Severe and Enduring Anorexia Nervosa: Enduring Wrong Assumptions?

Applying integrated enhanced cognitive behaviour therapy (I-CBTE) to severe and longstanding eating disorders (SEED) Paper 2: An in-depth case study for clinicians

BACKGROUND

This case study examines the application of Integrated Enhanced Cognitive Behavioural Therapy (I-CBTE) for a patient with severe, longstanding anorexia nervosa and multiple comorbidities, including organic hallucinosis, complex post-traumatic stress disorder (CPTSD), and severe self-harm. Such complex presentations often result in patients falling between services, which can lead to high chronicity and increased mortality risk. Commentaries from two additional patients who have recovered from severe and longstanding anorexia nervosa are included.

CASE STUDY

The patient developed severe anorexia nervosa and hallucinosis after a traumatic brain injury in 2000. Despite numerous hospitalisations and various psychotropic medications in the UK and France, standard treatments were ineffective for 17 years. However, Integrated Enhanced Cognitive Behaviour Therapy (I-CBTE) using a whole-team approach and intensive, personalised psychological treatment alongside nutritional rehabilitation proved effective.

METHODS

In this paper, we describe the application of the I-CBTE model for individuals with severe, longstanding, and complex anorexia nervosa, using lived experience perspectives from three patients to inform clinicians. We also outline the methodology for adapting the model to different presentations of the disorder.

OUTCOMES

The patient achieved and maintained full remission from her eating disorder over the last 6 years, highlighting the benefit of the I-CBTE approach in patients with complex, longstanding eating disorder histories. Successful treatment also saved in excess of £360 k just by preventing further hospitalisations and not accounting for the improvement in her quality of life. This suggests that this method can improve outcomes and reduce healthcare costs.

CONCLUSION

This case study, with commentaries from two patients with histories of severe and longstanding anorexia nervosa, provides a detailed description of the practical application of I-CBTE for patients with severe and longstanding eating disorders with complex comorbidities, and extensive treatment histories. This offers hope for patients and a framework for clinicians to enhance existing treatment frameworks, potentially transforming the trajectory of those traditionally deemed treatment resistant.

RECOMMENDATIONS

We advocate the broader integration of CBT for EDs into specialist services across the care pathway to help improve outcomes for patients with complex eating disorders. Systematic training and supervision for multidisciplinary teams in this specialised therapeutic approach is recommended. Future research should investigate the long-term effectiveness of I-CBTE through longitudinal studies. Patient feedback on experiences of integrated models of care such as I-CBTE is also needed. In addition, systematic health economics studies should be conducted.

Exploring body uneasiness in severe and enduring eating disorders: insights from clinical practice

INTRODUCTION

Body uneasiness is a central facet of body image disturbances observed in individuals with eating disorders (EDs). This study aimed to address gaps in understanding body uneasiness in severe and enduring eating disorders (SE-EDs) and explore variations in psychopathology between individuals with different durations of the disorder. We hypothesized that patients with SE-ED might develop habitual behaviors that contribute to ambivalence toward treatment and the persistence of symptoms.

METHODS

A sample of 360 ED patients was evaluated at the beginning and end of a specialized intensive rehabilitation program. All patients completed the Eating Disorder Examination Questionnaire (EDE-Q) and the Body Uneasiness Test (BUT). They were divided into two groups: SE-ED (> 7 years) and acute (aED, < 3 years) duration.

RESULTS

Compulsive self-monitoring showed a significant change between the start and end of treatment, differing between groups, with a larger change observed in SE-ED (p < 0.048). In SE-ED, it was associated with lower chances of dropout (p = 0.044), opposite to aED (p = 0.009). Treatment responses were primarily related to eating psychopathology, further highlighting differences between the two groups.

CONCLUSIONS

This study underscores the possible presence of a habit in SE-ED and the importance of tailoring interventions to address unique needs based on the duration of the disorder. Furthermore, it highlights the need for further research to improve treatment outcomes in SE-EDs.

