**5. Novel adjunct psychological treatments for AN**

In addition to the aforementioned NICE recommended treatments, a number of novel adjunct treatments are being used and explored, generally in addition to other more established intensive psychotherapies [82]. The two adjunct psychological interventions are relatively new, though a growing evidence base for them is emerging. **Table 2** gives a brief indication of the current climate regarding the literature for the two following treatments.

#### **5.1 Cognitive remediation therapy (CRT)**

CRT was originally developed to be used for the rehabilitation of individuals with various neuropsychological issues, however has since been adapted to address the common problem of cognitive inflexibility (i.e., poor set shifting inability to move flexibly between different tasks or stimuli—and weak central

**219**

endorse this.

**6. Discussion**

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

coherence—inability to process information as a whole leading to a focus on details) among individuals with anorexia. The therapy aims to encourage switching between tasks, multitasking and bigger picture thinking to break inflexible thinking patterns and habits through the practice of simple tasks and mental exercises. After practicing these tasks, patients are encouraged to reflect on what cognitive style they have used to complete the task, explore how this may be helpful or unhelpful in day-today life and learn new strategies to help make small positive behavioural changes. CRT can be delivered either on a 1:1 basis typically over 10 45-min sessions, or as a briefer format in a group setting over 5 or 6 sessions. It can be used with adults or children and adolescents and is suitable even for patients with very low BMI, unlike most talking therapies, allowing them to engage in psychological work early on in

Based on evidence from randomised treatment trials, CRT reduces drop-out rates, with a 10–20% drop-out rate reported across these studies, suggesting that CRT can be a useful step to begin patient engagement with psychological interventions. In addition to low drop-out rates, qualitative feedback about CRT from both patients and therapists is very positive [86–88]. There is evidence from several RCTs that CRT improves performance and subjective evaluation of cognitive processes. This general improvement in cognition supports better general functioning [84, 85]. Available research across the lifespan suggests CRT can be used as an adjunct therapy to engage patients, improve cognitive processes and prepare grounds for further psychological work. However, CRT is not a stand-alone treatment for eating disorders, does not directly target weight change and, as such, is

CREST is an intervention developed to address problems with identifying, managing and expressing emotions among individuals with anorexia nervosa. Like CRT, it is an intervention that can be offered early on in treatment when patients may not be able to use more complex psychological therapies. CREST is generally delivered over 8–10 sessions. Typically, if a patient has previously had CRT, they are offered eight individual sessions of CREST. If patients have not had any experience of CRT, they will first have two sessions focused on thinking styles, followed by eight sessions involving the psychoeducation and experiential elements of CREST [89]. The main evidence for CREST comes from qualitative and quantitative evaluation of the case series in individual (8–10 sessions) and group format (5–6 sessions). Whilst the majority of studies available examine the efficacy of CREST for adults, showing some promise, more recently there have been some studies published investigating CREST for adolescents with anorexia and findings suggest that is may also be suitable for this patient group [90]. At the present time, the efficacy of CREST in individual and group formats is still being examined. Detailed studies using qualitative data and self-report questionnaires offer positive feedback and show promise; however, more studies with RCT methodology are required to

The current chapter has given a brief introduction to the diagnosis of anorexia

nervosa and a short history of its treatment. It has then described the current evidence-based psychological treatments for anorexia, as recommended by the NICE guidelines, and presented a summary of the literature regarding the efficacy

**5.2 Cognitive remediation and emotion skills training (CREST)**

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

treatment [83–85].

not included in the NICE guidelines.

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

coherence—inability to process information as a whole leading to a focus on details) among individuals with anorexia. The therapy aims to encourage switching between tasks, multitasking and bigger picture thinking to break inflexible thinking patterns and habits through the practice of simple tasks and mental exercises. After practicing these tasks, patients are encouraged to reflect on what cognitive style they have used to complete the task, explore how this may be helpful or unhelpful in day-today life and learn new strategies to help make small positive behavioural changes. CRT can be delivered either on a 1:1 basis typically over 10 45-min sessions, or as a briefer format in a group setting over 5 or 6 sessions. It can be used with adults or children and adolescents and is suitable even for patients with very low BMI, unlike most talking therapies, allowing them to engage in psychological work early on in treatment [83–85].

