Why is anorexia hard to treat

FBT is administered in three phases. Phase FBT is considered an effective treatment for adolescents. One study showed that at the end of a course of FBT, two-thirds of adolescents with anorexia had recovered. FBT does not appear to be significantly superior to individual adolescent treatment at end of treatment, but it achieves greater symptom reduction by post-treatment follow-ups at six and 12 months. While FBT is highly recommended, it is not appropriate or possible for all adolescents with anorexia.

This can include:. For these adolescents, a different approach, such as cognitive-behavioral therapy, is recommended. The same three phases outlined in FBT are worked through in PFT, but with separate sessions for parents and adolescents. At the beginning of each session, a clinical nurse consultant weighs the adolescent, assesses medical stability as needed, and provides brief supportive counseling for up to 15 minutes.

The nurse then communicates any other pertinent information such as weight to the therapist, who then sees the parents for a minute session. The only direct contact between the therapist and adolescent is a brief introduction at the first session and a farewell to the family at the end of the final session.

A study showed that PFT was slightly more effective than FBT in bringing about remission in adolescents with anorexia at end of treatment, but the differences in remission rates at six- and month follow-ups were not statistically significant between PFT and FBT. For more mental health resources, see our National Helpline Database. CBT is a form of psychotherapy that focuses on changing distorted, problematic, and unhealthy thought patterns and replacing them with healthier ones. It involves a person facing their own fears, learning to understand their own behaviors and those of others, and learning problem-solving skills to help manage difficult situations.

It is highly individualized. While it was created for outpatient adults, it can be modified for younger people and for day patients or people in inpatient care. CBT-E addresses the psychopathology of all eating disorders, instead of focusing on individual diagnoses such as anorexia or bulimia. CBT-E is designed to treat the eating disorder as part of the person and places control in the hands of the individual, including for adolescents.

The person with anorexia is an active participant in every aspect of the treatment and has the final say on decisions, such as which procedures to use and which problems to address. They are kept fully informed and are not asked to do anything they do not want to do. With CBT-E, people with anorexia are encouraged to examine their concerns about shape, weight and eating, dietary restraint and restriction, low weight if applicable , and extreme weight control behaviors.

By identifying the thought processes and behaviors that contribute to their eating disorder and how they play out in their lives, people with anorexia can make changes to their thinking and actions, leading to healthier outcomes.

CBT-E involves four stages. Stage For people who are underweight, weight regain is part of the program, along with addressing eating disorder psychopathology. People with anorexia make the decision to regain weight rather than having this decision imposed upon them.

This is encouraged through discussions about what happens if they do or do not regain weight. Once appropriate regain has been achieved, the focus shifts to healthy weight management. A comparative study of 46 adolescents and 49 adults showed weight normalization occurred in On average, weight restoration was achieved approximately 15 weeks earlier by adolescents than by adults.

While not a treatment in and of themselves, support groups can be a helpful complement to more comprehensive treatments for anorexia. Support groups provide a place to talk to others who understand your experiences and feelings, and are often a way to find contacts for other valuable resources. Some places to look for or ask about support groups and other resources include:.

No medication has been shown to be very effective as a treatment for anorexia, but some medications may help. There is some indication that second-generation antipsychotics, especially olanzapine, may help with weight gain in anorexia, but these are not recommended as a standalone treatment.

Hormone medication and oral contraceptives are sometimes prescribed to people with anorexia to restore menstruation or to prevent or treat low bone mineral density, but there is no evidence to show that it is beneficial for people with anorexia. With that item serving as a kind of baseline, the researchers then asked each participant to choose between that food and two other foods, a low-fat option like carrots and a high-fat option like chocolate cake while their brains were being scanned by fMRI.

To make sure the decisions were as accurate as possible, the researchers then required each person to eat the food they had chosen as a snack. Not surprisingly, the women with anorexia were significantly less likely to choose the cake than the healthy controls.

But the brain-imaging data were much more striking. Individuals without eating disorders typically evaluate a variety of criteria when deciding what to eat, such as how hungry they are and how much they like the foods on offer, and their brain-imaging data reflected this.