Ovarian hormones and eating disorders

The eating disorders anorexia nervosa and bulimia nervosa are much more common in women than in men. Also, there is evidence for a role of gene mutations in these disorders. This review examines recent data about the possibility that ovarian estrogens may contribute to the symptoms of anorexia nervosa and partly account for the sex difference in incidence of this disorder. Possible mechanisms linking genes that are abnormal in anorexia to pathways that could produce abnormal responses to estrogen are also examined. In addition, recent data pointing to a role of ovarian androgens in the symptoms of bulimia nervosa are reviewed. These data may point to more effective adjustments for the therapy of these difficult to treat disorders.

Severe and enduring anorexia nervosa and the proposed "Terminal anorexia" category: an expanded meta synthesis

This updated meta-synthesis explores further dimensions of the lived experience of severe and enduring anorexia nervosa (SE-AN) since recent contention regarding proposed "terminal anorexia nervosa (T-AN)". The paper aims to update the original synthesis and to situate participant responses to the category of "T-AN". Thus, extending the proposed conceptualization of the SE-AN experience. A systematic search identified published scholarship (between August 2022 and July 2023), derived from five bibliographic databases. A comprehensive methodology combining Interpretative Phenomenological Analysis and a meta-ethnographic framework enabled the synthesis of meta-themes across 9 new studies. These meta-themes were mapped onto the primary synthesis to further develop upon the earlier LE conceptualization of SE-AN. Nine extracted papers expanded the voices to 447 people within 45 studies. All papers affirmed and enriched the previous themes, and a novel theme was generated from the recent papers. The new theme, "walking on a knife's edge, caught between worlds", informed an expanded conceptualization of SE-AN, termed the Web of Hope. Thus, demonstrating how participants held onto hope in the face of the SE-AN experience. Death, dying and "terminality", were notably absent in the 36 papers in the previous meta-synthesis. Since the proposal of the category of "terminal anorexia" in 2022, studies on the lived experience of SE-AN increasingly focused on how people hold onto hope alongside SE-AN. The findings further drive the field to reflect on therapeutic interventions, labelling and diagnosis, in the face of unknowns, on the premise of "first, do no harm".

Discordant conceptualisations of eating disorder recovery and their influence on the construct of terminality

Eating disorders (EDs) are complex, multifaceted conditions that significantly impact quality-of-life, often co-occur with multiple medical and psychiatric diagnoses, and are associated with a high risk of medical sequelae and mortality. Fortunately, many people recover even after decades of illness, although there are different conceptualisations of recovery and understandings of how recovery is experienced. Differences in these conceptualisations influence categorisations of ED experiences (e.g., longstanding vs. short-duration EDs), prognoses, recommended treatment pathways, and research into treatment outcomes. Within recent years, the proposal of a 'terminal' illness stage for a subset of individuals with anorexia nervosa and arguments for the prescription of end-of-life pathways for such individuals has ignited debate. Semantic choices are influential in ED care, and it is critical to consider how conceptualisations of illness and recovery and power dynamics influence outcomes and the ED 'staging' discourse. Conceptually, 'terminality' interrelates with understandings of recovery, efficacy of available treatments, iatrogenic harm, and complex co-occurring diagnoses, as well as the functions of an individual's eating disorder, and the personal and symbolic meanings an individual may hold regarding suffering, self-starvation, death, health and life. Our authorship represents a wide range of lived and living experiences of EDs, treatment, and recovery, ranging from longstanding and severe EDs that may meet descriptors of a 'terminal' ED to a variety of definitions of 'recovery'. Our experiences have given rise to a shared motivation to analyse how existing discourses of terminality and recovery, as found in existing research literature and policy, may shape the conceptualisations, beliefs, and actions of individuals with EDs and the healthcare systems that seek to serve them.

Specific psychological therapies versus other therapies or no treatment for severe and enduring anorexia nervosa

BACKGROUND

Anorexia nervosa is a psychological condition characterised by self-starvation and fear or wait gain or other body image disturbance. The first line of treatment is specific psychological therapy; however, there is no consensus on best practice for treating people who develop severe and enduring anorexia nervosa (SEAN). Notably, there is no universal definition of SEAN.

OBJECTIVES

To evaluate the benefits and harms of specific psychological therapies for severe and enduring anorexia nervosa compared with other specific therapies, non-specific therapies, no treatment/waiting list, antidepressant medication, dietary counselling alone, or treatment as usual.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The last search date was 22 July 2022.