Based on evidence from randomised treatment trials, CRT reduces drop-out rates, with a 10–20% drop-out rate reported across these studies, suggesting that CRT can be a useful step to begin patient engagement with psychological interventions. In addition to low drop-out rates, qualitative feedback about CRT from both patients and therapists is very positive [86–88]. There is evidence from several RCTs that CRT improves performance and subjective evaluation of cognitive processes. This general improvement in cognition supports better general functioning [84, 85]. Available research across the lifespan suggests CRT can be used as an adjunct therapy to engage patients, improve cognitive processes and prepare grounds for further psychological work. However, CRT is not a stand-alone treatment for eating disorders, does not directly target weight change and, as such, is not included in the NICE guidelines.

#### **5.2 Cognitive remediation and emotion skills training (CREST)**

CREST is an intervention developed to address problems with identifying, managing and expressing emotions among individuals with anorexia nervosa. Like CRT, it is an intervention that can be offered early on in treatment when patients may not be able to use more complex psychological therapies. CREST is generally delivered over 8–10 sessions. Typically, if a patient has previously had CRT, they are offered eight individual sessions of CREST. If patients have not had any experience of CRT, they will first have two sessions focused on thinking styles, followed by eight sessions involving the psychoeducation and experiential elements of CREST [89].

The main evidence for CREST comes from qualitative and quantitative evaluation of the case series in individual (8–10 sessions) and group format (5–6 sessions). Whilst the majority of studies available examine the efficacy of CREST for adults, showing some promise, more recently there have been some studies published investigating CREST for adolescents with anorexia and findings suggest that is may also be suitable for this patient group [90]. At the present time, the efficacy of CREST in individual and group formats is still being examined. Detailed studies using qualitative data and self-report questionnaires offer positive feedback and show promise; however, more studies with RCT methodology are required to endorse this.

#### **6. Discussion**

The current chapter has given a brief introduction to the diagnosis of anorexia nervosa and a short history of its treatment. It has then described the current evidence-based psychological treatments for anorexia, as recommended by the NICE guidelines, and presented a summary of the literature regarding the efficacy

*Weight Management*

thology than FBT [79].

**4.3 Conclusion**

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

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 psychopa-

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 addition to the aforementioned NICE recommended treatments, a number of novel adjunct treatments are being used and explored, generally in addition to other more established intensive psychotherapies [82]. The two adjunct psychological interventions are relatively new, though a growing evidence base for them is emerging. **Table 2** gives a brief indication of the current climate regarding the literature

CRT was originally developed to be used for the rehabilitation of individuals with various neuropsychological issues, however has since been adapted to address the common problem of cognitive inflexibility (i.e., poor set shifting inability to move flexibly between different tasks or stimuli—and weak central

in the treatment of children and adolescents with anorexia [81].

**5. Novel adjunct psychological treatments for AN**

for the two following treatments.

**5.1 Cognitive remediation therapy (CRT)**

from treatment in real life situations [38, 71, 77, 78].

**218**

of these treatments. In addition to the standard treatment for anorexia, a number of more recently developed adjunct therapies are under examination. Two of these are described and again a summary of the literature investigating their efficacy is presented.

An alternative to psychotherapy alone for anorexia nervosa is to treat using combinations of treatment types and approaches. The following presents some of the current combinations under examination in the treatment of anorexia. Adapting treatment approach may be particularly important for treating individuals with comorbid diagnoses, which is discussed in this section, as well as some of the difficulties conducting studies that explore psychotherapy for anorexia, limitations of this chapter and future directions of the literature.

