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

*Anna Carr, Kate Tchanturia, Emmanuelle Dufour, Mary Cowan and Hubertus Himmerich*

### **Abstract**

Anorexia nervosa (AN) is a serious and often highly persistent psychiatric disorder, whereby sufferers struggle to maintain a healthy weight. Its complexity creates challenges regarding treatment, however psychological therapy is recommended by the National Institute for Heath and Care Excellence (NICE). There are four major evidence-based psychotherapies recommended for treating adults – enhanced cognitive behavioural therapy (CBT-E), the Maudsley model of anorexia nervosa treatment for adults (MANTRA), specialist supportive clinical management (SSCM) and focal psychodynamic therapy (FPT)—and three main psychotherapies recommended for treating adolescents with anorexia-family therapy for anorexia nervosa (FT-AN), enhanced cognitive behavioural therapy (CBT-E) and adolescent focused therapy for anorexia nervosa (AFP-AN). Additionally, several novel adjunct treatments are under examination, two of which—cognitive remediation therapy (CRT) and cognitive remediation and emotion skills training (CREST)—are also discussed in this chapter. Other relevant areas regarding psychological treatment include: combinations of medication or occupational therapy and psychotherapy, treating individuals with comorbidities, the challenges of studying psychological treatment for anorexia and future directions of psychotherapies for anorexia, and are also discussed.

**Keywords:** anorexia nervosa, predisposing factors, precipitating factors, perpetuating factors, treatment, psychological therapy, psychotherapy

#### **1. Introduction**

Anorexia Nervosa (AN) is a serious and often highly persistent psychiatric disorder, whereby sufferers struggle to maintain a healthy weight. According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), the diagnostic criteria for AN are as follows:


c.disturbances to one's view of their body, e.g., the body being an unusually high basis for self-evaluation or an inability to recognise the seriousness of the low body weight [1].

It should be noted, here, the significant changes to the diagnostic criteria presented in the DSM-5 compared to the previous edition. These are revised guidelines for determining weight loss severity, revised weight loss criterion (specifying the significance of weight in relation to differences in individuals' age, gender, developmental stage or physical health), the omission of amenorrhoea and the absence of the need for the explicit verbalisation of fear of weight gain, so long as behaviours intentionally inhibiting weight gain are evident [1, 2]. Consistent with the DSM-5, AN can be divided into two subtypes, restricting and binge-eating/purging. A sufferer with restricting subtype predominantly uses dieting, fasting and/or excessive exercise to achieve a low body weight, with the absence of any recurrent binging or purging behaviours in the 3 months before diagnosis. Binging and purging behaviours include self-induced vomiting and/or laxative, diuretic or enema abuse. The binge-eating/purging subtype is characterised by repeated displays of such behaviours in the 3 months before diagnosis [1].

Anorexia can affect any individual, irrelevant of their age, gender, race or ethnicity, however it has been found to be most common in adolescent and young females [3]. Whilst some research has found a higher prevalence of AN in white adults, these findings are quite inconsistent, with others indicating no significant differences in rates of AN for different ethnicities [4]. Anorexia is highly comorbid, with significant numbers of sufferers reporting diagnoses of other psychiatric illnesses such as substance use disorders, personality disorders, anxiety disorders, mood disorders, obsessive–compulsive disorders and autism spectrum disorders [3, 5, 6], as well as an increased suicide risk [7]. Additionally, many negative physical consequences and health complications are associated with anorexia, including cardiovascular, gastrointestinal, endocrine and metabolic, pulmonary and dermatologic complications. Almost all of the body's organ systems can be negatively impacted as a result of malnutrition or other behaviours associated with AN (e.g., purging), and despite varying outcomes, anorexia is often extremely persistent, has a relatively high risk of relapse, and the highest mortality rate among psychiatric disorders [7].

## **2. Predisposing, precipitating and perpetuating factors of AN**

A functional analysis of anorexia by Slade [8] describes "antecedent events", divided into "general setting conditions" and "specific psychosocial stimuli", that cause changes in an individual's behaviour/biological adaptation, the consequences of which lead to anorexia. Setting conditions such as low self-esteem, issues during development or perfectionistic tendencies, combine with specific psychosocial stimuli such as comments from others about weight or learnt dieting behaviour and trigger initial food restricting behaviour, indicating the first step towards an eating disorder. Changes in behaviour/biological adaptation are shown in response to these events, specifically restricting food intake and weight loss, and endocrine disturbances that may result in amenorrhoea in females, either due to the effects of low weight or due to a stress induced functional disorder. Slade then describes "consequences" of these behaviours in the form of positive reinforcers, feelings of control, success etc., and negative reinforcers, avoiding weight gain, or changes in body shape. These limited "antecedent events," "specific psychosocial stimuli" and "consequences" discussed by Slade are now commonly referred to as predisposing,

**209**

anorexia [14, 18, 19].

