Specialist Supportive Clinical Management for anorexia nervosa: what it is (and what it is not)

Evidence of effectiveness of specialist supportive clinical management for anorexia nervosa in routine clinical practice: Outcomes from a clinical case series

OBJECTIVE

This study provides a preliminary report on the effectiveness of Specialist Supportive Clinical Management (SSCM) in a clinical case series of adults with anorexia nervosa, to supplement evidence of efficacy from controlled trials.

METHOD

Body mass index (BMI), eating disorder symptoms, mood and anxiety were measured at the start and end of treatment for 42 adults who received SSCM in a community eating disorders service.

RESULTS

Significant improvements were observed on all outcome measures, with larger effect sizes for symptom change than BMI. Recovery rates appear similar to those in clinical trials.

DISCUSSION

The study offers preliminary support for the effectiveness of SSCM in routine settings and identifies several areas for further research.

A novel outpatient treatment model for patients with severe and enduring anorexia nervosa: an observational study of patient characteristics, treatment goals, and treatment course

BACKGROUND

Approximately 20-30% of people with anorexia nervosa develop an enduring form of the disorder. In the present study a newly developed outpatient treatment unit for patients with severe and enduring anorexia nervosa was described. The treatment model is flexible, patient-centered, and aims at enhancing quality of life, maintaining medical stability, and minimizing harm. Treatment contents, patient characteristics, treatment goals, and course of treatment from the first five years of operation were described and analyzed.

METHODS

The participants (N = 22) consisted of all referrals resulting in an assessment or treatment period at the unit between May 2017 and May 2022. All participants were women. The study was a registry study. Information regarding patient characteristics, treatment goals, and the course of treatment was gathered from medical records.

RESULTS

On average, the participants had had a diagnosed eating disorder for 12.80 years, and self-reported eating disorder symptoms for 19 years. Their symptomatology included severe eating disorder symptoms, psychiatric comorbidities, extreme underweight, and co-occurring medical conditions. Their treatment goals commonly concerned improving physical health, reducing eating disorder symptoms, improving psychological well-being, and improving quality of life. The majority of participants for whom this information was available benefited from the treatment (60%) and their treatment goals were met or partly met (66.6%), as measured by evaluations made by the patient or the treatment team. More than two thirds (69.2%) of the participants for whom this information was available remained weight stable or showed an increase in BMI.

CONCLUSIONS

This observational study suggests that many individuals with severe and enduring anorexia nervosa may benefit from flexible treatment, aiming at supporting quality of life. The results highlight the importance of coordinating and integrating the treatment of severe and enduring anorexia nervosa and co-occurring psychiatric disorders as well as medical complications. Further research and international dialogue about the how treatment for this vulnerable patient group should best be organized is called for. Trial registration Trial registration number: NCT05708404. Date of registration: 01/23/2023 (retrospectively registered).

Implementing service transformation for children and adolescents with eating disorders across England: the theory, politics, and pragmatics of large-scale service reform

BACKGROUND

Eating disorders are among the most serious mental health problems affecting children and young people and without appropriate treatment often have a protracted course with high levels of morbidity and mortality. While considerable progress has been made in recent years in developing effective evidence-based outpatient treatments, these are not always readily available. In England, until recently, the usual care pathway for young people with an eating disorder was referral from primary care to local generic Child and Adolescent Mental Health Services with varying levels of expertise in eating disorders and a mix of outpatient treatments available. Poor treatment progress or physical deterioration would usually result in inpatient admission. Admission rates were high, with children and young people with an eating disorder accounting for nearly a quarter of all child and adolescent psychiatric hospital admissions. Inpatient treatment is costly and has high relapse rates with some evidence that it may contribute to poorer long-term outcomes in eating disorders. Accumulating clinical and research evidence that early expert outpatient treatment can significantly reduce the need for inpatient care indicates,+ that investing in dedicated community-based eating disorders services is likely to be both clinically and economically beneficial.

OVERVIEW OF PAPER

This paper describes a large-scale transformation programme following a major government investment (initially £30 million/year, since then increased to over £50 million/year) aimed at service level change in the provision of eating disorder services for children and adolescents in England. We describe the history, background, political context, and clinical and research evidence that contributed to the government's decision to invest in eating disorders. We also provide a brief account of the implementation of an England-wide whole team training to support the creation of a network of over 70 dedicated community-based eating disorders services for children and young people.

An exploratory examination of executive functioning as an outcome, moderator, and predictor in outpatient treatment for adults with anorexia nervosa

OBJECTIVE

People with anorexia nervosa often exhibit inefficiencies in executive functioning (central coherence and set shifting) that may negatively impact on treatment outcomes. It is unclear from previous research whether these inefficiencies can change over treatment. We aimed to (1) investigate whether executive functioning can improve over treatment, (2) determine whether baseline executive functioning moderates treatment outcome, and (3) examine whether baseline executive functioning predicts early change (i.e., increase in body mass index over the first 13 weeks of treatment) or remission.

METHOD

We conducted linear mixed model and logistic regression analyses on data from the Strong Without Anorexia Nervosa trial (Byrne et al. in Psychol Med 47:2823-2833, 2017). This study was a randomised controlled trial of three outpatient treatments for people with anorexia nervosa: Enhanced Cognitive Behavioural Therapy, Maudsley Model Anorexia Nervosa Treatment for Adults, and Specialist Supportive Clinical Management.

RESULTS

While set shifting clearly improved from baseline to end of treatment, the results for central coherence were less clear cut. People with low baseline central coherence had more rapid reductions in eating disorder psychopathology and clinical impairment than those with high baseline central coherence. Baseline executive functioning did not predict early change or remission.

