Literature Review on Anorexia Nervosa

Module title: Working with People with Distress and Disorder

 “You will then produce an essay, critically evaluating the current research about one

mental disorder, suggesting the future research (e.g., diagnosis, treatment)..”

In modern culture where food is readily available children and adolescents learn to progressively increase their food intake, in order to cater for their changing bodily functions and needs brought on by a biological growth spurt. This growth spurt occurs in girls between ages 12 to 14, where further nutrition requirements peak around the same time. However once they start their menstrual periods their body’s gain fat, but further muscle mass does not increase like it does with boys, which results in nutrition requirements decreasing. Some young women learn that they can change their eating patterns, or go on a diet in order to control their weight. But what if the desire to lose weight becomes so intense, and escalates beyond what is considered to be a normal eating behaviour and the individual develops anorexia nervosa as a consequence? (Abraham,2015) The purpose of this essay is to examine definitions, diagnoses, aetiology and treatment. Consideration will then be given to the merits of each of these things then offer suggestions for future research into this condition.

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Anorexia nervosa can be defined as a serious mental illness whereby a person fails to maintain an acceptable healthy weight, is fearful of gaining weight and are preoccupied about body shape or weight. (Attia,2010). The term anorexia is a Greek word meaning for “loss of appetite” this is very misleading, as this does not occur until the late stages of starvation. Anorexia nervosa sufferers do in fact feel hunger, but due to their intense fear of weight gain they deliberately and routinely deny themselves food. (Hall & Ostroff,2013). Although people with anorexia nervosa want to be rid of their symptoms they may not really want to recover, as their condition can provide them a sense of structure and control over their life along with a sense of identity. (McKnight & Boughton,2009)

Anorexia Nervosa is currently based in the “Diagnostic and Statistical Manual of Mental Disorders (DSM-5)” (American Psychiatric Association, 2013) under “Feeding and Eating Disorders” along with rumination disorder, avoidant/restrictive food intake disorder, binge eating disorder and bulimia nervosa. To reach a diagnosis an individual must show

“Persistent restriction of energy intake leading to significantly low body weight (in context of what is minimally expected for age, sex, developmental trajectory, and physical health) .

Either an intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain (even though significantly low weight).

Disturbance in the way one’s body weight or shape is experienced, undue influence of body shape and weight on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight”.

Reaching a diagnosis requires the use of a classification scheme that is mutually exclusive as this will ensure that only one of these diagnoses is made. Often these conditions have psychological and behavioural features in common, but the logic behind this approach is to highlight that these disorders differ substantially in regards to their clinical course, outcome and treatment needs.

The DSM III criteria which was released in 1980 does have similarities to the current diagnostic criteria. However there is one essential feature present in the DSM III that does not feature in the DSM 5 which is;

“ Weight loss of at least 25% of original body weight or, if under 18 years of age, weight loss from original body weight plus projected weight gain expected from growth charts may be combined to make the 25%.

(APA,1980)

There are similarities between the two criteria’s, but a percentage weight loss is not an essential component in DSM-5 for diagnosing anorexia nervosa.

One major advantage of using DSM-5 is that it has significantly reduced international linguistic confusion in regards to psychiatric conditions, and has contributed extensively towards one common language to help define psychiatric disorders as well as conceptualising them. (Van Der Kloet & Heugten, 2015)

There is no definitive singular cause for anorexia nervosa, rather it is a multifactorial complex condition with different theories, that all contribute to the manifestations of it. (Adler,2011).One of these factors that are believed to contribute is cultural factors. In Western society a stereotype has been developed, whereby being ‘thin’ is associated with being more ‘beautiful’ or attractive, which in turn promotes negative attitudes about obesity. This is further exacerbated with the bombardment of idealised images of underweight models, which makes adolescents particularly vulnerable to conform to these pressures. (Stevens & Rodin,2010) Research also suggests that genetic and biological factors have an influence, based on studies carried out on twins which estimates that 58-76% of the variance in the liability to anorexia nervosa is due to genetic factors, a higher concordance rate of 55% was show in monozygotic twins as opposed to 5% in dizygotic twins (Marwick & Birrell, 2013). Several sources of evidence also indicate that the brain-derived neurotrophic factor gene plays a critical role in eating behaviours, and cognitive impairments in anorexia nervosa. It works by regulating eating behaviours in the hypothalamus, which also includes the regulation of serotonin levels, where low levels are implicated with depression.(Nakazato,Hashimoto,Shimizu,Niitsu & Iyo,2012) Further studies also indicate that major depressive disorder is the most common comorbidity diagnosis associated with anorexia nervosa and is associated with a worse outcome. ( Mischoulon, Eddy, Keshaviah, Dinescu, Ross, Andrea, Kass, Franko & Herzog, 2010)

A 2013 UK based online survey was completed to assess the time taken to seek out help for anorexia nervosa. Of the 517 respondents only a small minority of (2.9%) sought out help immediately whereas the majority (40.9%) did not seek out help until they had suffered with anorexia nervosa for more than 12 months (Statistica,2013)