#### **6.1 Combinations of medications and psychological therapy**

One recognised potential treatment alternative to psychotherapy alone is the use of oxytocin, a hormone and neuropeptide that is involved in the modulation of a number of functions including eating behaviour and food consumption, emotional reactivity, stress and anxiety, trust and social interactions and bond formation [82, 91]. Evidence from reviews of the literature suggest that the oxytocin system becomes disrupted in individuals with anorexia, affecting oxytocin levels in response to stimulation or after a meal, among other things, that may return to "normal" following recovery [92]. If this is the case, there is the potential for oxytocin administration to be beneficial for treating anorexia. On the contrary, findings from RCTs show no significant weight gain following oxytocin administration in people with anorexia, however do propose that it may reduce the stress response in anticipation of food [91, 93]. Alternatively, oxytocin might impact some of the maintaining factors of anorexia, such as attachment and interpersonal issues or aspects of social cognition, e.g., emotion recognition [94–96]. With the suggestion that difficulties with emotional processing contribute to less effectivity from cognitive therapy [97], the addition of oxytocin to such psychotherapies may be beneficial, however findings on this remain inconclusive [94, 98, 99].

D-cycloserine is another drug that is suggested to show some promise in augmenting psychological treatment for anorexia [100]. For example, d-cycloserine is suggested to enhance CBT, by contributing to the consolidation of therapeutic learning from the treatment, and exposure therapy, by strengthening the mechanisms involved in fear extinction [101]. However, the results of one trial did not support this, finding that administering d-cycloserine to individuals with anorexia led to no significant differences in outcome measures following four exposuretherapy based training meals, though it was noted that the lack of effect may be due to the small sample size used [102]. On the other hand, a later RCT found that the administration of d-cycloserine with exposure therapy for individuals with anorexia led to significantly greater increases in BMI following treatment compared to placebo [103]. Still, there is certainly a need for a better understanding of the effect of combinations of medications and psychotherapies and it is clear that many more trials are required to investigate the impact of drugs such as oxytocin and d-cycloserine on treatment for anorexia [103, 104].

#### **6.2 Combinations of occupational therapy (OT) and psychological therapy**

Psychological treatment for anorexia nervosa should be part of a whole therapeutic programme including diet counselling, as well as weight and physical health monitoring, but may additionally offer occupational therapy (OT) and art therapy, typically led by occupational therapists [105]. OT is a profession which enables

**221**

with both AN and ASD [115, 117, 118].

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

therapy including strength training does also seem to be beneficial [111].

Autism spectrum disorder (ASD) is significantly overrepresented among individuals with eating disorders and a relatively common comorbidity of anorexia [112, 113]. Evidence suggests that this comorbidity is associated with more severe presentation, poorer illness outcomes and can hinder engagement with usual treatment, negatively impacting treatment outcome. This is perhaps due to some overlap in traits, e.g., poor flexibility, weak central coherence, emotional difficulties and poor introspection potentially exacerbating the maintaining factors of AN, such as rules and rigidity, which may be applied to food restriction or exercise, for example [6, 112, 114, 115]. There is the suggestion that cognitive remediation may be beneficial in the treatment of individuals high in traits like weak central coherence and poor flexibility, common to both ASD and AN [116]. As discussed, CRT and CREST are of interest in eating disorder literature and have attracted some attention regarding their use with individuals with both ASD and anorexia. Small trials and case studies indicate some potential and suitability for CRT and CREST in the treatment of AN, though further investigating is required regarding the efficacy of psychological treatment for anorexia in those with and without ASD traits, with the potential of adapting treatments to be more appropriate for use with individuals

Also of a high comorbidity with anorexia are personality disorders (PD), with estimates of over 50% of individuals with eating disorders having comorbid diagnoses of PDs, most commonly borderline personality disorder (BPD), avoidant personality disorder (APD) and obsessive–compulsive personality disorder