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

tory factors to the development, onset and maintenance of anorexia.

precipitating and perpetuating factors and cover a wide range of potential contribu-

It is now widely accepted that anorexia is developed, triggered and maintained by a combination of many different biological, psychological and social factors [9] with various models theorising the involvement of different core factors to different extents [10, 11]. Separating factors into those that predispose a person to anorexia and those that perpetuate the illness is crucial for identifying which are relevant for preventative strategies (i.e., predisposing or risk factors) and which are relevant to treatment and interventions (perpetuating or maintaining factors) [12]. It is also important to note that there is some overlap between factors as they converge and combine to increase risk of anorexia, for example some predisposing factors may also act as perpetuating factors. Additionally, some factors do not work independently and may be closely linked or impact upon each other, for example a social factor might serve to reinforce an existing psychological factor [11]. **Table 1** gives a summary of the predisposing, precipitating and perpetuating factors for anorexia and demonstrates how they can be categorised into psychological, biological and

Many theories and models of anorexia nervosa consider there to be a vital role for psychological factors in predisposing an individual to the disorder, such as personality and cognitive variables [13]. Literature frequently discusses personality characteristics that are thought to be common among individuals with anorexia including: traits associated with anxiety and depression, obsessive–compulsive traits such as rigidity and concern with detail, perfectionism, being high achieving, socially withdrawn, sensitive and introverted. These characteristics combine with other risk factors and increase an individual's vulnerability to the illness [14, 15]. In addition to personality characteristics, combinations of experiences and events lead to the creation of various distorted cognitions, creating vulnerability in an individual for developing anorexia, for example beliefs about the importance of thinness and the need to feel in control, or a cognitive bias towards food, eating, weight or body shape information processing. Fairburn et al.'s [16] cognitive behavioural theory focuses on the need for control as a central feature of anorexia and suggests that a combination of existing feelings of ineffectiveness, perfectionistic tendencies and low self-esteem underpin this need for control. Other predisposing cognitive factors for anorexia include difficulties switching between tasks (set shifting) and a preference for 'detail-focused' thinking rather than 'bigger picture' thinking (poor central coherence) [9]. Biological models highlight a number of genetic predispositions and neurobiological factors involved in the development of anorexia [14], such as malfunctions of particular neurotransmitters that may increase risk of anorexia by altering appetite regulation and increasing locomotor activity levels, or specific inherited genes that may be responsible for altered mechanisms involved in energy metabolism or appetite and feeding regulation. For a full review see [17]. Sociocultural influences might also predispose an individual to anorexia, for example insecure attachment types as a child or stressful or traumatic life events can result in interpersonal issues and emotional avoidance, common in those with

With existing predisposing factors in place, the onset of the illness may be triggered by one or more precipitating factors [14] such as periods of isolation or self-doubt, interpersonal conflict, existing loss or trauma, culture among particular occupations, e.g., ballet dancers, models or athletes, disrupted family dynamics and peer influence, for example dieting behaviour, teasing or body dissatisfaction. Additionally, biological factors like pregnancy [20–22] or weight loss [23] may influence eating disorder symptomology, psychopathology or behaviours.

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

socio-cultural factors.

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

precipitating and perpetuating factors and cover a wide range of potential contributory factors to the development, onset and maintenance of anorexia.

It is now widely accepted that anorexia is developed, triggered and maintained by a combination of many different biological, psychological and social factors [9] with various models theorising the involvement of different core factors to different extents [10, 11]. Separating factors into those that predispose a person to anorexia and those that perpetuate the illness is crucial for identifying which are relevant for preventative strategies (i.e., predisposing or risk factors) and which are relevant to treatment and interventions (perpetuating or maintaining factors) [12]. It is also important to note that there is some overlap between factors as they converge and combine to increase risk of anorexia, for example some predisposing factors may also act as perpetuating factors. Additionally, some factors do not work independently and may be closely linked or impact upon each other, for example a social factor might serve to reinforce an existing psychological factor [11]. **Table 1** gives a summary of the predisposing, precipitating and perpetuating factors for anorexia and demonstrates how they can be categorised into psychological, biological and socio-cultural factors.