For people who have been diagnosed with anorexia nervosa and are accessing specialist services, regardless of whether they are receiving specialist treatment or not they should receive psycho-education about their disorder, involve the persons family and carers where appropriate, be multidisciplinary and coordinated between services and monitor the patients weight, mental and physical health as well as any potential risk factors. Recommended psychological treatments for anorexia nervosa include individual eating disorder focused cognitive behavioural therapy (CBT-ED), Maudsley Anorexia Nervosa Treatment for Adults (MANTRA), specialist supportive clinical management (SSCM) (NICE,2017)

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CBT focuses on thoughts, beliefs, values and the behaviours that maintain an eating disorder rather than causal factors. CBT includes education components, the prescription of a meal plan and written self-observation.(Herrin,2012). One study was carried out on the effectiveness of enhanced cognitive behavioural therapy (CBT-E) in the treatment of anorexia nervosa on 99 patients in an outpatient facility. The results show that two thirds of the patients completed the 40 week treatment intervention, with outcomes of clinically significant weight gains and significant reductions in eating disorder pathology. However higher symptom severity, longer duration of illness, lower baseline BMI, higher number of prior treatment attempts and dropouts, higher age and degree of psychiatric symptoms and comorbidity are often considered to make treatment and recovery of anorexia nervosa more difficult. (Danielsen, Rekkedel, Frostad & Kessler,2016)

Specialist Supportive Clinical Management (SSCM) is a psychotherapy with promising treatment potential. It compromises of two distinct components which are clinical management, which focuses on alleviating symptoms or anorexia nervosa with the particular focus of weight gain via resumption of eating and a supportive psychotherapeutic approach to issues raised by the patient deemed to be important. (McIntosh,2015)

MANTRA is a cognitive-interpersonal treatment of anorexia nervosa, which is innovative in several respects. It is biologically informed and empirically based, it also draws on and incorporates recent neuroimaging, neuropsychological, social cognitive, and personality traits research. It also takes on a very warm and empathetic approach that is reflective, responsive and collaborative incorporates motivational interviewing (Schmidt, Wade & Treasure, 2014). One study evaluated the efficacy and acceptability of MANTRA compared with Specialist Supportive Clinical Management (SSCM). One hundred and forty two patients with broadly defined anorexia nervosa were allocated at random to receive 20 to 30 weekly sessions dependent on clinical severity, and additional sessions which included four further follow up sessions, and optional sessions with a dietician that could be attended with family and carers. Assessments were then carried out which were blind to treatment condition baseline at 6 and 12 month intervals. Both treatments showed significant improvement in body mass index, eating disorder symptomatology, distress symptoms and clinical impairment over time. However the MANTRA patients rated their treatment as significantly more acceptable and credible at the 12 month point. (Schmidt et al,2015).

If these treatments are unacceptable, contraindicated or ineffective for a patient, then eating disorder focused focal psychodynamic therapy (FPT) will need to be considered, with treatment sessions typically occurring once a week over a period of 40 weeks. The focus of FPT is to explore what the symptoms mean to the person, how the symptoms affect the person and how these symptoms influence the person’s relationship with others and with the therapist. (NICE,2017)

Resistance to treatment or low treatment acceptability is very common in eating disorders, and may contribute to patients dropping out or why their treatments fail. Generally speaking resistance can refer to conscious and unconscious and unconscious factors that prevent a patient from engaging in the treatment process. (Aspen, Darcy & Lock,2014). In spite of its clinical relevance, very little research has been done on resistance to treatment. (Abbate-Daga, Amianto, Delsedime, De-Bacco & Fassino,2013). The combination of high drop out and low treatment acceptability has led some researchers to suggest pausing large scale clinical trials until these obstacles have been resolved. (Schauenburg, Friederich, Wild,Zipfel & Herzog,2009). This therefore indicates a gap in this particular area of research, if research in resistance to treatment was pursued further, with the aim of getting to the root cause of what contributes to it could potentially be of benefit to future treatment and treatment outcomes. To further add progress in new treatments is believed to be slow because of insufficient research funding allocated for eating disorders. In the UK this disparity is highlighted with 7.2% of funding being allocated for depression research, 4.9% for psychosis research but only 0.4% for eating disorders research. (Chaturvedi & Patwardhan,2016)

In conclusion this essay has highlighted numerous issues surrounding anorexia nervosa. Anorexia nervosa is an extremely complex condition,that if left untreated poses devastating consequences for people who are suffering from it as well as for their family and carers. However actually treating it appears to be difficult for certain patients that are suffering with the condition, especially those that have had numerous previous attempts at treatment, numerous previous relapses and those who have a lower baseline. Despite the difficulties encountered with these therapies, for other patients they hold significant credibility. There are some positives theoretically with the diagnostic criteria set out in the DSM-5, it has a very clear, concise and specific criteria, which should make reaching a definitive diagnosis of anorexia nervosa quite straight forward. However the DSM-5 is not without its criticisms, with claims that the current edition ‘over-diagnoses’ and ‘under-diagnoses’ other psychiatric conditions in general, which potentially raises a concern that someone may receive unnecessary interventions or treatment or not receive adequate treatment (Bolton,2013). Insufficient funding for research into the aetiology and potential new treatments of anorexia nervosa has an impact on the speed in which progress can be made, but this reiterates the point that continuous research is essential to strive towards better knowledge and understanding of the condition.

