Anorexia nervosa is one of the deadliest mental illnesses and can be one of the most challenging eating disorders to treat. Individuals with anorexia nervosa struggle with dysfunctional behaviors and thoughts about food and weight, which are accompanied by negative emotions about their bodily appearance and shape. Their symptoms often impact their physical, emotional, and social development.
Contrary to the common belief that anorexia is a rare disease, recent studies have shown that anorexia is a common eating disorder among many people around the world. In a recent study, its lifetime prevalence among women was found to be about 1 in 200.
Given the acuity of the symptoms and the long-term consequences of impairment in various aspects of a patient’s life, it is every patient’s right to be treated using interventions that have been proven to effectively treat his or her condition. Conducting therapy is both a science and an art. It is an art to truly understand a person and to create a meaningful connection on a humanistic level; however, therapy also is a science, since therapists ethically need to use interventions that have been supported by research to successfully treat anorexia’s symptoms.
As someone who works in residential and outpatient settings, I am often surprised to hear about the quality of treatment that many of my patients have received prior to being referred to a higher level of care, such as residential or inpatient settings. Eating disorders are treatable, and with early detection and using evidence-based interventions, we can cure this illness.
Two years ago, I received a call from a family friend, Mary, who was worried about her daughter Sarah. I’ve known this family for ten years and I had had the pleasure of watching Sarah transform from an energetic, curious child to a smart and driven teenager with a long list of achievements at school and in sports. Mary told me that Sarah had begun dieting last year around her fourteenth birthday, after a classmate commented on her “fat hips.” Sarah decided to make minor changes in her diet, to eat healthier and be more active.
According to Mary, as Sarah started seeing changes in her weight, her diet became more and more restrictive, up to the point that she had lost twenty-five percent of her body weight in the last six months. Shortly afterward, she was diagnosed with anorexia nervosa by her pediatrician and was recommended to seek therapy. Since Mary knew of my experience in the field of eating disorders, she asked me if I could recommend a therapist. Since they lived in a different part of California, I wasn’t able to provide specific referrals, but I gave her some resources on where she could find eating disorder specialists.
I did not hear from Mary or Sarah again until I saw them at a family gathering eight months after our initial conversation. I almost didn’t recognize Sarah. She appeared extremely emaciated and looked nothing like the Sarah I knew. Mary told me that she had found a therapist from her insurance panel and Sarah had been seeing this therapist for the past eight months with no success.
Upon further inquiry, I learned that this therapist advised Mary to stop forcing Sarah to eat and did not believe in monitoring patient weight. Apparently, she was meeting with Sarah alone and was not in contact with Sarah’s pediatrician, who had serious concerns about Sarah’s health. Mary appeared frustrated and told me that even by looking at Sarah she could see that she was continuing to lose weight.
Although it was obvious to me that Sarah would be an excellent candidate for Family Based Treatment (FBT), based on her developmental stage and the onset of her eating disorder, I didn’t say anything to Mary, because I didn’t want to undermine another therapist’s work. Mary added that they were ready to stop therapy since it wasn’t helpful for Sarah. I encouraged them to talk about it with Sarah’s therapist.
Twelve months later, Sarah had a car accident because she had fainted while driving. Mary told me that this was the second time that Sarah had fainted that week. As her weight continued to drop, the physical symptoms associated with anorexia got worse. Shortly afterward, Sarah was sent to an inpatient facility for severe malnutrition and risk of heart attack. She was later discharged to a residential facility and had to take a semester off from school to go to another town where she could receive a higher level of care. Since then, because of the acuity of Sarah’s symptoms, most of the family resources have gone to providers for residential and inpatient treatments for Sarah.
I often wonder how Sarah’s course of treatment might have been different if she had been initially treated with an intervention that has proven to work with people like her. Sometimes, I feel in the field of mental health, therapists emphasize the art of therapy too much and disregard the science. If you had a heart problem that required surgery, would you rather your cardiologist start with a procedure that has been proven to work on your illness or would you want her or him to start with a procedure that he or she “feels” might be helpful but that has not been proven to be effective?