Many theories and models of anorexia nervosa consider there to be a vital role for psychological factors in predisposing an individual to the disorder, such as personality and cognitive variables [13]. Literature frequently discusses personality characteristics that are thought to be common among individuals with anorexia including: traits associated with anxiety and depression, obsessive–compulsive traits such as rigidity and concern with detail, perfectionism, being high achieving, socially withdrawn, sensitive and introverted. These characteristics combine with other risk factors and increase an individual's vulnerability to the illness [14, 15]. In addition to personality characteristics, combinations of experiences and events lead to the creation of various distorted cognitions, creating vulnerability in an individual for developing anorexia, for example beliefs about the importance of thinness and the need to feel in control, or a cognitive bias towards food, eating, weight or body shape information processing. Fairburn et al.'s [16] cognitive behavioural theory focuses on the need for control as a central feature of anorexia and suggests that a combination of existing feelings of ineffectiveness, perfectionistic tendencies and low self-esteem underpin this need for control. Other predisposing cognitive factors for anorexia include difficulties switching between tasks (set shifting) and a preference for 'detail-focused' thinking rather than 'bigger picture' thinking (poor central coherence) [9]. Biological models highlight a number of genetic predispositions and neurobiological factors involved in the development of anorexia [14], such as malfunctions of particular neurotransmitters that may increase risk of anorexia by altering appetite regulation and increasing locomotor activity levels, or specific inherited genes that may be responsible for altered mechanisms involved in energy metabolism or appetite and feeding regulation. For a full review see [17]. Sociocultural influences might also predispose an individual to anorexia, for example insecure attachment types as a child or stressful or traumatic life events can result in interpersonal issues and emotional avoidance, common in those with anorexia [14, 18, 19].

With existing predisposing factors in place, the onset of the illness may be triggered by one or more precipitating factors [14] such as periods of isolation or self-doubt, interpersonal conflict, existing loss or trauma, culture among particular occupations, e.g., ballet dancers, models or athletes, disrupted family dynamics and peer influence, for example dieting behaviour, teasing or body dissatisfaction. Additionally, biological factors like pregnancy [20–22] or weight loss [23] may influence eating disorder symptomology, psychopathology or behaviours.

*Weight Management*

body weight [1].

iours in the 3 months before diagnosis [1].

c.disturbances to one's view of their body, e.g., the body being an unusually high basis for self-evaluation or an inability to recognise the seriousness of the low

It should be noted, here, the significant changes to the diagnostic criteria presented in the DSM-5 compared to the previous edition. These are revised guidelines for determining weight loss severity, revised weight loss criterion (specifying the significance of weight in relation to differences in individuals' age, gender, developmental stage or physical health), the omission of amenorrhoea and the absence of the need for the explicit verbalisation of fear of weight gain, so long as behaviours intentionally inhibiting weight gain are evident [1, 2]. Consistent with the DSM-5, AN can be divided into two subtypes, restricting and binge-eating/purging. A sufferer with restricting subtype predominantly uses dieting, fasting and/or excessive exercise to achieve a low body weight, with the absence of any recurrent binging or purging behaviours in the 3 months before diagnosis. Binging and purging behaviours include self-induced vomiting and/or laxative, diuretic or enema abuse. The binge-eating/purging subtype is characterised by repeated displays of such behav-

Anorexia can affect any individual, irrelevant of their age, gender, race or ethnicity, however it has been found to be most common in adolescent and young females [3]. Whilst some research has found a higher prevalence of AN in white adults, these findings are quite inconsistent, with others indicating no significant differences in rates of AN for different ethnicities [4]. Anorexia is highly comorbid, with significant numbers of sufferers reporting diagnoses of other psychiatric illnesses such as substance use disorders, personality disorders, anxiety disorders, mood disorders, obsessive–compulsive disorders and autism spectrum disorders [3, 5, 6], as well as an increased suicide risk [7]. Additionally, many negative physical consequences and health complications are associated with anorexia, including cardiovascular, gastrointestinal, endocrine and metabolic, pulmonary and dermatologic complications. Almost all of the body's organ systems can be negatively impacted as a result of malnutrition or other behaviours associated with AN (e.g., purging), and despite varying outcomes, anorexia is often extremely persistent, has a relatively high risk

of relapse, and the highest mortality rate among psychiatric disorders [7].