SELECTION CRITERIA

We included parallel randomised controlled trials (RCTs) of people (any age) with anorexia nervosa of at least three years' duration. Eligible experimental interventions were any specific psychological therapy for improved physical and psychological health in anorexia nervosa, conducted in any treatment setting with no restrictions in terms of number of sessions, modality, or duration of therapy. Eligible comparator interventions included any other specific psychological therapy for anorexia nervosa, non-specific psychological therapy for mental health disorders, no treatment or waiting list, antipsychotic treatment (with or without psychological therapy), antidepressant treatment (with or without psychological therapy), dietary counselling, and treatment as usual as defined by the individual trials.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Our primary outcomes were clinical improvement (weight restoration to within the normal weight range for participant sample) and treatment non-completion. Results were presented using the GRADE appraisal tool.

MAIN RESULTS

We found two eligible studies, but only one study provided usable data. This was a parallel-group RCT of 63 adults with SEAN who had an illness duration of at least seven years. The trial compared outpatient cognitive behaviour therapy for SEAN (CBT-SEAN) with specialist supportive clinical management for SEAN (SSCM-SE) over eight months. It is unclear if there is any difference between the effect of CBT-SEAN versus SSCM-SE on clinical improvement at 12 months (risk ratio (RR) 1.42, 95% confidence interval (CI) 0.66 to 3.05) or treatment non-completion (RR 1.72, 95% CI 0.45 to 6.59). There were no reported data on adverse effects. The trial was at high risk of performance and detection bias. We rated the GRADE level of evidence as very low-certainty for both primary outcomes, downgrading for imprecision and risk of bias concerns.

AUTHORS' CONCLUSIONS

This review reports evidence from one trial that evaluated CBT-SEAN versus SSCM-SE. There was very low-certainty evidence of little or no difference in clinical improvement and treatment non-completion between the two therapies. There is a need for larger high-quality trials to determine the benefits of specific psychological therapies for people with SEAN. These should take into account the duration of illness as well as participants' previous experience with evidence-based psychological therapy for anorexia nervosa.

Conceptualisation of severe and enduring anorexia nervosa: a qualitative meta-synthesis

BACKGROUND

Severe and enduring anorexia nervosa (SE-AN) is amongst the most impairing of all mental illnesses. Collective uncertainties about SE-AN nosology impacts treatment refinement. Qualitative research, particularly lived experience literature, can contribute to a process of revision and enrichment of understanding the SE-AN experience and further develop treatment interventions. Poor outcomes to date, as evidenced in clinical trials and mortality for people with SE-AN (1 in 20) demonstrate the need for research that informs conceptualisations and novel treatment directions. This interpretative, meta-ethnographic meta-synthesis aimed to bridge this gap.

METHODS

A systematic search for qualitative studies that explored the AN experiences of people with a duration of greater than 3 years was undertaken. These studies included those that encompassed phenomenology, treatment experiences and recovery.

RESULTS

36 papers, comprising 382 voices of SE-AN experiences informed the meta-ethnographic findings. Four higher order constructs were generated through a synthesis of themes and participant extracts cited in the extracted papers: (1) Vulnerable sense of self (2) Intra-psychic processes (3) Global impoverishment (4) Inter-psychic temporal processes. Running across these meta-themes were three cross cutting themes (i) Treatment: help versus harm, (ii) Shifts in control (iii) Hope versus hopelessness. These meta-themes were integrated into conceptualisations of SE-AN that was experienced as a recursive process of existential self-in-relation to other and the anorexia nervosa trap.

CONCLUSIONS

The alternative conceptualisation of SE-AN proposed in this paper poses a challenge to current conceptualisations of AN and calls for treatments to engage with the complex intra and inter-psychic processes of the SE-AN, more fully. In doing so, clinicians and researchers are asked to continue to be bold in testing novel ideas that may challenge our own rigidity and attachment to dominant paradigms to best serve the individual person with SE-AN. The 'global impoverishment of self', found in this synthesis of AN experiences, should inform proposed diagnostic criteria for SE-AN.