**6.3 Psychological treatment for people with comorbidities**

engagement and performance [106]. It is a patient-centred health profession concerned with promoting health and well-being through occupation by enabling people to participate in activities they want to do, need to do and are expected to do [107]. Occupational therapists use psychotherapeutic skills and approaches and reflect on their relationship with the patients and families. They use approaches from psychodynamic therapy and DBT such as transference and countertransference. Occupational therapists use similar frames of reference to psychologists but through an activity-orientated approach in order to maximise the person's level of psychosocial functioning [108]. Eating disorders influence people's lives and the way they engage in meaningful occupations and OT can explore the meaning of new occupations which can emerge from the eating disorder. Through specific OT assessments using the Model of Human Occupation [109], OT can examine people's motivation, routine, habits, roles and skills in a range of areas such as self-care, leisure and productivity in order to promote a more adaptive occupational participation in daily activities. OT provides a unique opportunity to implement individual and group work provided in eating disorders services supporting plans made for the patients within the multidisciplinary team. OT works with the person within their social and physical environments using meaningful activities, which often support CBT and psychological changes in different areas of life. Providing occupationally focused interventions means that most goals can be addressed using everyday activities. Through OT interventions, people can learn to transfer their experience and skills from intervention to daily life. OT teams can receive psychotherapeutic supervision and are involved in handovers, meetings and ward rounds to feed information back to the multidisciplinary team, and thus contribute to or even lead the psychotherapeutic process by bringing a unique perspective of function to the team. Its contribution can be beneficial regarding improvements to self-awareness, self-esteem and greater independence [110]. For some patients, additional physio-

*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*

engagement and performance [106]. It is a patient-centred health profession concerned with promoting health and well-being through occupation by enabling people to participate in activities they want to do, need to do and are expected to do [107]. Occupational therapists use psychotherapeutic skills and approaches and reflect on their relationship with the patients and families. They use approaches from psychodynamic therapy and DBT such as transference and countertransference. Occupational therapists use similar frames of reference to psychologists but through an activity-orientated approach in order to maximise the person's level of psychosocial functioning [108]. Eating disorders influence people's lives and the way they engage in meaningful occupations and OT can explore the meaning of new occupations which can emerge from the eating disorder. Through specific OT assessments using the Model of Human Occupation [109], OT can examine people's motivation, routine, habits, roles and skills in a range of areas such as self-care, leisure and productivity in order to promote a more adaptive occupational participation in daily activities. OT provides a unique opportunity to implement individual and group work provided in eating disorders services supporting plans made for the patients within the multidisciplinary team. OT works with the person within their social and physical environments using meaningful activities, which often support CBT and psychological changes in different areas of life. Providing occupationally focused interventions means that most goals can be addressed using everyday activities. Through OT interventions, people can learn to transfer their experience and skills from intervention to daily life. OT teams can receive psychotherapeutic supervision and are involved in handovers, meetings and ward rounds to feed information back to the multidisciplinary team, and thus contribute to or even lead the psychotherapeutic process by bringing a unique perspective of function to the team. Its contribution can be beneficial regarding improvements to self-awareness, self-esteem and greater independence [110]. For some patients, additional physiotherapy including strength training does also seem to be beneficial [111].

#### **6.3 Psychological treatment for people with comorbidities**

Autism spectrum disorder (ASD) is significantly overrepresented among individuals with eating disorders and a relatively common comorbidity of anorexia [112, 113]. Evidence suggests that this comorbidity is associated with more severe presentation, poorer illness outcomes and can hinder engagement with usual treatment, negatively impacting treatment outcome. This is perhaps due to some overlap in traits, e.g., poor flexibility, weak central coherence, emotional difficulties and poor introspection potentially exacerbating the maintaining factors of AN, such as rules and rigidity, which may be applied to food restriction or exercise, for example [6, 112, 114, 115]. There is the suggestion that cognitive remediation may be beneficial in the treatment of individuals high in traits like weak central coherence and poor flexibility, common to both ASD and AN [116]. As discussed, CRT and CREST are of interest in eating disorder literature and have attracted some attention regarding their use with individuals with both ASD and anorexia. Small trials and case studies indicate some potential and suitability for CRT and CREST in the treatment of AN, though further investigating is required regarding the efficacy of psychological treatment for anorexia in those with and without ASD traits, with the potential of adapting treatments to be more appropriate for use with individuals with both AN and ASD [115, 117, 118].

Also of a high comorbidity with anorexia are personality disorders (PD), with estimates of over 50% of individuals with eating disorders having comorbid diagnoses of PDs, most commonly borderline personality disorder (BPD), avoidant personality disorder (APD) and obsessive–compulsive personality disorder

*Weight Management*

presented.

of these treatments. In addition to the standard treatment for anorexia, a number of more recently developed adjunct therapies are under examination. Two of these are described and again a summary of the literature investigating their efficacy is

this chapter and future directions of the literature.

