SAN FRANCISCO: Anorexia nervosa is a psychiatric illness that primarily effects young people during their adolescence. While anorexia is relatively uncommon, it can be lethal.
Indeed, despite its relatively early onset, anorexia can last for several decades for more than half of those afflicted. It can lead to many associated psychiatric and medical risk factors, which in part explains why anorexia has the highest mortality rates of any psychiatric disorder.
Those who suffer with anorexia have a powerful fear of weight gain and a cruelly distorted self-perception. As a result, some restrict caloric consumption to fewer than 400 calories per day, which is less than a quarter of what is typically recommended for adolescents.
Those with anorexia may quickly become emaciated and lose more than 25 per cent of their typical body weight. This rapid weight loss causes cardiac abnormalities, structural and functional brain alterations, irreparable bone disease, and in some instances, sudden death.
The effective treatment of anorexia is therefore very important.
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FEW ADVANTAGES IN SPECIALISED TREATMENTS
Colleagues and I recently completed the largest analysis ever undertaken of outcomes for existing treatments for anorexia.
We pooled the findings from 35 randomised controlled trials between 1980 to 2017, which cumulatively assessed the outcomes of specialised treatments in over 2,500 patients with anorexia, and examined outcomes according to both weight, and the core cognitive symptoms of anorexia, such as fear of weight gain and a drive for thinness.
I am sad to say that what we found was bleak. In essence, specialised treatments for anorexia, such as cognitive behavioural therapy, family-based treatment and emerging medication treatments, appear to have few advantages over standard control treatment-as-usual, such as supportive counseling.
In fact, the only advantage of specialised treatments, relative to control treatment-as-usual conditions, was a greater chance of having a higher weight by the end of treatment. There was no difference in body weight across specialised versus control treatments at follow-up.
In addition, there were no differences in the core cognitive symptoms of anorexia between specialised versus control treatments at any one point.
This means that, even if a treatment helps restore normal weight, a focus on thinness and an unease around eating is common, making a relapse into low weight likely.
Equally importantly, specialised treatments do not appear to be more tolerable to patients, with comparable rates of patient dropout to control treatments.
When time trends within these data over the last four decades were analysed, it was found that the outcomes of specialised treatment are not incrementally improving over time.
MORE THAN WEIGHT
These findings are sobering. The notion that our best efforts to advance treatment outcomes over the last four decades have failed to move the needle is cause for grave concern.
However, an important outcome of this study lies in giving those of us who study and treat anorexia a better idea of how we might move the needle. We believe these findings speak to an urgent need to better understand the neurobiological mechanisms of anorexia.
We can no longer assume that improvements in patient weight ought to be the terminal goal of treatment for anorexia, and will confer improvements in cognitive symptoms.
While weight normalisation reduces the acute risk of complex medical events, ongoing fear of weight gain and food intake will likely mean future bouts of low weight and starvation.
We have reached a plateau in the treatment of anorexia. Future research endeavors must elucidate the precise mechanisms that underpin cognitive symptoms of anorexia, and altering these mechanisms must become the goal of treatment.
Stuart Murray is assistant professor of psychiatry at University of California, San Francisco. A version of this commentary first appeared on The Conversation. Read it here.