References

• Abbate-Daga, G., Amianto, F., Delsedime, N., De-Bacco, C. and Fassino, S. (2013). Resistance to treatment and change in anorexia nervosa: a clinical overview. BMC Psychiatry, 13(1).
• Adler, C. (2011). Sober University. 1st ed. USA: iUniverse.
• Aspen, V., Darcy, A. and Lock, J. (2014). Patient Resistance in Eating Disorders. Psychiatric Times, 31(9), p.1.
• Attia, E. (2010). Anorexia Nervosa: Current Status and Future Directions. Annual Review of Medicine, 61(1), pp.425-435.
• Birmingham., C. and Treasure, J. (2010). Medical Management of Eating Disorders, 2nd Edition. 2nd ed. Cambridge: Cambridge University Press.
• Bolton, D. (2013). Overdiagnosis Problems in the DSM-IV and the New DSM-5: Can They Be Resolved by the Distress–Impairment Criterion?. The Canadian Journal of Psychiatry, 58(11), p.613.
• Chaturvedi, S. and Patwardhan, B. (2016). Top 10 research priorities for eating disorders. The Lancet, 3, p.706.
• Danielsen, Y., Årdal Rekkedal, G., Frostad, S. and Kessler, U. (2016). Effectiveness of enhanced cognitive behavioral therapy (CBT-E) in the treatment of anorexia nervosa: a prospective multidisciplinary study. BMC Psychiatry, 16(1).
• Hall, L. and Ostroff, M. (2013). Anorexia Nervosa: A Guide to Recovery. 1st ed. Carlsbad, Calif.: Gürze Books.
• Herrin, M. (2012). Nutrition counseling in the treatment of eating disorders. London: Routledge.
• Marwick, K. and Birrell, S. (2013). Crash Course Psychiatry – E-Book. 4th ed. UK: Mosby Elsevier.
• McKnight, R. and Boughton, N. (2009). Anorexia nervosa. BMJ, 339(sep24 2), pp.b3800-b3800.
• Mischoulon, D., Eddy, K., Keshaviah, A., Dinescu, D., Ross, S., Kass, A., Franko, D. and Herzog, D. (2011). Depression and eating disorders: Treatment and course. Journal of Affective Disorders, 130(3), pp.470-477.
• Mischoulon, D., Eddy, K., Keshaviah, A., Dinescu, D., Ross, S., Kass, A., Franko, D. and Herzog, D. (2010). Depression and eating disorders: Treatment and course. Journal of Affective Disorders, 130(3), pp.470-477.
• National Institute for Health and Care Excellence. (2017) Eating disorders: recognition and treatment.(NICE Guidelines NG69). Available at:https://www.nice.org.uk/guidance/ng69/chapter/Recommendations#treating-anorexia-nervosa [Accessed 3^rd Dec 2018]
• Petrovich, A. and Garcia, B. (1980). Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. American Psychiatric Association.
• Schmidt, U., Magill, N., Renwick, B., Keyes, A., Kenyon, M., Dejong, H., Lose, A., Broadbent, H., Loomes, R., Yasin, H., Watson, C., Ghelani, S., Bonin, E., Serpell, L., Richards, L., Johnson-Sabine, E., Boughton, N., Whitehead, L., Beecham, J., Treasure, J. and Landau, S. (2015). The Maudsley Outpatient Study of Treatments for Anorexia Nervosa and Related Conditions (MOSAIC): Comparison of the Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA) with specialist supportive clinical management (SSCM) in outpatients with broadly defined anorexia nervosa: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 83(4), pp.796-807.
• Schmidt, U., Wade, T. and Treasure, J. (2014). The Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA): Development, Key Features, and Preliminary Evidence. Journal of Cognitive Psychotherapy, 28(1), pp.48-71.
• Van Heugten – van der Kloet, D. and van Heugten, T. (2015). The classification of psychiatric disorders according to DSM-5 deserves an internationally standardized psychological test battery on symptom level. Frontiers in Psychology, 6.
• Zipfel, S., Wild, B., Groß, G., Friederich, H., Teufel, M., Schellberg, D., Giel, K., de Zwaan, M., Dinkel, A., Herpertz, S., Burgmer, M., Löwe, B., Tagay, S., von Wietersheim, J., Zeeck, A., Schade-Brittinger, C., Schauenburg, H. and Herzog, W. (2009). Focal psychodynamic therapy, cognitive behaviour therapy, and optimised treatment as usual in outpatients with anorexia nervosa (ANTOP study): randomised controlled trial.