**6.1 Combinations of medications and psychological therapy**

beneficial, however findings on this remain inconclusive [94, 98, 99].

d-cycloserine on treatment for anorexia [103, 104].

D-cycloserine is another drug that is suggested to show some promise in augmenting psychological treatment for anorexia [100]. For example, d-cycloserine is suggested to enhance CBT, by contributing to the consolidation of therapeutic learning from the treatment, and exposure therapy, by strengthening the mechanisms involved in fear extinction [101]. However, the results of one trial did not support this, finding that administering d-cycloserine to individuals with anorexia led to no significant differences in outcome measures following four exposuretherapy based training meals, though it was noted that the lack of effect may be due to the small sample size used [102]. On the other hand, a later RCT found that the administration of d-cycloserine with exposure therapy for individuals with anorexia led to significantly greater increases in BMI following treatment compared to placebo [103]. Still, there is certainly a need for a better understanding of the effect of combinations of medications and psychotherapies and it is clear that many more trials are required to investigate the impact of drugs such as oxytocin and

**6.2 Combinations of occupational therapy (OT) and psychological therapy**

Psychological treatment for anorexia nervosa should be part of a whole therapeutic programme including diet counselling, as well as weight and physical health monitoring, but may additionally offer occupational therapy (OT) and art therapy, typically led by occupational therapists [105]. OT is a profession which enables

An alternative to psychotherapy alone for anorexia nervosa is to treat using combinations of treatment types and approaches. The following presents some of the current combinations under examination in the treatment of anorexia. Adapting treatment approach may be particularly important for treating individuals with comorbid diagnoses, which is discussed in this section, as well as some of the difficulties conducting studies that explore psychotherapy for anorexia, limitations of

One recognised potential treatment alternative to psychotherapy alone is the use of oxytocin, a hormone and neuropeptide that is involved in the modulation of a number of functions including eating behaviour and food consumption, emotional reactivity, stress and anxiety, trust and social interactions and bond formation [82, 91]. Evidence from reviews of the literature suggest that the oxytocin system becomes disrupted in individuals with anorexia, affecting oxytocin levels in response to stimulation or after a meal, among other things, that may return to "normal" following recovery [92]. If this is the case, there is the potential for oxytocin administration to be beneficial for treating anorexia. On the contrary, findings from RCTs show no significant weight gain following oxytocin administration in people with anorexia, however do propose that it may reduce the stress response in anticipation of food [91, 93]. Alternatively, oxytocin might impact some of the maintaining factors of anorexia, such as attachment and interpersonal issues or aspects of social cognition, e.g., emotion recognition [94–96]. With the suggestion that difficulties with emotional processing contribute to less effectivity from cognitive therapy [97], the addition of oxytocin to such psychotherapies may be

**220**

(OCPD) [119]. There is the suggestion that a comorbid diagnosis of a PD with anorexia may lead to adverse implications regarding more chronic illness course, lower levels of functioning, higher rates of treatment termination and less positive outcomes. Such implications may be due to various influences of PD traits including increased self-harm/suicide risk, a lack of trust in the therapist interfering with therapy engagement, poor insight into own illness and exacerbated maintaining factors of anorexia like dysregulated emotion control [114, 119–121]. In light of this there appears to be a need for adapting the therapy approach used to better suit these individuals and their co-occurring symptoms [122], for example using adapted versions of alternative psychotherapies such as dialectical behavioural therapy (DBT) to treat individuals with comorbid diagnoses of anorexia and BPD [123, 124]. Likewise, similar dysfunctions in brain circuitry suggested to underlie both obsessive–compulsive personality traits and impairments to cognitive flexibility may explain some of the overlap in diagnoses of anorexia and OCPD and obsessive–compulsive disorder (OCD). Perhaps, then, therapies that target these cognitive maintaining factors of anorexia, such as CRT or CREST, could be most appropriate for treating individuals with comorbid diagnoses of OCPD or OCD and AN, though this merits further examination [125].

