ESCAP Expert Paper: New developments in the diagnosis and treatment of adolescent anorexia nervosa—a European perspective

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Abstract

Anorexia nervosa is a potentially life-threatening disorder with a typical onset in adolescence and high rates of medical complications and psychiatric comorbidity. This article summarizes issues relating to classification in DSM-5 and presents a narrative review of key evidence-based medical and behavioral interventions for adolescent AN and subthreshold restricting eating disorders, mainly, but not exclusively published between 2012 and 2014. In addition, it systematically compares the clinical guidelines of four European countries (Germany, Spain, The Netherlands, and United Kingdom) and outlines common clinical practice, in relation to treatment settings, nutritional rehabilitation, family-oriented and individual psychotherapy, and psychopharmacological treatment. With the exception of family-based treatment, which is mainly evaluated and practiced in Anglo-American countries, the evidence base is weak, especially for medical interventions such as refeeding and pharmacological intervention. There is a need for common European research efforts, to improve the available evidence base and resulting clinical guidance.

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Most cited references 104

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Randomized clinical trial comparing family-based treatment with adolescent-focused individual therapy for adolescents with anorexia nervosa.

James Lock, Daniel Le Grange, W Stewart Agras … (2010)

Evidence-based treatment trials for adolescents with anorexia nervosa are few. To evaluate the relative efficacy of family-based treatment (FBT) and adolescent-focused individual therapy (AFT) for adolescents with anorexia nervosa in full remission. Randomized controlled trial. Stanford University and The University of Chicago (April 2005 until March 2009). One hundred twenty-one participants, aged 12 through 18 years, with DSM-IV diagnosis of anorexia nervosa excluding the amenorrhea requirement. Intervention Twenty-four outpatient hours of treatment over 12 months of FBT or AFT. Participants were assessed at baseline, end of treatment (EOT), and 6 months' and 12 months' follow-up posttreatment. Full remission from anorexia nervosa defined as normal weight (≥95% of expected for sex, age, and height) and mean global Eating Disorder Examination score within 1 SD of published means. Secondary outcome measures included partial remission rates (>85% of expected weight for height plus those who were in full remission) and changes in body mass index percentile and eating-related psychopathology. There were no differences in full remission between treatments at EOT. However, at both the 6- and 12-month follow-up, FBT was significantly superior to AFT on this measure. Family-based treatment was significantly superior for partial remission at EOT but not at follow-up. In addition, body mass index percentile at EOT was significantly superior for FBT, but this effect was not found at follow-up. Participants in FBT also had greater changes in Eating Disorder Examination score at EOT than those in AFT, but there were no differences at follow-up. Although both treatments led to considerable improvement and were similarly effective in producing full remission at EOT, FBT was more effective in facilitating full remission at both follow-up points. clinicaltrials.gov Identifier: NCT00149786.

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An evaluation of family therapy in anorexia nervosa and bulimia nervosa.

Donna Dare, I Eisler, David Russell … (1987)

A controlled trial comparing family therapy with individual supportive therapy in anorexia nervosa and bulimia nervosa was undertaken. Eighty patients (57 with anorexia nervosa; 23 with bulimia nervosa) were first admitted to a specialized unit to restore their weight to normal. Before discharge, they were randomly allocated to family therapy or the control treatment (individual supportive therapy). After one year of psychological treatment, they were reassessed, using body weight, menstrual function, and ratings on the Morgan and Russell scales. Family therapy was found to be more effective than individual therapy in patients whose illness was not chronic and had begun before the age of 19 years. A more tentative finding was the greater value of individual supportive therapy in older patients. To our knowledge, this is the first controlled trial of family therapy in anorexia nervosa and clarifies the specific indications for this treatment.

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Update on the treatment of anorexia nervosa: review of clinical trials, practice guidelines and emerging interventions.

H. J. Watson, C M Bulik (2013)

Anorexia nervosa is a potentially deadly psychiatric illness that develops predominantly in females around puberty but is increasingly being recognized as also affecting boys and men and women across the lifespan. The aim of this environmental scan is to provide an overview of best practices in anorexia nervosa treatment across the age spectrum. A triangulation approach was used. First, a detailed review of randomized controlled trials (RCTs) for anorexia nervosa published between 1980 and 2011 was conducted; second, clinical practice guidelines were consulted and reviewed; third, information about RCTs currently underway was sourced. This approach facilitated a comprehensive overview, which addressed the extant evidence base, recent advances in evidence and improvements in treatment, and future directions. The evidence base for the treatment of anorexia nervosa is advancing, albeit unevenly. Evidence points to the benefit of family-based treatment for youth. For adults no specific approach has shown superiority and, presently, a combination of renourishment and psychotherapy such as specialist supportive clinical management, cognitive behavioral therapy, or interpersonal psychotherapy is recommended. RCTs have neither sufficiently addressed the more complex treatment approaches seen in routine practice settings, such as multidisciplinary treatment or level of care, nor specifically investigated treatment in ethnically diverse populations. Methodological challenges that hinder progress in controlled research for anorexia nervosa are explained. The review highlights evidence-based and promising treatment modalities for anorexia nervosa and presents a triangulated analysis including controlled research, practice guidelines, and emerging treatments to inform and support clinical decision making.

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Author and article information

Contributors

Beate Herpertz-Dahlmann: 492418088737 , bherpertz@ukaachen.de

Journal

Journal ID (nlm-ta): Eur Child Adolesc Psychiatry

Journal ID (iso-abbrev): Eur Child Adolesc Psychiatry

Title: European Child & Adolescent Psychiatry

Publisher: Springer Berlin Heidelberg (Berlin/Heidelberg )

ISSN (Print): 1018-8827

ISSN (Electronic): 1435-165X

Publication date (Electronic): 31 July 2015

Publication date PMC-release: 31 July 2015

Publication date (Print): 2015

Volume: 24

Issue: 10

Pages: 1153-1167

Affiliations

[ ]Department of Child & Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Clinics, RWTH Aachen, Neuenhofer Weg 21, 52074 Aachen, Germany

[ ]Department of Social Sciences, Rintveld, Center for Eating Disorders, Altrecht Mental Health Institute, Utrecht University, Utrecht, The Netherlands

[ ]Department of Child & Adolescent Psychiatry, Neurosciences Institute, Hospital Clinic of Barcelona, CIBERSAM, IDIBAPS, University of Barcelona, Barcelona, Spain

[ ]Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK

Article

Publisher ID: 748

DOI: 10.1007/s00787-015-0748-7

PMC ID: 4592492

PubMed ID: 26226918

SO-VID: 7c7116c8-4ab9-457e-b1bc-663f091aae5d

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.