DISCUSSION

The detail-focused thinking style commonly observed among people with anorexia nervosa may aid treatment outcomes. Future research that is more adequately powered should replicate this study and examine whether the same pattern of results is observed among people with non-underweight eating disorders.

Conceptualising specialist supportive clinical management (SSCM): current evidence and future directions

BACKGROUND

Current evidence-based treatments for adult anorexia nervosa (AN) have limitations, with high attrition, very poor outcomes for 20% of people, and no clearly superior manualised therapy for adults with AN. Specialist Supportive Clinical Management (SSCM) was designed as a control treatment but has evolved as a valid first line treatment. The present paper aims to provide an overview of the evidence base for SSCM and a pedagogical reconceptualization with expansion by theoretical integration (TI). BODY: A secondary meta-analysis endorses SSCM as a promising treatment. This paper positions SSCM as a manualised therapy for adult AN with six unique features, namely (1) a philosophy which is person-centred, non-prescriptive, and informed by the person's strengths and values, (2) a focus on the person through inclusion of supportive psychotherapy and problem (clinical management), within target symptoms as defined in relation to AN, (3) a flexible and responsive therapy that could be delivered by a variety of clinicians with experience treating AN (4) a commitment to reversing starvation though a directional approach and a defined yet flexible stance on dietetic intervention (5) a commitment to the therapeutic relationship within all three phases of treatment, and (6) a therapy 'uncluttered' by specific mandates. In addition, this paper positions SSCM as a treatment that may be strengthened by other modalities and may also be adapted to the treatment of other eating disorders (ED), not just AN. The level of therapist sophistication to deliver upon the supportive psychotherapy component is explored and future directions are offered.

CONCLUSION

SSCM is a unique and valid first line treatment for AN and would benefit from further expansion in line with emerging understandings of AN to strengthen it as a treatment. Speculation on aspects of potency would benefit from further testing. The proposed re-conceptualisation of SSCM in the context of its evidence may strengthen it as a treatment overall, position it as adaptable for treatment of other eating disorders and make it more accessible to clinicians.

Recovery from anorexia nervosa: the influence of women's sociocultural milieux

OBJECTIVE

Young women living in industrialised westernised societies have a higher prevalence of anorexia nervosa, partly due to a cultural emphasis on thinness as a beauty ideal. Sociocultural milieux might promote recovery from anorexia nervosa amongst young women. The current article is a commentary about the social influences on recovery from anorexia nervosa - based on social anthropology, narratives of people with lived experience, and clinical studies.

CONCLUSION

Anorexia nervosa increases social withdrawal, and recovery leads to re-engagement with meaningful relationships. Recovery also empowers women as 'cultural critics' who challenge assumptions about the thinness beauty ideal and gender roles. The gradual process of full or partial recovery often occurs during emerging adulthood (aged 20-29). In this life stage, adolescent friendship groups are dissolving as women move from education to work, reducing the danger of weight-based teasing by peers, which is an environmental risk factor for disordered eating. Women recovering from anorexia nervosa may connect with those aspirations of peers and mentors that eschew a focus on weight and shape, but relate to the life-stage tasks of starting careers, beginning new friendships, selecting life partners and family formation - that is, a broader role in larger relationship networks.

Severe and Enduring Anorexia Nervosa: Enduring Wrong Assumptions?

To the extent that severe and lasting anorexia nervosa (SE-AN) is defined in terms of refractoriness to the best treatments available, it is mandatory to scrutinize the proven effectiveness of the treatments offered to patients. The array of so-called current evidence-based treatments for anorexia nervosa (AN) encompasses the entire spectrum of treatments ranging from specialized brand-type treatments to new treatments adapted to the specific characteristics of people suffering from AN. However, after several randomized control trials, parity in efficacy is the characteristic among these treatments. To further complicate the landscape of effective treatments, this "tie score" extends to the treatment originally conceived as control conditions, or treatment as usual conditions. In retrospection, one can understand that treatments considered to be the best treatments available in the past were unaware of their possible iatrogenic effects. Obviously, the same can be said of the theoretical assumptions underpinning such treatments. In either case, if the definition of chronicity mentioned above is applied, it is clear that the responsibility for the chronicity of the disorder says more about the flagrant inefficacy of the treatments and the defective assumptions underpinning them, than the nature of the disorder itself. A historical analysis traces the emergence of the current concept of "typical" AN and Hilde Bruch's contribution to it. It is concluded that today's diagnostic criteria resulting from a long process of acculturation distort rather than capture the essence of the disorder, as well as marginalizing and invalidating patients' perspectives.

Current Therapeutic Approaches to Anorexia Nervosa: State of the Art

Anorexia nervosa (AN) is a devastating psychiatric disorder characterized by extreme restriction of food intake and low body weight, both associated with significant medical and psychological morbidity. The clinical severity of AN has prompted the consideration and study of behavioral and pharmacological treatments in efforts to establish empirically based methods to reduce the burden of the disorder. Among adolescents, family-based treatment is considered a first-line behavioral treatment. Research continues to explore the efficacy of family-based treatment and predictors of treatment response to further improve outcomes. Several behavioral treatments for adults also exist, including cognitive-behavioral therapy, exposure and response prevention, third-wave acceptance-based treatments, and supportive psychotherapy, all of which help to improve symptoms and promote modest weight gain. Despite this, no one treatment is considered superior, and all existing behavioral approaches leave a proportion of adults symptomatic or at a high risk of relapse. As such, among adults, there is continued need for development of novel, mechanism-based approaches to better target the core symptoms of AN. Although antidepressants impart little benefit on weight or symptoms, the second-generation antipsychotic olanzapine has shown ability to promote modest weight gain in outpatients with AN. Most recently, the field's evolving conceptualization of AN as a biologically based disorder coupled with technological advancements has led to consideration of varying neuromodulation strategies as a potential therapeutic approach that remains under investigation.