## **6.4 Difficulties conducting studies exploring psychotherapy for anorexia**

Several factors make exploring the efficacy of psychotherapy for anorexia nervosa particularly difficult, leaving almost all treatment trials in the field inherently methodologically limited before they have even begun [50]. For example, the severity of the illness makes recruiting participants challenging and participant that are recruited are almost always female only samples, with very few studies investigating the efficacy of treatments for males or minority groups with anorexia [50, 126]. This leaves an absence of knowledge regarding the way males respond to treatment and the impact of culture, race, gender and sexuality on treatment, creating a large gap in the literature regarding the efficacy of treatments for males and minority groups with anorexia [81]. Additionally, drop-out rates are particularly high leading to small or incomplete data sets, or a lack of follow-up data. These issues create problems regarding cost, statistical power, interpretation and comparison of results, and potentially undermine research results, biasing estimates of treatment effects [50, 126]. One suggested explanation for the high drop-out rates is the role of personality. With PDs having relatively high comorbidity with anorexia, issues forming and maintaining interpersonal therapeutic relationships may be exacerbated due to the nature of the PD, making continued engagement in therapy difficult [119].

Despite the growing evidence base for psychotherapies for anorexia, another major issue that persists is the absence of untreated comparison groups or control groups altogether [69]. Due to the severity of the physical effects of anorexia, as well as its high mortality rate and often chronic course of development, it is unethical for patient groups to remain untreated or on waiting lists as a control group as part of a study. For this reason, it is only possible to evaluate the superiority of a treatment when compared to an alternative active treatment, often referred to as "treatment as usual" (TAU), rather than its real efficacy when compared to no treatment. However, this creates further methodological issues as TAU varies from study to study and so does not provide a common comparison group, meaning findings supporting a treatment's superiority, or inferiority, to another still cannot be reliably compared [50, 69]. Likewise, with recovery rates varying due to different definitions of recovery, varying outcome measures and inconsistent follow-up lengths between studies, the problem of reliably comparing treatments

**223**

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

for anorexia is exacerbated [82]. Poor clarity of the "criteria" for recovery and measures of recovery being based on physical changes, such as weight gain, skews the apparent efficacy of treatment, sometimes ignoring the impact of the participants' initial weights (some perhaps being much lower than others), as well as cognitive and behavioural changes that might indicate recovery leading to outcomes appearing more or less positive [69, 81]. For example, one systematic review found that family-based therapies yielded a very slight superiority regarding impact on weight outcome, but the same was not true for psychological outcomes [127]. Furthermore, a lack of independently replicated studies comparing treatments for anorexia contributes to the lack of reliable estimates of which treatments are most

Several limitations of this chapter should be noted. The chapter has summarised some of the literature relevant to psychological therapies for anorexia nervosa however is not a systematic review, therefore does not present *all* of the current research in the field. Additionally, the therapies discussed that make up the main section of the chapter are those recommended by the National Institute for Health and Care Excellence (NICE) who provide recommendations for health and care only in the UK [128]. Therefore these are not necessarily the first choice of treatment for other countries, though it does not go unrecognised that many other countries have developed practices and guidelines for treating eating disorders including anorexia. This is relevant as despite a consensus regarding the importance of psychotherapy in the treatment of anorexia across a number of countries' guidelines, including several European countries, Australia, New Zealand and the US, there still remains some inconsistencies regarding the recommended first-line treatment, optimal intensity of treatment (i.e., inpatient, outpatient or day patient) for different stages of the illness and criteria for hospitalisation. Furthermore, many of the available studies evaluating the various therapies for anorexia come from highly Westernised, English speaking countries such as the UK, US, Australia and some of Europe, with few to none from places such as Africa, South America, Eastern Europe and Asia. This may impact heavily on the efficacy of different treatments and their formats, as well as treatment adherence, due to sociocultural influences such as family ties, cultural beliefs and values, parenting styles and education [81]. Thus, this chapter may be most helpful for colleagues who practice in the UK or for readers who are interested in the psychological treatment of AN in the UK, but our chapter does not

There appears to still be a lot of progression required regarding treatment for anorexia nervosa and what is most effective, though looking to the future there are a number of suggestions under investigation. For example, identifying individuals who may not be suitable for conventional treatments, perhaps those with comorbidities, and adapting treatments in response to this may increase the number of patients that treatments are efficacious for. For example, systemic family therapy may be more beneficial than FBT for individuals with obsessive–compulsive traits [66], and an adapted version of DBT might be a more suitable and effective way of treating individuals with comorbid diagnoses of anorexia and PD [123, 124]. For individuals with a comorbid diagnosis of ASD, specific maintaining factors of AN, such as weak central coherence, poor flexibility and emotional difficulties, are often particularly apparent and problematic. Therefore, for these patients it may

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

efficacious [69].

