**3. History of treatment for AN**

Historically, treatment for AN relied heavily on antipsychotic medication up until the second half of the 1990s when the shift towards a more complex approach to treatment began, taking into account an individual's biological and developmental factors and involving individual psychotherapy [25]. Advancements were made following this shift such as the introduction of cognitive and behavioural treatments. For example, an operant conditioning technique used from the mid-1960s involved the delivery of positive (e.g., more freedom) or negative reinforcers (e.g., bed rest) in response to desired behaviour (e.g., completing a meal). Despite being deemed effective at the time, questions surrounding its durability and wider impact (not just on weight), along with concerns about its coercive and controlling nature and lack of regard for other maintaining factors of the illness, dispute the claim of its superiority to other existing approaches for intervention [26].

A number of the cognitive techniques used at the time resemble a more basic and general version of cognitive therapy still used in present times [27], originating from the work of Bruch [28]. Bruch argued that psychotherapy to treat anorexia should be aimed at addressing the distorted thinking patterns and flawed core beliefs/assumptions that the sufferer holds, acquired as a result of their experiences during development. This might be accomplished using cognitive techniques such as *decentering* (adopting a less egocentric perspective for example by asking oneself 'do I notice this as much in others as I do in myself?') or *decatastrophising* (encouraging patients to imagine right through to the end of a feared situation to gauge the realistic likelihood of an event occurring and how bad it will be, rather

*Weight Management*

**210**

**Predisposing factors**

Psychological

•

factors

Personality traits (e.g., anxiousness,

• •

Salient eating behaviours in the

family shifting need for control

to focus on food

Direct reinforcement that

• • •

Association of self-control with self-worth

High standards and perfectionism applied to restriction of food intake

Effects of starvation threaten self-control and strengthen value of controlling food, e.g.,

Emotions less salient/numbed – belief that anorexia can manage adverse emotional states

preoccupation with food, poor concentration

restricting food intake = control

concern with detail, perfectionism,

high achieving)

•

Distorted cognitions, e.g., regarding

need for control

• weight etc.

•

Biological

•

Inherited malfunctions to neurotransmitters involved in appetite regulation

• •

Pregnancy

Weight loss

or locomotor activity levels

•

Genetic predisposition for altered

energy metabolism or appetite and

feeding regulation

• Social factors •

Pre-natal stress exposure

Learnt beliefs/adopted values about

• • •

Occupational cultures, e.g.,

ballet dancers, models, athletes

Loss or trauma

Interpersonal conflict

• • • • • • •

Body dissatisfaction

Extreme concern/overvalued importance of weight/shape

Comments from others boosts confidence/gives attention

Societal ideals for thinness

Lack of family coping strategies

Difficult family dynamics/family conflicts

Concern from close others/enabling behaviours

importance of weight/shape

• •

> **Table 1.**

*Summary of predisposing, precipitating and perpetuating factors in AN.*

Stressful/traumatic life events, e.g.,

abuse, disrupted family dynamics

• •

Peer influence, e.g., dieting,

teasing, body dissatisfaction

Disrupted family dynamics

Insecure attachment types

factors

Cognitive inflexibility

Cognitive bias towards food, eating,

• •

Negative psychological states,

e.g., isolation, self-doubt

•

Developmental crisis, e.g.,

fearing puberty/independence

Threat to self-control

• • • • • • • • • •

Changes to serotonin/dopamine systems

Distorted cognitive beliefs, e.g., about benefits of anorexia

Impaired cognitive functioning, e.g., weak central coherence, poor set-shifting ability

Altered physiological processes cause cognitive and psychological disturbances

Changes to hormone levels and digestive system due to malnourishment

Low self-esteem

Personality traits, e.g., perfectionism, high achieving, fear of making mistakes

Anxiety

Mood intolerance

**Precipitating factors**

**Perpetuating factors**

than assuming the worst and catastrophising immediately) [29]. After further refining of Bruch's (1973) ideas, a cognitive-behavioural approach to treatment for AN based on Beck's cognitive model of depression was developed by Garner and Bemis [16, 29, 30], which involved a mixture of cognitive techniques like those mentioned, along with behavioural techniques such as "scheduling pleasant events" (to help establish other reinforcers for pleasure other than those driving the eating disorder) and "behavioural rehearsal" (e.g., role playing scary events to they can be better coped with) [30]. Other research around this time emphasised the importance of therapy that addresses the need for control [8]. Garner et al.'s [31] model of cognitive-behavioural therapy for anorexia became the leading approach of its time and involved addressing core maintaining mechanisms such as low weight, the use of weight and shape as means of achieving self-control/self-worth and body checking, as well as other issues such as low self-esteem, poor emotion recognition and expression, disruptions in the family and interpersonal difficulties [16]. Following this, and with more recent research and models highlighting the importance of other maintaining factors for the illness, cognitive-behavioural therapy (CBT) for anorexia was further adapted and developed to become more focused on the central mechanisms involved in the maintenance of the disorder, with the suggestion that other issues only be targeted by treatment if they are preventative of change [16, 32], allowing a more person-centred treatment [9].

