Treatment for severe and enduring anorexia nervosa: a review.

OBJECTIVE: Many patients with anorexia nervosa develop an intractable and debilitating illness course. Our aims were to (i) conduct a systematic review of randomised controlled trials (RCTs) of treatment for chronic anorexia nervosa participants, and (ii) identify research informing novel therapeutic approaches for this group. METHODS: Systematic search (SCOPUS plus previous reviews date 2011) of literature for (i) RCTs of treatment that included anorexia nervosa participants with a mean duration of illness of at least 3 years, (ii) studies reporting new treatments addressing factors associated with chronicity. RESULTS: Evidence of efficacy for treatment approaches in severe and enduring anorexia nervosa is limited. Only one unpublished RCT designed to test a specific psychological approach for these patients was identified. There is a probable advantage for specialist psychotherapy over treatment as usual, and a promising study of relapse prevention with cognitive behaviour therapy (CBT) for anorexia nervosa (CBT-AN). Open trials have, however, reported developments in psychological therapies that warrant further specific evaluation. These include forms of CBT modified for anorexia nervosa, cognitive remediation therapy with emotion skills training, the Maudsley Model for Treatment of Adults with Anorexia Nervosa, the Community Outreach Partnership Program, Specialist Supportive Clinical Management and the approach of Strober with its emphasis on therapeutic alliance and flexible goals. CONCLUSIONS: Treatment trials need to move beyond targeting core eating disorder pathology (primarily weight restoration) and examine efficacy and effectiveness in minimising harm and reducing personal and social costs of chronic illness. There is also a need to develop better definitions of chronicity, with or without treatment 'resistance' specifiers.

Eating disorder features in indigenous Aboriginal and Torres Strait Islander Australian peoples.

BACKGROUND: Obesity and related cardiovascular and metabolic conditions are well recognized problems for Australian Aboriginal and Torres Strait Islander peoples. However, there is a dearth of research on relevant eating disorders (EDs) such as binge eating disorder in these groups. METHODS: Data were obtained from interviews of 3047 (in 2005) and 3034 (in 2008) adults who were participants in a randomly selected South Australian household survey of individuals' age > 15 years. The interviewed comprised a general health survey in which ED questions were embedded. Data were weighted according to national census results and comprised key features of ED symptoms. RESULTS: In 2005 there were 94 (85 weighted) First Australian respondents, and in 2008 65 (70 weighted). Controlling for secular differences, in 2005 rates of objective binge eating and levels of weight and shape influence on self-evaluation were significantly higher in indigenous compared to non-indigenous participants, but no significant differences were found in ED features in 2008. CONCLUSIONS: Whilst results on small numbers must be interpreted with caution, the main finding was consistent over the two samples. For First Australians ED symptoms are at least as frequent as for non-indigenous Australians.

Eating disorders "mental health literacy" in low risk, high risk and symptomatic women: implications for health promotion programs.

Attitudes and beliefs concerning the nature and treatment of bulimia nervosa (BN) were compared among young adult women at low risk of an eating disorder (n = 332), at high risk (n = 83), or already showing symptoms (n = 94). Participants completed a self-report questionnaire that included a measure of eating disorder symptoms. A vignette of a fictional person suffering from BN was presented, followed by a series of questions addressing the nature and treatment of the problem described. High-risk and symptomatic participants were more likely than low-risk participants to report that they would not approach anyone for advice or help, were they to have BN or a similar problem, because they would not want anyone to know. Symptomatic participants were more likely to believe that someone with BN would be discriminated against, more likely to consider bulimic behaviors to be acceptable, and more likely to view BN as being common among women in the community, than low-risk participants, participants in the high-risk group being intermediate on each of these questions. The findings suggest that the attitudes and beliefs of individuals with eating disorder symptoms differ systematically from those of individuals at high risk, but who do not yet have symptoms, and from those at low risk. They also indicate specific attitudes and beliefs that may need to be addressed in prevention and early intervention programs. The potential benefits of assessing individuals' attitudes and beliefs concerning the nature and treatment of eating-disordered behaviour and tailoring program content accordingly may be worthy of investigation.

Bulimic eating disorders in primary care: hidden morbidity still?