**6.5 Limitations of chapter**

provide a comprehensive worldwide view on the topic.

**6.6 Future directions**

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

for anorexia is exacerbated [82]. Poor clarity of the "criteria" for recovery and measures of recovery being based on physical changes, such as weight gain, skews the apparent efficacy of treatment, sometimes ignoring the impact of the participants' initial weights (some perhaps being much lower than others), as well as cognitive and behavioural changes that might indicate recovery leading to outcomes appearing more or less positive [69, 81]. For example, one systematic review found that family-based therapies yielded a very slight superiority regarding impact on weight outcome, but the same was not true for psychological outcomes [127]. Furthermore, a lack of independently replicated studies comparing treatments for anorexia contributes to the lack of reliable estimates of which treatments are most efficacious [69].

#### **6.5 Limitations of chapter**

*Weight Management*

(OCPD) [119]. There is the suggestion that a comorbid diagnosis of a PD with anorexia may lead to adverse implications regarding more chronic illness course, lower levels of functioning, higher rates of treatment termination and less positive outcomes. Such implications may be due to various influences of PD traits including increased self-harm/suicide risk, a lack of trust in the therapist interfering with therapy engagement, poor insight into own illness and exacerbated maintaining factors of anorexia like dysregulated emotion control [114, 119–121]. In light of this there appears to be a need for adapting the therapy approach used to better suit these individuals and their co-occurring symptoms [122], for example using adapted versions of alternative psychotherapies such as dialectical behavioural therapy (DBT) to treat individuals with comorbid diagnoses of anorexia and BPD [123, 124]. Likewise, similar dysfunctions in brain circuitry suggested to underlie both obsessive–compulsive personality traits and impairments to cognitive flexibility may explain some of the overlap in diagnoses of anorexia and OCPD and obsessive–compulsive disorder (OCD). Perhaps, then, therapies that target these cognitive maintaining factors of anorexia, such as CRT or CREST, could be most appropriate for treating individuals with comorbid diagnoses of OCPD or OCD

**6.4 Difficulties conducting studies exploring psychotherapy for anorexia**

Several factors make exploring the efficacy of psychotherapy for anorexia nervosa particularly difficult, leaving almost all treatment trials in the field inherently methodologically limited before they have even begun [50]. For example, the severity of the illness makes recruiting participants challenging and participant that are recruited are almost always female only samples, with very few studies investigating the efficacy of treatments for males or minority groups with anorexia [50, 126]. This leaves an absence of knowledge regarding the way males respond to treatment and the impact of culture, race, gender and sexuality on treatment, creating a large gap in the literature regarding the efficacy of treatments for males and minority groups with anorexia [81]. Additionally, drop-out rates are particularly high leading to small or incomplete data sets, or a lack of follow-up data. These issues create problems regarding cost, statistical power, interpretation and comparison of results, and potentially undermine research results, biasing estimates of treatment effects [50, 126]. One suggested explanation for the high drop-out rates is the role of personality. With PDs having relatively high comorbidity with anorexia, issues forming and maintaining interpersonal therapeutic relationships may be exacerbated due to the nature of the PD, making continued engagement in therapy

Despite the growing evidence base for psychotherapies for anorexia, another major issue that persists is the absence of untreated comparison groups or control groups altogether [69]. Due to the severity of the physical effects of anorexia, as well as its high mortality rate and often chronic course of development, it is unethical for patient groups to remain untreated or on waiting lists as a control group as part of a study. For this reason, it is only possible to evaluate the superiority of a treatment when compared to an alternative active treatment, often referred to as "treatment as usual" (TAU), rather than its real efficacy when compared to no treatment. However, this creates further methodological issues as TAU varies from study to study and so does not provide a common comparison group, meaning findings supporting a treatment's superiority, or inferiority, to another still cannot be reliably compared [50, 69]. Likewise, with recovery rates varying due to different definitions of recovery, varying outcome measures and inconsistent follow-up lengths between studies, the problem of reliably comparing treatments

and AN, though this merits further examination [125].