Family therapy for the treatment of eating disorders was introduced in the 1970s following changes to the accepted general beliefs and assumptions of the role family processes play in the development and maintenance of anorexia [25, 33]. For example, Minuchin et al.'s [34] psychosomatic family model argues that family processes involving rigidity, over-involvement and conflict avoidance, along with existing psychological vulnerability in the individual, underpin the development of anorexia, and therapy should therefore involve the family to work towards changing the family dynamic. Until this time, families were generally considered to hinder treatment and so patients were treated in isolation from their parents [35]. Other associations between eating disorders and family dynamics have since been examined suggesting specific areas where families have an impact, such as attachment, parenting style, communication orientation or family conflict [18, 36, 37], though more recent models hold in mind that no blame should be attributed to the family, rather treatment works with the family [33].

By the end of the twentieth century AN was rarely treated with medication alone, instead using a multifaceted approach involving both medication and psychological intervention to better suit the individual [25].

#### **4. Evidence-based psychological treatment for AN**

The current recommended treatment for AN is guided by The National Institute for Health Care and Excellence (NICE) guidelines and aims to improve care for sufferers of anorexia by providing details of what are considered to be the most effective interventions for AN in both adults, children and young people, and allowing for an individualized and integrated approach to be adopted. According to the guidelines, treatment for anorexia should involve one or more psychological therapy, along with additional support including psychoeducation about the illness, monitoring of mental and physical health including weight and risk factors, family/carer involvement and a multidisciplinary team approach from health-care professionals. The recommended psychological interventions differ for adults and children and young people as indicated below [38]. See **Table 2** for a brief summary of the psychological therapies for AN in adults and adolescents.

**213**

*Evidence-Based and Novel Psychological Therapies for People with Anorexia Nervosa*

**clinical studies**

+ +

+ +

+ +

+ +

+ +

−/+ −/+

−/+ N/A

+ −/+

−/+ N/A

*Abbreviations: Not tested (N/A), negative study results (−), positive study result (+), inconsistent or limited results* 

*Psychological therapies for AN in adults and adolescents: Evidence from clinical studies (including feasibility studies and non-randomised trials) and randomised controlled trials (RCTs) and whether they are* 

*(−/+), recommended in the NICE guidelines ( ), not mentioned in the NICE guidelines ( ).*

**Evidence from RCTs**

**Recommended in NICE** 

**guidelines**

*DOI: http://dx.doi.org/10.5772/intechopen.92680*

**Established treatments**

Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)

Specialist supportive clinical management (SSCM)

Eating-disorder-focused focal psychodynamic therapy (FPT)

Anorexia-nervosa-focused family

Eating-disorder-focused cognitive behavioural therapy (CBT-ED)

Adolescent-focused psychotherapy for anorexia nervosa (AFP-AN)

*Psychological treatments for AN in adults* Cognitive Remediation Therapy

Cognitive Remediation and Emotion

Skills Training (CREST)

*recommended by the NICE guidelines.*

therapy (FT-AN)

**Novel treatments**

(CRT)

**Table 2.**

*Psychological treatments for AN in adults* Eating-disorder-focused cognitive behavioural therapy (CBT-ED)

**Psychological treatments Evidence from** 

*Psychological treatments for AN in children and young people*

**4.1 Psychotherapies for AN in adults**

The NICE guidelines recommend four major evidence-based psychological interventions for the treatment of AN in adults. These are: individual eatingdisorder-focused cognitive behavioural therapy (CBT-ED), Maudsley Anorexia Nervosa Treatment for Adults (MANTRA), specialist supportive clinical management (SSCM) and eating-disorder-focused focal psychodynamic therapy (FPT). The guidelines recommend beginning with the first three mentioned therapies and,

CBT-ED is delivered on an individual basis, consisting of 20–40 sessions over 20 weeks, depending on the version used. An enhanced version of CBT is most commonly used (CBT-E) which originated from CBT for bulimia nervosa (CBT-BN), though as a "transdiagnostic" treatment can be used to treat a broad range of eating disorders including anorexia. It has two versions, a focused version which is shorter and just involves the core treatment, and a broad version which addresses further

if found to be unsuitable or ineffective, then considering FPT [38].

*4.1.1 Eating-disorder-focused cognitive behavioural therapy (CBT-ED)*


*Evidence-Based and Novel Psychological Therapies for People with Anorexia Nervosa DOI: http://dx.doi.org/10.5772/intechopen.92680*

*Abbreviations: Not tested (N/A), negative study results (−), positive study result (+), inconsistent or limited results (−/+), recommended in the NICE guidelines ( ), not mentioned in the NICE guidelines ( ).*