Anorexia nervosa and microbiota: systematic review and critical appraisal

PURPOSE

Recent studies have reported a gut microbiota imbalance or dysbiosis associated with anorexia nervosa (AN), which has prompted an appraisal of its aetiological role, and the reformulation of AN as a metabo-psychiatric disorder. Thus, the aim of this paper was to critically review the current scientific findings regarding the role of microbiota in anorexia nervosa.

METHODS

A systematic study of peer-reviewed literature published in four databases between 2009 and 2022 was conducted according to PRISMA guidelines. Both human and animal studies were included.

RESULTS

A total of 18 studies were included. In animal models, both the preclinical and clinical findings were inconsistent regarding microbiota composition, faecal metabolite concentrations, and the effects of human faecal microbiota transplants.

CONCLUSION

The methodological limitations, lack of standardisation, and conceptual ambiguity hinder the analysis of microbiota as a key explanatory factor for AN.

LEVEL OF EVIDENCE

Level I, systematic review.

Weighing in: qualitative explorations of weight restoration as recovery in anorexia nervosa

BACKGROUND

Anorexia Nervosa (AN) continues to capture the public's imagination, centered around physical appearance, particularly weight. Clinical conceptions of AN also emphasize weight. The objective of this study was to explore how individuals with lived AN experience thought about the role of weight in illness and recovery.

METHODS

The current study employed a grounded theory approach through qualitative inductive inquiry and analysis of 150 anonymous narratives, exploring firsthand experience of AN and recovery of adult individuals, based in the United States of America.

RESULTS

Individuals with AN histories contested intersecting popular cultural and medical presumptions of their health and illness positioned in weight. Respondents indicated that while weight does not measure recovery, it matters to recovery in unanticipated ways. Others' expectations for a low weight served as a gatekeeper to various forms of social and institutional support. Respondents felt that the weight obsessions of other people made it difficult to earn the illness legitimacy to access sufficient care.

CONCLUSIONS

Research findings bear implications for future AN research, advocacy, and clinical practice, as respondents pivot research emphasis from weight as a sociocultural motivation for AN, to weight as a sociocultural obstacle to AN recovery.

Restlessness and an Increased Urge to Move (Drive for Activity) in Anorexia Nervosa May Strengthen Personal Motivation to Maintain Caloric Restriction and May Augment Body Awareness and Proprioception: A Lesson From Leptin Administration in Anorexia Nervosa

Anorexia nervosa (AN), a disorder of voluntary food restriction leading to severe weight loss in female adolescents, remains an enigma. In particular, the appropriation of the starved thin body into the self-concept in AN is a process insufficiently researched and still poorly understood. Healthy humans undergoing starvation experience a slowing of movements and avoid voluntary exercise. By contrast, AN tends to be not infrequently associated with voluntary, sometimes excessive and/or compulsive exercise. Such deliberate exercise, not reported in starvation, seems to be facilitated by an increased urge for movement and physical restlessness, particular to AN. The increased urge to move would reflect spontaneous daily activity, the energy expended for everything that is not sleeping, eating, or voluntary exercise. Our hypothesis is that the starvation-induced increased urge to move and restlessness may promote the development of AN. Reversal of the fasting state, by either high caloric food or by leptin administration, would be expected to reduce restlessness and the increased urge to move along with improvement in other symptoms in AN. This review explores the idea that such restless activation in AN, in itself and through accelerating body weight loss, might foster the integration of the starving body into the self-concept by (1) enhancing the person’s sense of self-control and sense of achievement and (2) through invigorating proprioception and through intensifying the perception of the changing body shape. (3) Tentative evidence from studies piloting leptin administration in chronic AN patients which support this hypothesis is reviewed. The findings show that short term administration of high doses of leptin indeed mitigated depressive feelings, inner tension, intrusive thoughts of food, and the increased urge to be physically active, easing the way to recovery, yet had little influence on the patients’ personal commitment to remain at a low weight. Full recovery then requires resolution of the individuals’ personal unresolved psychological conflicts through psychotherapy and frequently needs specialized treatment approaches to address psychiatric co-morbidities. AN might be conceptualized as a hereditary form of starvation resistance, facilitated by the effects of starvation on fitness allowing for an exceptionally intense personal commitment to perpetuate food restriction.