Those with anorexia, however, showed increased activity in the area of the brain called the dorsal striatum, which plays a role in decision-making, reward, and, importantly, habitual behaviors. When her patients left treatment, they often returned to their old environment, which was filled with cues related to eating-disorder behaviors.

These cues, then, triggered the behaviors that her patients had struggled so hard to break. That these behaviors had become habitual on the neurological level was a key finding, since it meant that many with anorexia were making these decisions without being aware of it.

However these habits started and no one really knows exactly why , they became cemented in place. People with anorexia automatically searched the restaurant menu for the lowest-calorie option without even thinking about it.

They cut their food into tiny pieces because it was just how they ate. As treatment progresses, the model can be refined and elaborated, highlighting emerging targets for treatment. One way to use this model is to ask the patient if the eating disorder is helping her accomplish the original goal-often this is related to improving self-esteem.

In most cases, the co-created formulation will reflect that the behaviors and cognitions related to the eating disorder are not working and the model illustrates instead that the eating disorder is making her feel worse. This use of the model may be the first time that a patient is able to step back and see the difference between what she is doing and what she is trying to achieve. For example, a patient may focus on the fact that vomiting makes her feel better immediately after a binge, although this is obviously a dysfunctional strategy because it undermines her self-esteem.

The Figure provides an example of a typical model that uses a cognitive-behavioral framework. If the patient wants to stop binge eating, the formulation created by the therapist and patient would clearly show the cause behind the desire to binge eg, rigid rules around food and what is required eg, adopting flexible guidelines around meals instead of rules to change the behavior.

Once the patient understands this dilemma-it is up to her to determine how much she wants to stop binge eating. If patients are unsure about wanting to change their rules around food, the therapist might help the patient explore this by generating a list of the costs and benefits associated with this behavior change. Finally, negative thinking about oneself often perpetuates disordered eating behaviors. A useful strategy to reduce resistance is to provide positive feedback and reinforcement especially for younger patients for any effort toward homework and attempts at behavior change.

By modeling this consistently ie, distinguishing between effort and outcome , patients can learn how to think more positively about themselves, which can give them the confidence to push forward.

Adult patients with low or no motivation to change. For adults with anorexia nervosa , there is sometimes little to no motivation to recover from the disorder, although there is often a recognition of other problems that anorexia nervosa is causing for them eg, isolation, poor physical health. This lack of motivation is largely due to the ego-syntonic nature of the disorder coupled with chronicity. The combination causes the disorder to become engrained and drastically reduces the likelihood of weight gain, even when the patient appears motivated for treatment.

Given the poor remission rates for patients with chronic anorexia nervosa, novel approaches sometimes focus on minimizing the burden of illness rather than attempting to bring about full weight and cognitive recovery.

An example of a therapeutic goal that targets functional improvement that both patient and therapist can agree on would be minimizing harmful exercise practices that lead to injury. Another example of a functional improvement target is cognitive inefficiencies that contribute to poor quality of life-for example, excessively rigid and detail-oriented thinking. CRT is intentionally designed to be nonthreatening and, thus, it is not focused on the eating disorder. The notion that our best efforts to advance treatment outcomes over the last four decades have failed to move the needle is cause for grave concern.

However, an important outcome of this study lies in giving those of us who study and treat anorexia a better idea of how we might move the needle. We believe these findings speak to an urgent need to better understand the neurobiological mechanisms of anorexia. We can no longer assume that improvements in patient weight ought to be the terminal goal of treatment for anorexia, and will confer improvements in cognitive symptoms. While weight normalization reduces the acute risk of complex medical events, ongoing fear of weight gain and food intake will likely mean future bouts of low weight and starvation.

We have reached a plateau in the treatment of anorexia. Future research endeavors must elucidate the precise mechanisms that underpin cognitive symptoms of anorexia, and altering these mechanisms must become the goal of treatment. This article was originally published on The Conversation by Stuart Murray.