#### **Table 2.**

*Weight Management*

than assuming the worst and catastrophising immediately) [29]. After further refining of Bruch's (1973) ideas, a cognitive-behavioural approach to treatment for AN based on Beck's cognitive model of depression was developed by Garner and Bemis [16, 29, 30], which involved a mixture of cognitive techniques like those mentioned, along with behavioural techniques such as "scheduling pleasant events" (to help establish other reinforcers for pleasure other than those driving the eating disorder) and "behavioural rehearsal" (e.g., role playing scary events to they can be better coped with) [30]. Other research around this time emphasised the importance of therapy that addresses the need for control [8]. Garner et al.'s [31] model of cognitive-behavioural therapy for anorexia became the leading approach of its time and involved addressing core maintaining mechanisms such as low weight, the use of weight and shape as means of achieving self-control/self-worth and body checking, as well as other issues such as low self-esteem, poor emotion recognition and expression, disruptions in the family and interpersonal difficulties [16]. Following this, and with more recent research and models highlighting the importance of other maintaining factors for the illness, cognitive-behavioural therapy (CBT) for anorexia was further adapted and developed to become more focused on the central mechanisms involved in the maintenance of the disorder, with the suggestion that other issues only be targeted by treatment if they are preventative of change

Family therapy for the treatment of eating disorders was introduced in the 1970s following changes to the accepted general beliefs and assumptions of the role family processes play in the development and maintenance of anorexia [25, 33]. For example, Minuchin et al.'s [34] psychosomatic family model argues that family processes involving rigidity, over-involvement and conflict avoidance, along with existing psychological vulnerability in the individual, underpin the development of anorexia, and therapy should therefore involve the family to work towards changing the family dynamic. Until this time, families were generally considered to hinder treatment and so patients were treated in isolation from their parents [35]. Other associations between eating disorders and family dynamics have since been examined suggesting specific areas where families have an impact, such as attachment, parenting style, communication orientation or family conflict [18, 36, 37], though more recent models hold in mind that no blame should be attributed to the family,

By the end of the twentieth century AN was rarely treated with medication alone, instead using a multifaceted approach involving both medication and

The current recommended treatment for AN is guided by The National Institute

for Health Care and Excellence (NICE) guidelines and aims to improve care for sufferers of anorexia by providing details of what are considered to be the most effective interventions for AN in both adults, children and young people, and allowing for an individualized and integrated approach to be adopted. According to the guidelines, treatment for anorexia should involve one or more psychological therapy, along with additional support including psychoeducation about the illness, monitoring of mental and physical health including weight and risk factors, family/carer involvement and a multidisciplinary team approach from health-care professionals. The recommended psychological interventions differ for adults and children and young people as indicated below [38]. See **Table 2** for a brief summary

[16, 32], allowing a more person-centred treatment [9].

rather treatment works with the family [33].

psychological intervention to better suit the individual [25].

**4. Evidence-based psychological treatment for AN**

of the psychological therapies for AN in adults and adolescents.

**212**

*Psychological therapies for AN in adults and adolescents: Evidence from clinical studies (including feasibility studies and non-randomised trials) and randomised controlled trials (RCTs) and whether they are recommended by the NICE guidelines.*

#### **4.1 Psychotherapies for AN in adults**

The NICE guidelines recommend four major evidence-based psychological interventions for the treatment of AN in adults. These are: individual eatingdisorder-focused cognitive behavioural therapy (CBT-ED), Maudsley Anorexia Nervosa Treatment for Adults (MANTRA), specialist supportive clinical management (SSCM) and eating-disorder-focused focal psychodynamic therapy (FPT). The guidelines recommend beginning with the first three mentioned therapies and, if found to be unsuitable or ineffective, then considering FPT [38].

#### *4.1.1 Eating-disorder-focused cognitive behavioural therapy (CBT-ED)*

CBT-ED is delivered on an individual basis, consisting of 20–40 sessions over 20 weeks, depending on the version used. An enhanced version of CBT is most commonly used (CBT-E) which originated from CBT for bulimia nervosa (CBT-BN), though as a "transdiagnostic" treatment can be used to treat a broad range of eating disorders including anorexia. It has two versions, a focused version which is shorter and just involves the core treatment, and a broad version which addresses further

maintaining mechanisms, such as perfectionism, low self-esteem or interpersonal difficulties, in addition to the core treatment. CBT-E aims to alter faulty cognitions by focusing on behavioural changes and monitoring the effects and implications of behaviours that reinforce the eating disorder [38, 39].

CBT-E is delivered in four main stages, the first of which aims to encourage the patient to engage with treatment, identify the processes that are maintaining the individual's illness, provide psychoeducation and introduce two essential elements of the therapy: weighing and regular eating. Stage two is a chance for the patient and therapist to review progress so far and plan for stage three, the main body of treatment. This main stage is tailored to the individual and targets the patient's own maintaining processes. These processes generally fall under six core headings: the over-evaluation of shape and weight, the over-evaluation of control over eating, dietary restraint, dietary restriction, being underweight and event- or moodtriggered changes in eating. If the patient has additional factors that are creating a barrier to change, e.g., high perfectionism, core low self-esteem or pronounced interpersonal problems, the broad form of therapy might be used and these additional maintaining mechanisms are addressed more specifically. Mood intolerance was originally included as an additional mechanism to be addressed in the broad form of therapy however is now included in the core treatment. Finally, stage four is in place to ensure changes are maintained following treatment ending and to minimise the risk of relapse [40].