**2. Predisposing, precipitating and perpetuating factors of AN**

A functional analysis of anorexia by Slade [8] describes "antecedent events", divided into "general setting conditions" and "specific psychosocial stimuli", that cause changes in an individual's behaviour/biological adaptation, the consequences of which lead to anorexia. Setting conditions such as low self-esteem, issues during development or perfectionistic tendencies, combine with specific psychosocial stimuli such as comments from others about weight or learnt dieting behaviour and trigger initial food restricting behaviour, indicating the first step towards an eating disorder. Changes in behaviour/biological adaptation are shown in response to these events, specifically restricting food intake and weight loss, and endocrine disturbances that may result in amenorrhoea in females, either due to the effects of low weight or due to a stress induced functional disorder. Slade then describes "consequences" of these behaviours in the form of positive reinforcers, feelings of control, success etc., and negative reinforcers, avoiding weight gain, or changes in body shape. These limited "antecedent events," "specific psychosocial stimuli" and "consequences" discussed by Slade are now commonly referred to as predisposing,

**208**


 **1.**

**211**

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

It has been suggested that the most useful models for understanding the illness in terms of advancing treatment are maintenance models, focusing more specifically on factors that maintain the illness rather than those involved in the development of it [19, 24], though there is often a lot of overlap with some factors acting not only as perpetuating factors but also precipitating or predisposing ones. Many models of AN discuss psychological factors that perpetuate anorexia, either internally (self-perpetuating factors) or externally. Fairburn et al.'s [16] cognitive behavioural theory proposes a number of psychological maintaining factors. Fairburn et al. posit that achieving successful dietary restriction creates a sense of self-control in an individual, in turn improving their self-worth until restriction becomes an indication of both self-control and self-worth. This may be exacerbated by a highly perfectionist individual applying their high standards to restriction in the form of strict dietary rules. A second maintaining factor suggested in the theory is the direct effect of starvation on cognition. Intense feelings of hunger, exaggerated feelings of fullness, poorer concentration and preoccupation with food may cause an individual to feel their self-control is threatened or failing and strengthen the value that controlling food holds on the individual's self-control and self-worth. Finally, Fairburn et al. suggest extreme concerns about weight or shape is involved in perpetuating the illness, whereby an individual evaluates their self-worth highly on their weight and shape. This may be exacerbated by body checking behaviours, particularly when an individual is in an aroused and anxious state, which serves to enhance the individual's perceived imperfections regarding their body shape, encouraging further restricting and creating a vicious cycle. As a consequence of starvation, many of the aforementioned maintaining factors are worsened, facilitating the formation of vicious cycles that allow these maintaining factors and the illness to persist [15]. Further psychological, biological and social perpetuating

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

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

its superiority to other existing approaches for intervention [26].

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

factors are listed in **Table 1**.

**3. History of treatment for AN**

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

It has been suggested that the most useful models for understanding the illness in terms of advancing treatment are maintenance models, focusing more specifically on factors that maintain the illness rather than those involved in the development of it [19, 24], though there is often a lot of overlap with some factors acting not only as perpetuating factors but also precipitating or predisposing ones. Many models of AN discuss psychological factors that perpetuate anorexia, either internally (self-perpetuating factors) or externally. Fairburn et al.'s [16] cognitive behavioural theory proposes a number of psychological maintaining factors. Fairburn et al. posit that achieving successful dietary restriction creates a sense of self-control in an individual, in turn improving their self-worth until restriction becomes an indication of both self-control and self-worth. This may be exacerbated by a highly perfectionist individual applying their high standards to restriction in the form of strict dietary rules. A second maintaining factor suggested in the theory is the direct effect of starvation on cognition. Intense feelings of hunger, exaggerated feelings of fullness, poorer concentration and preoccupation with food may cause an individual to feel their self-control is threatened or failing and strengthen the value that controlling food holds on the individual's self-control and self-worth. Finally, Fairburn et al. suggest extreme concerns about weight or shape is involved in perpetuating the illness, whereby an individual evaluates their self-worth highly on their weight and shape. This may be exacerbated by body checking behaviours, particularly when an individual is in an aroused and anxious state, which serves to enhance the individual's perceived imperfections regarding their body shape, encouraging further restricting and creating a vicious cycle. As a consequence of starvation, many of the aforementioned maintaining factors are worsened, facilitating the formation of vicious cycles that allow these maintaining factors and the illness to persist [15]. Further psychological, biological and social perpetuating factors are listed in **Table 1**.
