in Eating Disorders and professor of psychiatry and biobehavioral sciences at UCLA’s David Geffen School of Medicine. “No particular treatment stands out above any other–though you will have people who argue to the contrary, but I think that’s misguided and false,” he told Psychiatry Advisor.

It is well-established that early intervention is essential and offers the best chance of successful recovery. The specific types of interventions may vary and depend on certain factors. It is important to note that there is a major difference between adolescents and adults with AN. In most individuals with the disease, onset occurs around age 14 or 15, on average, and onset after age 25 is rare. That means that most people with AN who become adults have been ill for a significant portion of their lives, noted James Lock, MD, PhD, director of the Eating Disorder Program for Children and Adolescents, and professor of child psychiatry and pediatrics at Stanford University School of Medicine.

“I point that out because the data we have suggest there are no treatments that are known to be effective for anorexia that has persisted into adulthood,” he told Psychiatry Advisor. He likens it to cancer in that the chances of recovery are much better if it is detected at stage 1 or 2, while it is not likely to respond to treatment at the later stages. “The chances that a standard treatment will be effective are not high,” at that point, he said. “That doesn’t mean no one gets better, it’s just that empirical data is lacking–it’s a huge gap.”

The most empirically supported treatment for adolescents with anorexia is family-based treatment (FBT), also known as the Maudsley Approach, in which parents are involved in restoring the patient’s healthy eating behaviors and weight. Researchers at Stanford have been studying FBT since 1998, and it has since been investigated elsewhere as well. In a randomized trial that Dr Lock co-authored, which was published in the Archives of General Psychiatry, FBT was associated with higher rates of full remission vs individual therapy at 6-month (40% vs 18%, P =.029, NNT = 5) and 12-month (49% vs 23%, P = .024, NNT = 4) follow-up points.3 More recent studies by Dr Lock and colleagues have demonstrated potential cost savings associated with FBT.4,5 As those findings indicate, individual therapy can be effective for some patients, but that is typically the case with those who have lower levels of symptoms. “So, severity of illness makes a difference in the types of treatment that could be effective,” explained Dr Lock.

Cognitive retraining therapy, which aims to shift the style of thinking rather than targeting the content of thoughts–for example, through interventions designed to increase cognitive flexibility–is another current area of inquiry, as is the potential role of oversensitivity to reward in patients with AN. Our understanding of the neurobiological underpinnings of the disease will continue to grow with ongoing advances in neuroimaging, according to Dr Strober. In studying the visual information processing of AN patients who are weight-restored, he and colleagues have discovered that circuitry involved in such processing is impaired to some degree.6,7 “Whether this maps onto appearance-related issues in anorexia remains to be seen.”

He stated that there is also neuroimaging research underway that might demonstrate which aspects of brain functioning are truly risk factors for AN rather than correlates or consequences. “A crucial future need is to obtain very large samples for rigorous genetic studies like those that have been used research of other major mental illnesses such as schizophrenia and bipolar disorder,” he said.

Findings from a randomized trial, published in PLoS ONE in 2016, suggest that repetitive transcranial magnetic stimulation (rTMS) applied to the left dorsolateral prefrontal cortex (dlPFC) may reduce core AN symptoms and improve patients’ decision-making.8 These results will need to be replicated in studies involving multiple sessions.

Dr Lock points out that AN’s 1% prevalence rate is not trivial and is similar to the prevalence of schizophrenia, yet “so little has been invested compared to other serious illnesses–it’s amazing how little research has been done.” He attributes the lack of attention to several factors: AN was historically trivialized as a choice or adolescent fad; the patients who were initially studied were chronically ill, and treatment did not lead to improvement; and until relatively recently, illness in women and children has not generally receive much focus. Though the tide appears to be slowly turning, AN is “common enough and serious enough that we should be doing more,” he said.

In addition to the necessity of early identification and effective intervention, Dr Lock advises clinicians to keep in mind that families can be helpful and should not be blamed for the illness, despite historical documents that imply otherwise. Finally, practitioners should avoid treating AN if it is outside their scope of expertise. “If you don’t know how to treat it, don’t try to–you can do more harm than good,” he cautions. Seek appropriate consultation, and refer to colleagues who specialize in treating AN if needed.

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1. National Eating Disorders Association. Get the facts on eating disorders. Retrieved 10/18/16 from http://www.nationaleatingdisorders.org/get-facts-eating-disorders

2. National Association of Anorexia Nervosa and Related Disorders. Eating disorder statistics. Retrieved 10/18/16 from  http://www.anad.org/get-information/about-eating-disorders/eating-disorders-statistics

3. Lock J, Le Grange D, Agras WS, Moye A, Bryson SW, Jo B. Randomized clinical trial comparing family-based treatment with adolescent-focused individual therapy for adolescents with anorexia nervosa. Arch Gen Psychiatry. 2010; 67(10): 1025–1032.

4. Agras WS, Lock J, Brandt H, et al. Comparison of 2 family therapies for adolescent anorexia nervosa: a randomized parallel trial. JAMA Psychiatry. 2014; 71(11):1279-86.

5. Madden S, Miskovic-Wheatley J, Wallis A, et al. A randomized controlled trial of in-patient treatment for anorexia nervosa in medically unstable adolescents. Psychol Med. 2015; 45(2):415-27.

6. Li W, Lai TM, Bohon C, et al. Anorexia nervosa and body dysmorphic disorder are associated with abnormalities in processing visual information. Psychol Med. 2015; 45(10):2111-22.

7. Li W, Lai TM, Loo SK, et al. Aberrant early visual neural activity and brain-behavior relationships in anorexia nervosa and body dysmorphic disorder. Front Hum Neurosci. 2015; 9:301.

8. McClelland J, Kekic M, Bozhilova N, et al. A Randomised controlled trial of neuronavigated repetitive transcranial magnetic stimulation (rTMS) in anorexia nervosa. PLoS One. 2016; 11(3):e0148606.