Below you will find few treatment modalities that have been proven by research to help with the treatment of anorexia nervosa.
Treatment Approaches for Anorexia
Family Based Treatment (Maudsley)
FBT is the gold-standard eating disorder treatment for children, teens, and adolescents. It was developed in 1980 at the Institute of Psychiatry at Maudsley Hospital in London. The focus of the first phase of this treatment is to empower parents to take appropriate parental control over their children’s and adolescents’ eating behaviors and weight gain. This theory rests on the insight that teenagers and children are embedded in families and parental involvement is an essential aspect of treatment.
As the child’s or teen’s eating behaviors and weight normalize, the treatment shifts to helping the patient focus on regaining control over food and exploring other issues contributing to his or her eating disorder. At this stage of treatment, the therapist focuses on helping the patient negotiate the issues of separation and individuation. This treatment is idea for children and adolescents with a less than three-year history of eating disorder.
The video below provides an overview of FBT for anorexia nervosa and provides insight from families who used this treatment:
Cognitive Behavioral Therapy for Eating Disorders
Cognitive Behavioral Therapy for Eating Disorders (CBT-E) is a leading treatment modality for many eating disorders, including anorexia in adults. It was developed by Christopher Fairburn and Zafra Cooper in 2003. In this modality, the therapist and the patient work together as a team to change the patient’s overvaluation of thinness and shape.
The focus of CBT-E is addressing the beliefs that maintain one’s disordered eating rather than examining the initial reasons that led to the development of the eating disorder. The treatments usually last a minimum of twenty sessions, but this may vary depending on acuity of the eating disorder.
Dialectical Behavior Therapy
Dialectical Behavior Therapy (DBT) was created by Dr. Marsha Linehan in 1991 for the treatment of individuals with personality disorders; however, since then, studies have looked at the effectiveness of this intervention for individuals with anorexia nervosa. Many clinicians use DBT principally to address eating disorder symptoms in patients with complex and multidiagnostic issues. I have seen excellent results with my clients who struggled with addictions and eating disorders using DBT.
Although there have been few studies examining treatment outcomes for DBT compared to CBT-E or FBT, existing studies show promising results for addressing teens’ and adults’ eating disorders using DBT. DBT treatment often takes the form of a combination of group and individual therapy combined with off-hour telephone skill-coaching sessions. This treatment helps patients effectively address the emotional difficulties that give rise to eating disorder behaviors and focuses on the reduction and cessation of unhealthy coping mechanisms.
In a study conducted at the Western Psychiatric Institute and Clinic at the University of Pittsburgh Medical Center in 2002, DBT was found to be effective in addressing patients’ ambivalent feelings about recovery. The DBT clinician will often focus on promoting change using a cognitive behavioral technique in addition to teaching acceptance and mindfulness tools in order to normalize any ambivalence regarding seeking treatment.
Furthermore, this modality increases patients’ ability to express their emotions adaptively, which in turn often reduces their eating disorder behaviors. Research studies show that it usually takes a minimum of six months for a person to see changes in their eating disorder behaviors.
Although the interventions mentioned above are a few of the most well-known modalities that have been found to be effective for the treatment of anorexia, there are other interventions and modalities that a clinician may choose to use, depending on his or her clinical judgment. However, it is important for all clinicians working with anorexia nervosa to be trained in delivering evidence-based treatment. This way, a lack of training won’t get in the way of providing effective patient care.
Many eating disorder therapists I encounter at various events tell me that they are not familiar with recent developments and training in the field of eating disorders. They also say that what they learned decades ago applies “just fine” to their current anorexia patients. Although I value experience highly, I believe we cannot make such comparisons without learning and delivering new interventions.
Dr. Nazanin Moali is a clinical psychologist and eating disorder specialist in Torrance (South Bay region of Los Angeles County). After receiving her doctoral degree in clinical psychology, she completed an APA-accredited post-doctoral residency in the treatment of adolescent and adult eating disorders. Dr. Moali currently lives with her family in Rancho Palos Verdes.