A review of treatments for adults with anorexia concludes that there is a moderate evidence base for CBT-E for adults, with evidence suggesting that it produces a moderate and lasting beneficial effect. This is an improvement on the older version of CBT which was found to have weak evidence base and only a slight beneficial effect [9]. Another review found a large effect of CBT-E on EDE-Q (Eating Disorder Examination Questionnaire—indicating eating disorder psychopathology) outcomes specifically for AN [41]. Generally, studies show that CBT-E produces good outcomes regarding increases in BMI and decreases in eating disorder psychopathology and conclude that it is an effective and viable treatment option for anorexia. However, there does not yet appear to be any consistent convincing evidence to suggest it is superior to comparable psychotherapies [42–50]. There is some evidence to suggest that CBT-E may be feasible to deliver in a group setting for patients with eating disorders, including those with anorexia, without losing the desired positive outcomes regarding weight gain and reduction in eating disorder psychopathology [51], however sample sizes are small and so this requires further examining.

Despite its apparent success in the treatment of other eating disorders such as bulimia or binge eating disorder, and theoretical suitability for treating anorexia, there is less evidence to support its success in those with anorexia [49, 52]. It has been suggested that a combination of the malnourished brain, as a result of extremely low weight, and the ego-syntonic nature of anorexia makes motivation to engage with treatment low and the challenging of distorted cognitions even more difficult and distressing for the individual [52, 53].

#### *4.1.2 Maudsley anorexia nervosa treatment for adults (MANTRA)*

MANTRA is a flexible treatment based around a patient workbook and delivered over 10–20 sessions depending on the complexity of the patient's problems [38]. It is based on Schmidt and Treasure's [24] cognitive-interpersonal maintenance model and aims to target the maintaining factors of anorexia, for example unhelpful thinking styles, including rigidity, perfectionism and obsessive–compulsive traits, faulty cognition and beliefs, e.g., the benefits of AN, emotion avoidance and

**215**

*Evidence-Based and Novel Psychological Therapies for People with Anorexia Nervosa*

responses from others that do not support recovery such as criticism or enabling of behaviours [15, 54]. MANTRA is taught in modules that address various aspects of the patient's life and recovery, for example nutrition, identity, cognitive styles or interpersonal relationships. It can be individualised once the core module of case formulation is complete by emphasising the optional modules to a greater or lesser extent depending on how ready or motivated the individual is, and by tailoring the therapy to match an individual's clinical symptoms, personality and neuropsychological traits. It is specifically designed for anorexia treatment and is tailored to suit the common temperamental traits associated with the illness, delivered using

In a number of RCTs comparing treatment for anorexia, MANTRA was found to have positive outcomes regarding BMI and eating disorder psychopathology though was not statistically significantly different in comparison with CBT-E or SSCM. However, MANTRA was more favourably rated by patients and resulted in increasing weight even in severely unwell patients [44, 54, 55]. A review of evidence from RCTs comparing treatments for anorexia concluded that MANTRA has a moderate evidence base which shows that it produces a moderate and lasting

SSCM was developed as a standardised outpatient treatment to help support individuals with anorexia through education, advice, therapeutic guidance and reassurance [56, 57]. It is delivered in an outpatient setting as weekly sessions for 20 or more weeks depending on the severity of the individual's illness. The treatment aims to support the patient in gradually normalising their eating behaviour and gaining weight through physical health monitoring, clinical management and therapeutic content. This includes psychoeducation, nutritional advice and support in setting goals and understanding the link between their symptoms and abnormal

Evidence from RCTs suggests SSCM to be at least comparable to CBT and IPT regarding improved outcomes and global anorexia rating [56, 58]. Compared to MANTRA, SSCM seems to perform equally well overall, however in the treatment of particularly severely ill patients SSCM is slightly less successful in producing longer-term weight gain than MANTRA. There is the suggestion that SSCM might produce quicker responses to treatment and be best used for patients with less severe cases of anorexia who have higher motivation for treatment [54, 55, 58]. Still, other findings show no significant differences in outcome regarding BMI, eating disorder psychopathology or general psychopathology between SSCM, MANTRA and CBT-E [44]. Despite some mixed findings, a review of evidence from RCTs comparing treatments for anorexia concluded that SSCM has a moderate evidence

Designed as an outpatient treatment, FPT is a person-centred treatment whereby an individualised hypothesis is created regarding how the person experiences their own symptoms. The patient's relevant central psychodynamic features are identified by the therapist using a standardised interview tool. Treatment is then delivered in three rough phases, the first of which centres around building a good therapeutic relationship, self-esteem, pro-AN beliefs and the ego-syntonic nature of anorexia. The second phase is focused on the link between interpersonal relationships and eating disorder behaviours, and the

*DOI: http://dx.doi.org/10.5772/intechopen.92680*

beneficial effect [9].

eating behaviour [9, 38].

elements of motivational interviewing and CBT [9, 55].

*4.1.3 Specialist supportive clinical management (SSCM)*

based that demonstrates its moderate beneficial effect [9].

*4.1.4 Eating-disorder-focused focal psychodynamic therapy (FPT)*

#### *Evidence-Based and Novel Psychological Therapies for People with Anorexia Nervosa DOI: http://dx.doi.org/10.5772/intechopen.92680*

responses from others that do not support recovery such as criticism or enabling of behaviours [15, 54]. MANTRA is taught in modules that address various aspects of the patient's life and recovery, for example nutrition, identity, cognitive styles or interpersonal relationships. It can be individualised once the core module of case formulation is complete by emphasising the optional modules to a greater or lesser extent depending on how ready or motivated the individual is, and by tailoring the therapy to match an individual's clinical symptoms, personality and neuropsychological traits. It is specifically designed for anorexia treatment and is tailored to suit the common temperamental traits associated with the illness, delivered using elements of motivational interviewing and CBT [9, 55].

In a number of RCTs comparing treatment for anorexia, MANTRA was found to have positive outcomes regarding BMI and eating disorder psychopathology though was not statistically significantly different in comparison with CBT-E or SSCM. However, MANTRA was more favourably rated by patients and resulted in increasing weight even in severely unwell patients [44, 54, 55]. A review of evidence from RCTs comparing treatments for anorexia concluded that MANTRA has a moderate evidence base which shows that it produces a moderate and lasting beneficial effect [9].

#### *4.1.3 Specialist supportive clinical management (SSCM)*

SSCM was developed as a standardised outpatient treatment to help support individuals with anorexia through education, advice, therapeutic guidance and reassurance [56, 57]. It is delivered in an outpatient setting as weekly sessions for 20 or more weeks depending on the severity of the individual's illness. The treatment aims to support the patient in gradually normalising their eating behaviour and gaining weight through physical health monitoring, clinical management and therapeutic content. This includes psychoeducation, nutritional advice and support in setting goals and understanding the link between their symptoms and abnormal eating behaviour [9, 38].

Evidence from RCTs suggests SSCM to be at least comparable to CBT and IPT regarding improved outcomes and global anorexia rating [56, 58]. Compared to MANTRA, SSCM seems to perform equally well overall, however in the treatment of particularly severely ill patients SSCM is slightly less successful in producing longer-term weight gain than MANTRA. There is the suggestion that SSCM might produce quicker responses to treatment and be best used for patients with less severe cases of anorexia who have higher motivation for treatment [54, 55, 58]. Still, other findings show no significant differences in outcome regarding BMI, eating disorder psychopathology or general psychopathology between SSCM, MANTRA and CBT-E [44]. Despite some mixed findings, a review of evidence from RCTs comparing treatments for anorexia concluded that SSCM has a moderate evidence based that demonstrates its moderate beneficial effect [9].

#### *4.1.4 Eating-disorder-focused focal psychodynamic therapy (FPT)*

Designed as an outpatient treatment, FPT is a person-centred treatment whereby an individualised hypothesis is created regarding how the person experiences their own symptoms. The patient's relevant central psychodynamic features are identified by the therapist using a standardised interview tool. Treatment is then delivered in three rough phases, the first of which centres around building a good therapeutic relationship, self-esteem, pro-AN beliefs and the ego-syntonic nature of anorexia. The second phase is focused on the link between interpersonal relationships and eating disorder behaviours, and the

*Weight Management*

maintaining mechanisms, such as perfectionism, low self-esteem or interpersonal difficulties, in addition to the core treatment. CBT-E aims to alter faulty cognitions by focusing on behavioural changes and monitoring the effects and implications of

CBT-E is delivered in four main stages, the first of which aims to encourage the patient to engage with treatment, identify the processes that are maintaining the individual's illness, provide psychoeducation and introduce two essential elements of the therapy: weighing and regular eating. Stage two is a chance for the patient and therapist to review progress so far and plan for stage three, the main body of treatment. This main stage is tailored to the individual and targets the patient's own maintaining processes. These processes generally fall under six core headings: the over-evaluation of shape and weight, the over-evaluation of control over eating, dietary restraint, dietary restriction, being underweight and event- or moodtriggered changes in eating. If the patient has additional factors that are creating a barrier to change, e.g., high perfectionism, core low self-esteem or pronounced interpersonal problems, the broad form of therapy might be used and these additional maintaining mechanisms are addressed more specifically. Mood intolerance was originally included as an additional mechanism to be addressed in the broad form of therapy however is now included in the core treatment. Finally, stage four is in place to ensure changes are maintained following treatment ending and to

A review of treatments for adults with anorexia concludes that there is a moderate evidence base for CBT-E for adults, with evidence suggesting that it produces a moderate and lasting beneficial effect. This is an improvement on the older version of CBT which was found to have weak evidence base and only a slight beneficial effect [9]. Another review found a large effect of CBT-E on EDE-Q (Eating Disorder Examination Questionnaire—indicating eating disorder psychopathology) outcomes specifically for AN [41]. Generally, studies show that CBT-E produces good outcomes regarding increases in BMI and decreases in eating disorder psychopathology and conclude that it is an effective and viable treatment option for anorexia. However, there does not yet appear to be any consistent convincing evidence to suggest it is superior to comparable psychotherapies [42–50]. There is some evidence to suggest that CBT-E may be feasible to deliver in a group setting for patients with eating disorders, including those with anorexia, without losing the desired positive outcomes regarding weight gain and reduction in eating disorder psychopathology [51], however sample sizes are small and so this requires

Despite its apparent success in the treatment of other eating disorders such as bulimia or binge eating disorder, and theoretical suitability for treating anorexia, there is less evidence to support its success in those with anorexia [49, 52]. It has been suggested that a combination of the malnourished brain, as a result of extremely low weight, and the ego-syntonic nature of anorexia makes motivation to engage with treatment low and the challenging of distorted cognitions even more

MANTRA is a flexible treatment based around a patient workbook and delivered

over 10–20 sessions depending on the complexity of the patient's problems [38]. It is based on Schmidt and Treasure's [24] cognitive-interpersonal maintenance model and aims to target the maintaining factors of anorexia, for example unhelpful thinking styles, including rigidity, perfectionism and obsessive–compulsive traits, faulty cognition and beliefs, e.g., the benefits of AN, emotion avoidance and

behaviours that reinforce the eating disorder [38, 39].

minimise the risk of relapse [40].

further examining.

difficult and distressing for the individual [52, 53].

*4.1.2 Maudsley anorexia nervosa treatment for adults (MANTRA)*

**214**

third attends to the transfer from treatment to real life and preparing the patient for the end of treatment [9, 43, 59].

Although being an effective treatment in terms of weight gain, when compared to other specialist psychological treatments (family therapy and cognitive analytical therapy), FPT does not appear to be superior [60]. Additionally, FPT has shown no greater success than CBT-E and TAU regarding weight gain or reduction in anorexic psychopathology after treatment, though at 12-month follow up has shown significantly higher recovery rates than TAU as measured by global outcome (a combination of BMI and eating disorder psychopathology) [43].

One review of treatment for anorexia conclude there is a moderate evidence base for the treatment, and a moderate and lasting beneficial treatment effect of FPT for adults with anorexia [9]. There is the suggestion from existing eating disorder literature that due to the interpersonal element in psychodynamic interventions, they may need a longer timeframe for their positive effects to be exhibited [58]. In light of this, and due to a large part of FPT being focused on interpersonal relationships, there is the possibility that its strength lies in better long-term results [43].

#### **4.2 Psychological treatment for AN in children and young people**

For treating anorexia in children and young people, the NICE guidelines recommend one of the following: anorexia-nervosa-focused family therapy (FT-AN), CBT-ED or adolescent-focused psychotherapy for anorexia nervosa (AFP-AN). It is recommended that FT-AN is considered first, with CBT-ED or AFP-AN being considered if FT-AN is unacceptable, ill-advised or ineffective for the individual [38].

#### *4.2.1 Anorexia-nervosa-focused family therapy (FT-AN)*

FT-AN (or family-based therapy; FBT) is typically delivered in 10–20 sessions over 6 months to a year and is structured in three rough phases. FBT has a behavioural focus, whereby the family is encouraged to take some control and support the patient with weight restoration, making healthy diet decisions and gaining autonomy around eating. Despite an emphasis on the role that an individual's family has in their recovery, care should be taken to ensure no blame is attributed to either the patient or their family. The family should be encouraged to temporarily be part of helping the individual to manage their eating. The first phase of treatment is centred on the forming of therapeutic relationships between the therapist, patient and family members, weight restoration and a return to a more physically healthy state. The next phase involves supporting the patient to gradually acquire some autonomy that is appropriate for their age and development, for example portioning their own meals under the supervision of a parent or carer. Finally, phase three aims to identify any anticipated developmental challenges for the young person and how to manage them and establish plans following termination of treatment or in case of relapse [38, 61]. Family therapy is thought to be particularly useful for treating adolescents with the illness as it is during this time that individuals are going through critical development times that are often taking place in a home environment among family [62].

Reviews of FBT have summarised studies comparing different formats of FBT, and different types of family therapy to FBT [33, 61], finding no significant differences between the various formats and types. For example, comparing conjoint therapy (for family and patient together) to separate therapy (patient and family seen separately), studies have found no significant differences in outcomes [63, 64]. Additionally, a comparison of FBT of different lengths found no significant differences between short- and long-term FBT at end of treatment and 4-year

**217**

*Evidence-Based and Novel Psychological Therapies for People with Anorexia Nervosa*

consistently been significantly more successful than another [50, 62, 67]. An expanding pool of evidence exists that supports the use of FBT as the primary intervention for treating children and young people with anorexia [9, 68] however there is still limited evidence to suggest FBT is consistently superior to other psychological treatments or treatment as usual [33]. Despite much of the research on anorexia treatment for adolescents focusing on FT-AN, a lack of high-quality studies comparing FT-AN to individual treatments means it cannot reliably be deemed superior [69]. Other reviews have concluded that FBT is no more successful in addressing anorexic psychopathology than other psychotherapies [70] and highlight the issue that it is not necessarily successful for all adolescents, for example for families with single or separated parents, or where the young person

has high levels of obsessive–compulsive traits [61, 71].

*4.2.2 Eating-disorder-focused cognitive behavioural therapy (CBT-ED)*

Although designed as a treatment for adults, CBT-E for eating disorders can be adapted to be suitable for treating young people several ways. For example, many young people live at home in a family unit where they might become dependent on a parent or carer, therefore treatment should be delivered in such a way that encourages and facilitates the young person to take some responsibility and develop independence so that a return to normal adolescent development can be made following treatment. Due to the family involvement that is common and expected among young people living at home, care should also be taken to ensure the best use of the family's involvement, without the patient perceiving this as over-involvement

and threating their autonomy. Motivation for treatment is often quite low in

it is suitable and meets the additional needs of young people [72].

*4.2.3 Adolescent-focused psychotherapy for anorexia nervosa (AFP-AN)*

AFP-AN (previously named ego-oriented individual therapy before being manualised) [77] is delivered primarily through up to around 40 individual sessions with the individual, with an additional 8–12 sessions involving the patient's family or carer(s) to support the individual work. Treatment begins more intensively, with regular sessions aiming to allow the therapist to establish a strong therapeutic relationship with the patient, as well as build the patient's motivation for behaviour change. The aim of AFP-AN is to facilitate independence and self-efficacy around eating behaviour through sessions focusing on the link between the person's eating

beneficial effects for CBT-E [9].

younger patients making it important to incorporate strategies to engage the patient with the therapy. The therapy itself is delivered in largely the same way for children and adolescents as it is for adults, though minor adaptations may be made to ensure

Studies show some promise from CBT-E regarding weight gain and reduced eating disorder and general psychopathology among adolescents with anorexia which lasted at follow up [73–75], and suggest that CBT-E may be even more successful in adolescents than adults [76]. Despite this, one study review concluded that there is a weak to moderate evidence base for CBT for young people with eating disorders, with inconsistent results regarding effects of treatment for CBT and only slightly

follow-up [65]. Comparisons of FBT with different types of family therapy, for example systemic family therapy, which is concerned more with the family system and issues surrounding relationships, interactions and dynamics [66], reveal no significant differences in terms of primary outcome, though FBT did produce more rapid weight gain and less incidents of hospitalisation for those assigned to it. Several reviews conclude that no one format for content/delivery of FT-AN has

*DOI: http://dx.doi.org/10.5772/intechopen.92680*

#### *Evidence-Based and Novel Psychological Therapies for People with Anorexia Nervosa DOI: http://dx.doi.org/10.5772/intechopen.92680*

follow-up [65]. Comparisons of FBT with different types of family therapy, for example systemic family therapy, which is concerned more with the family system and issues surrounding relationships, interactions and dynamics [66], reveal no significant differences in terms of primary outcome, though FBT did produce more rapid weight gain and less incidents of hospitalisation for those assigned to it. Several reviews conclude that no one format for content/delivery of FT-AN has consistently been significantly more successful than another [50, 62, 67].

An expanding pool of evidence exists that supports the use of FBT as the primary intervention for treating children and young people with anorexia [9, 68] however there is still limited evidence to suggest FBT is consistently superior to other psychological treatments or treatment as usual [33]. Despite much of the research on anorexia treatment for adolescents focusing on FT-AN, a lack of high-quality studies comparing FT-AN to individual treatments means it cannot reliably be deemed superior [69]. Other reviews have concluded that FBT is no more successful in addressing anorexic psychopathology than other psychotherapies [70] and highlight the issue that it is not necessarily successful for all adolescents, for example for families with single or separated parents, or where the young person has high levels of obsessive–compulsive traits [61, 71].

#### *4.2.2 Eating-disorder-focused cognitive behavioural therapy (CBT-ED)*

Although designed as a treatment for adults, CBT-E for eating disorders can be adapted to be suitable for treating young people several ways. For example, many young people live at home in a family unit where they might become dependent on a parent or carer, therefore treatment should be delivered in such a way that encourages and facilitates the young person to take some responsibility and develop independence so that a return to normal adolescent development can be made following treatment. Due to the family involvement that is common and expected among young people living at home, care should also be taken to ensure the best use of the family's involvement, without the patient perceiving this as over-involvement and threating their autonomy. Motivation for treatment is often quite low in younger patients making it important to incorporate strategies to engage the patient with the therapy. The therapy itself is delivered in largely the same way for children and adolescents as it is for adults, though minor adaptations may be made to ensure it is suitable and meets the additional needs of young people [72].

Studies show some promise from CBT-E regarding weight gain and reduced eating disorder and general psychopathology among adolescents with anorexia which lasted at follow up [73–75], and suggest that CBT-E may be even more successful in adolescents than adults [76]. Despite this, one study review concluded that there is a weak to moderate evidence base for CBT for young people with eating disorders, with inconsistent results regarding effects of treatment for CBT and only slightly beneficial effects for CBT-E [9].

#### *4.2.3 Adolescent-focused psychotherapy for anorexia nervosa (AFP-AN)*

AFP-AN (previously named ego-oriented individual therapy before being manualised) [77] is delivered primarily through up to around 40 individual sessions with the individual, with an additional 8–12 sessions involving the patient's family or carer(s) to support the individual work. Treatment begins more intensively, with regular sessions aiming to allow the therapist to establish a strong therapeutic relationship with the patient, as well as build the patient's motivation for behaviour change. The aim of AFP-AN is to facilitate independence and self-efficacy around eating behaviour through sessions focusing on the link between the person's eating

*Weight Management*

for the end of treatment [9, 43, 59].

tion of BMI and eating disorder psychopathology) [43].

*4.2.1 Anorexia-nervosa-focused family therapy (FT-AN)*

**4.2 Psychological treatment for AN in children and young people**

third attends to the transfer from treatment to real life and preparing the patient

Although being an effective treatment in terms of weight gain, when compared to other specialist psychological treatments (family therapy and cognitive analytical therapy), FPT does not appear to be superior [60]. Additionally, FPT has shown no greater success than CBT-E and TAU regarding weight gain or reduction in anorexic psychopathology after treatment, though at 12-month follow up has shown significantly higher recovery rates than TAU as measured by global outcome (a combina-

One review of treatment for anorexia conclude there is a moderate evidence base for the treatment, and a moderate and lasting beneficial treatment effect of FPT for adults with anorexia [9]. There is the suggestion from existing eating disorder literature that due to the interpersonal element in psychodynamic interventions, they may need a longer timeframe for their positive effects to be exhibited [58]. In light of this, and due to a large part of FPT being focused on interpersonal relationships, there is the possibility that its strength lies in better long-term results [43].

For treating anorexia in children and young people, the NICE guidelines recommend one of the following: anorexia-nervosa-focused family therapy (FT-AN), CBT-ED or adolescent-focused psychotherapy for anorexia nervosa (AFP-AN). It is recommended that FT-AN is considered first, with CBT-ED or AFP-AN being considered if FT-AN is unacceptable, ill-advised or ineffective for the individual [38].

FT-AN (or family-based therapy; FBT) is typically delivered in 10–20 sessions over 6 months to a year and is structured in three rough phases. FBT has a behavioural focus, whereby the family is encouraged to take some control and support the patient with weight restoration, making healthy diet decisions and gaining autonomy around eating. Despite an emphasis on the role that an individual's family has in their recovery, care should be taken to ensure no blame is attributed to either the patient or their family. The family should be encouraged to temporarily be part of helping the individual to manage their eating. The first phase of treatment is centred on the forming of therapeutic relationships between the therapist, patient and family members, weight restoration and a return to a more physically healthy state. The next phase involves supporting the patient to gradually acquire some autonomy that is appropriate for their age and development, for example portioning their own meals under the supervision of a parent or carer. Finally, phase three aims to identify any anticipated developmental challenges for the young person and how to manage them and establish plans following termination of treatment or in case of relapse [38, 61]. Family therapy is thought to be particularly useful for treating adolescents with the illness as it is during this time that individuals are going through critical development times that are often taking place in a home environ-

Reviews of FBT have summarised studies comparing different formats of FBT, and different types of family therapy to FBT [33, 61], finding no significant differences between the various formats and types. For example, comparing conjoint therapy (for family and patient together) to separate therapy (patient and family seen separately), studies have found no significant differences in outcomes [63, 64].

Additionally, a comparison of FBT of different lengths found no significant differences between short- and long-term FBT at end of treatment and 4-year

**216**

ment among family [62].

disorder and their self-image, emotion processing and regulation, and interpersonal processes. This helps the individual develop an understanding of how their selfconcept perpetuates the illness and how they use their anorexia as a coping strategy. Unlike CBT, however, AFP is more concerned with employing strategies to challenge underlying psychological or developmental deficits rather than issues directly associated with food, weight or shape, for example. AFP supports the individual to manage fears surrounding weight gain and find alternative ways to cope with stress or adverse emotions, as well as providing psychoeducation about the consequences of malnourishment and the importance of nutrition and weight gain. As treatment is in its final stage, the emphasis is on applying the skills and knowledge acquired from treatment in real life situations [38, 71, 77, 78].

AFP was found to match FBT in terms of treatment completion and outcome in a clinical trial comparing the two [78]. However, at follow-up AFP was found to be statistically inferior to FBT regarding outcome, suggested to be due to fewer instances of full-remission threshold being met following treatment, as well as higher relapse rates, in individuals who completed AFP. One trial also found that AFP was less successful in treating patients with severe eating disorder psychopathology than FBT [79].

### **4.3 Conclusion**

Though there appears to be some success for psychotherapies, still it is proving difficult to achieve consistently good outcomes with the treatments that are currently available for anorexia, particularly in adults [44]. Additionally, there is a consensus that despite a growing evidence-base for treatments for anorexia and a preference for psychotherapy as treatment, there still remains no established leading treatment [9, 80]. A number of treatment reviews conclude that among a variety of psychotherapies, including the aforementioned treatments recommended by the NICE guidelines, there is no convincing evidence to suggest one consistently superior intervention for treating adults, children or adolescents with anorexia nervosa [44, 50, 69, 81]. This is largely due to the difficulty of trialling treatments for anorexia because of difficulty recruiting participants, high rates of patient drop-out or non-adherence to treatment and withdrawal from clinicians as a result of risk not being stabilised [50]. Still, psychotherapies that include the family seem to be more promising and tentatively deemed most appropriate and preferred in the treatment of children and adolescents with anorexia [81].