**222**

difficult [119].

Several limitations of this chapter should be noted. The chapter has summarised some of the literature relevant to psychological therapies for anorexia nervosa however is not a systematic review, therefore does not present *all* of the current research in the field. Additionally, the therapies discussed that make up the main section of the chapter are those recommended by the National Institute for Health and Care Excellence (NICE) who provide recommendations for health and care only in the UK [128]. Therefore these are not necessarily the first choice of treatment for other countries, though it does not go unrecognised that many other countries have developed practices and guidelines for treating eating disorders including anorexia. This is relevant as despite a consensus regarding the importance of psychotherapy in the treatment of anorexia across a number of countries' guidelines, including several European countries, Australia, New Zealand and the US, there still remains some inconsistencies regarding the recommended first-line treatment, optimal intensity of treatment (i.e., inpatient, outpatient or day patient) for different stages of the illness and criteria for hospitalisation. Furthermore, many of the available studies evaluating the various therapies for anorexia come from highly Westernised, English speaking countries such as the UK, US, Australia and some of Europe, with few to none from places such as Africa, South America, Eastern Europe and Asia. This may impact heavily on the efficacy of different treatments and their formats, as well as treatment adherence, due to sociocultural influences such as family ties, cultural beliefs and values, parenting styles and education [81]. Thus, this chapter may be most helpful for colleagues who practice in the UK or for readers who are interested in the psychological treatment of AN in the UK, but our chapter does not provide a comprehensive worldwide view on the topic.

#### **6.6 Future directions**

There appears to still be a lot of progression required regarding treatment for anorexia nervosa and what is most effective, though looking to the future there are a number of suggestions under investigation. For example, identifying individuals who may not be suitable for conventional treatments, perhaps those with comorbidities, and adapting treatments in response to this may increase the number of patients that treatments are efficacious for. For example, systemic family therapy may be more beneficial than FBT for individuals with obsessive–compulsive traits [66], and an adapted version of DBT might be a more suitable and effective way of treating individuals with comorbid diagnoses of anorexia and PD [123, 124]. For individuals with a comorbid diagnosis of ASD, specific maintaining factors of AN, such as weak central coherence, poor flexibility and emotional difficulties, are often particularly apparent and problematic. Therefore, for these patients it may

that treatments that target these traits, e.g., CRT or CREST, could be most effective [116], particularly if modified to suit these individuals' needs [129]. Perhaps, then, the answer to this could be identifying patient subgroups that might respond particularly well (or not) to one treatment over another and tailoring treatment accordingly [69], though this is yet to be examined fully.

An additional consideration looking forward it that much of the current research is conducted in outpatient settings, omitting those most critically ill (who are most likely to be using inpatient services) from being participants and limiting the ability of researchers to evaluate the impact that different treatment settings have on the efficacy of psychological treatments, how successfully treatments translate to different levels of care and make recommendations regarding the best setting for treatment [50]. More intense treatment contexts such as inpatient or day-patient typically mean that patients live-in or spend up to around 10 h at the treatment location, which is significantly more therapeutic input than the typical 1 h per week of treatment offered to less chronically ill patients who access outpatient treatment [130]. Despite this, research indicates that evidence comparing inpatient and outpatient treatment shows there to be little or no differences regarding outcome between the two treatment settings and the majority of young people suffering with anorexia can be kept safe and managed well as outpatients, with high levels of patient satisfaction and significantly lower costs [131, 132]. Though the severity of some cases might mean that inpatient treatment is necessary to reduce immediate risk, research shows that a short inpatient stay followed by day-patient treatment was no less successful or safe than inpatient treatment [133], and extended hospital admissions might actually have adverse impacts on long-term recovery [134]. Considering such research, further investigation about effective settings for psychological treatment would be beneficial so that better informed decisions can be made regarding efficacy, safety, suitability for various age groups or stages of illness and cost effectiveness of treatment for anorexia in various settings.
