Challenging rigidity in Anorexia (treatment, training and supervision): questioning manual adherence in the face of complexity

From symptoms to subjective and bodily experiences: the contribution of the Psychodynamic Diagnostic Manual (PDM-2) to diagnosis and treatment monitoring in eating disorders

PURPOSE

Atheoretical and descriptive conceptualizations of eating disorders (EDs) have faced substantial criticism due to their limited ability to assess patients' subjective characteristics and experiences, as needed to determine the most appropriate treatment options. The present article provides an overview of the clinical and empirical literature supporting the potential contribution of the Psychodynamic Diagnostic Manual (PDM-2) to both diagnostic assessment and treatment monitoring.

METHODS

Following a discussion of the most relevant shortcomings of current diagnostic models of EDs and a description of the rationale and structure of the PDM-2, evidence supporting the core PDM-2 dimensions of ED patients' subjective experiences (i.e., affective states, cognitive processes, relational patterns, somatic/bodily experiences and states) are examined, alongside their relevance to ED diagnosis and treatment.

RESULTS

Overall, the reviewed studies support the diagnostic importance of these patterns of subjective experiences in EDs, highlighting their potential role as either predisposing or maintaining factors to target in psychotherapy. A growing body of multidisciplinary evidence also shows that bodily and somatic experiences are central to the diagnosis and clinical management of ED patients. Moreover, there is evidence that a PDM-based assessment may enable closer monitoring of patient progress during treatment, with regard to both subjective experiences and symptom patterns.

CONCLUSIONS

The study suggests that current diagnostic frameworks for EDs would benefit from the addition of a person-centered perspective that considers not only symptoms, but also patients' full range of functioning-including their deep and surface-level emotional, cognitive, interpersonal, and social patterns-to improve patient-tailored interventions.

LEVEL OF EVIDENCE

Level V, narrative review.

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.