The current study examined the features of women with bulimic-type eating disorders (n = 24) attending primary care in two smaller urban regions of the USA. The assessment included measures of eating disorder psychopathology, medical comorbidity, impairment in role functioning, potential barriers to treatment and actual use of health services. Eating disorders, primarily variants of bulimia nervosa and binge eating disorder not meeting formal diagnostic criteria, were associated with marked impairment in psychosocial functioning. Although two-thirds of participants recognized a problem with their eating, less than 40% had ever sought treatment from a health professional for an eating or weight problem and only one in ten had sought such treatment from a mental health specialist. Only one-third had ever been asked about problems with eating by a primary care practitioner or other health professional. However, more than 80% had sought treatment from a health professional for symptoms of anxiety or depression. Most reported some degree of discomfort in discussing eating problems with others, and half reported that they would not be truthful about such problems if asked. Having an eating disorder was associated with several chronic medical conditions, including joint pain, gastrointestinal problems and fatigue. Although the small sample size limits any firm conclusions, the findings suggest that the health burden of bulimic-type eating disorders is substantial but remains largely hidden. Efforts may be needed to improve the eating disorders "mental health literacy" of both patients and primary care practitioners in order to facilitate early, appropriate intervention.

Comparing the health burden of eating-disordered behavior and overweight in women.

OBJECTIVE AND METHODS: We compared the health burden of eating-disordered behavior with that of overweight in a community-based sample of women aged 18-42 years residing in the Australian Capital Territory region of Australia. Participants (n = 4643) completed self-report measures of eating disorder psychopathology, health-related quality of life and health service utilization. Body mass index (BMI) was derived from self-reported height and weight. RESULTS: Overweight was associated with marked impairment in physical health functioning and comparatively little impairment in psychosocial functioning, whereas eating-disordered behavior was associated with marked impairment in psychosocial functioning and comparatively little impairment in physical health functioning. Further, (1) impairment in psychosocial functioning associated with eating-disordered behavior was greater than impairment in physical health functioning associated with overweight, and (2) impairment in physical health functioning associated with eating-disordered behavior was greater than impairment in psychosocial functioning associated with overweight. Overweight and eating-disordered behavior were associated with similarly elevated rates of primary care consultations during the past 6 months and of lifetime treatment from a health professional for an eating or weight problem. CONCLUSIONS: In young adult women, the health burden of eating-disordered behavior may be more substantial than previously recognized. Better information concerning the spectrum of disordered eating that exists at the population level needs to be made available. Eating-disordered behavior warrants greater attention when considering the public health burden of obesity and in developing programs to reduce this burden.

Health service utilization for eating disorders: findings from a community-based study.

BACKGROUND: Prior use of health services was examined in a community sample of women with bulimic-type eating disorders. METHOD: Participants (n = 159) completed a structured interview for the assessment of eating disorder psychopathology as well as questions concerning treatment-seeking and type of treatment received. RESULTS: Whereas a minority (40.3%) of participants had received treatment for an eating problem, most had received treatment for a general mental health problem (74.2%) and/or weight loss (72.8%), and all had used one or more self-help treatments. Where treatment was received for an eating or general mental health problem, this was from a primary care practitioner in the vast majority of cases. Only half of those participants who reported marked impairment associated with an eating problem had ever received treatment for such a problem and less than one in five had received such treatment from a mental health professional. CONCLUSION: Women with bulimic-type eating disorders rarely receive treatment for an eating problem, but frequently receive treatment for a general mental health problem and/or for weight loss. The findings underscore the importance of programs designed to improve the detection and management of eating disorders in primary care.

Correlates of the use of purging and non-purging methods of weight control in a community sample of women.

OBJECTIVE: To inform the classification of bulimic-type eating disorders, the correlates of purging and non-purging methods of weight control were examined in a large community sample of young adult women reporting recurrent episodes of binge eating. METHOD: Scores on self-report measures of eating disorder psychopathology, functional impairment and health-service utilization were compared among individuals who reported (recurrent episodes of binge eating and) the use of either purging (self-induced vomiting, laxative or diuretic misuse; n = 41) or non-purging (extreme dietary restriction, excessive exercise, or use of diet pills; n = 62) methods of weight control. Individuals who reported recurrent binge eating in the absence of extreme weight control behaviours (n = 442) were also included in the analysis. RESULTS: Non-purgers tended to be younger and heavier and have higher levels of eating disorder psychopathology and functional impairment than purgers and non-compensating binge eaters, however these differences were not statistically significant. Purgers were more likely than non-purgers to have sought treatment specifically for a problem with eating, however this difference was no longer significant after age and body mass index were statistically controlled. In multivariate analysis, frequency of extreme dietary restriction was the best predictor of functional impairment. CONCLUSIONS: These findings call into question the validity of subtyping of bulimia nervosa into purging and non-purging forms as outlined in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders.