Anorexia Nervosa

Contributors:
Shannon L. Karl, Nova Southeastern University

Essential features of anorexia nervosa (AN) include energy intake restriction, significantly low weight, intense fear of becoming fat, and emotional disturbance related to body weight or shape (American Psychiatric Association [APA], 2013).

  • Significantly low body weight for developmental stage is calculated by Body Mass Index (BMI) and is defined as weighing less than “minimally” expected (APA, 2013).
  • There are two subtypes: restricting type and binge-eating/purging type. Based on BMI, severity levels are mild, moderate, severe, and extreme (APA, 2013).
  • AN has many deleterious health effects [National Institute of Mental Health (NIMH), 2013] and holds one of the highest mortality rates among all psychiatric disorders (approximately 4%). AN can be the most physically and emotionally damaging of the eating disorders (Crow et al., 2009).
  • Biological risk factors include: female sex; relatives with a history of eating, depressive, or obsessive-compulsive disorders; and the developmental period of adolescence/early adulthood (average age of onset is 19 years).
  • Environmental risk factors include: occupational or vocational activities that support thinness, cultural variants, socioeconomic status, and psychosocial stressors (Berg & Peterson, 2013; Berg, Peterson, & Frazer, 2012; Crow et al., 2009; Dailey, Gill, Karl, & Barrio Minton, 2014; Fichter, Quadflieg, & Hedlund, 2006; Harris & Barraclough,
    1998; Lindberg & Hjem, 2003; NIMH, 2013).
  • AN occurs predominately in females and is most often found in post-industrialized countries with relatively high per capita incomes. Cultural and geographic norms, risk factors, and peer influences should be taken into consideration. Prevalence rates are highest among those who identify as non-Hispanic and white (Dailey et al.,
    2013; Hudson et al., 2007).

Prevalence

  • Annual prevalence rates are 0.4% to 0.9% for females with a lifetime prevalence rate of up to 0.3% in males
    (APA, 2013; Hudson, Hiripi, Pope, & Kessler, 2007). Female to male ratio of AN is between 4:1 and 10:1 (Hudson et al., 2007; Oudijn, Storosum, Nelis, & Denis, 2013).

Resources:

Identification / Assessment Strategies

Longstanding assessment instruments that measure the symptomology and severity of eating disordered behaviors are available for clinical use. The Eating Attitudes Test and the Eating Disorder Examination Interview represent two commonly used assessments. Specific information about the design, administration, and application of these instruments is provided below.

Eating Attitudes Test (EAT-40© and EAT-26©; Garner and Garfinkel, 1979; Garner, Olmsted, Bohr, & Garfinkel, 1982)
The Eating Attitudes Test (EAT) is a time-tested, widely used screening instrument that has been applied to assess eating disorder risk in clinical and non-clinical settings. The EAT is a self-report measure administered by mental health and educational professionals who seek to determine if an individual should be referred to a specialist for an eating disorder evaluation. The EAT is not designed to provide a diagnosis, but instead identifies behaviors that may be indicative of an eating disorder. The original 40-item assessment (Garner & Garfinkel, 1979) was designed with AN as a primary evaluation target, while the updated 26-item assessment (Garner, Olmsted, Bohr, & Garfinkel, 1982) is designed to be both more efficient and more general in nature.  The test items are rated on a six-point scale in regards to how often the subject engages in specific behaviors. The subjects may answer “always,” “usually,” “often,” “rarely,” “sometimes,” and “never” to each inquiry, and answers are weighted to construct the overall “referral index” score. A total score of 20 or more, or pre-defined thresholds on certain criteria, indicate a need for further assessment. The EAT-26 and EAT-40 tests are copyrighted, but the copyright holders offer use permission at no cost.

Resources:

Eating Disorder Examination Interview (EDE and EDE-Q; Cooper and Fairburn, 1987)
The Eating Disorder Examination Interview (EDE) is a semi-structured, clinician-completed interview that is designed to assess the presence of psychopathologies that are associated with eating disorder diagnoses (Cooper & Fairburn, 1987). The EDE-Q is a questionnaire adapted from the EDE and allows for self-reporting in the same structure as the original. The EDE and EDE-Q are rated through the use of four subscales (restraint, eating concern, shape concern, and weight concern) and provide a global score. Forty-one responses are recorded based on behavioral frequency over a 28-day period. Scores for each item use a 0–6 point scale, with an everyday occurrence scoring a 6, and no occurrences scoring a zero. Point assessments from 1–5 are tallied for responses of “1–5 days,” “6–12 days,” “13–15 days,” “16–22 days,” and “23–27 days,” respectively.

Resource:

Intervention / Treatment Strategies

According to the NIMH (2013), there are three necessary components in the treatment of AN: weight restoration, addressing the psychological sequelae, and reducing maladaptive thoughts/behaviors.  Of primary importance is specific focus on achieving and maintaining a healthy weight range (Hebebrank & Bulik, 2011). Approximately 1/3 of individuals diagnosed with AN receive treatment (Hudson et al., 2007), which can be lengthy and occur over the course of multiple years (Fichter et al., 2006).

Physical health represents a paramount treatment issue as AN causes disturbance to most organ systems (Marzola, Nasser, Hashim, Shih, & Kaye, 2013). Initial inpatient treatment is often recommended; this allows for careful monitoring of physical health (Garber et al., 2013; Leclerc, Turrini, Sherwood, & Katzman, 2013). AN also negatively impacts reproductive health; although no longer a criterion for AN in the DSM-5, amenorrhea remains a negative indicator of overall physical health in females of childbearing age (APA, 2013; Berg & Peterson, 2013; Linna et al., 2013).

Resource:

  • Center for Disease Control BMI calculator: http://www.cdc.gov

Family-Based Treatment (FBT)
Family-based treatment (FBT) is efficacious for children/adolescents with AN (Lock & Le Grange, 2012). Also referred to as the Maudsley approach, FBT is a long duration, outpatient treatment program for youth and their families (Lock & Le Grange, 2012). FBT focuses on the critical inclusion of parents/caregivers in treatment, including their oversight of the youth’s nutritional intake, and takes approximately one year to complete. There are three phases of treatment: (1) weight restoration, (2) transitioning control of eating back to the adolescent, and (3) adolescent issues and termination.  With positive and sustainable treatment results, FBT is often the intervention of choice for children/adolescents with AN (Eisler, Simic, Russell, & Dare, 2007; Kress & Paylo, 2015).

Family Therapy
Including family members in the therapeutic process fosters success, especially with the treatment of AN in children and adolescents (Chavez & Insel, 2007; Linville, Stice, Gau, & O’Neil, 2011). Family therapy assists with impairment in emotional regulation (Racine & Wildes, 2013) and serves as an adjunctive treatment intervention for AN (Ghoch et al., 2013; Goddard et al., 2013). Barriers to address in family therapy include: parental consistency, family time commitment, and application of behavior change in real-world situations such as family mealtime (Linville et al., 2011).

Behavior Therapy
Individuals with AN benefit from behavioral reinforcement systems that reward healthy eating patterns (Lock et al., 2013). Behavioral interventions target adaptive eating and weight restoration with the goal of healthy weight achievement and maintenance (Brown, Mountford & Waller, 2013; Hebebrand & Bulik, 2011). Counselors can target intervention strategies to maximize coping with frequent residual symptoms (Kaye, Klump, Frank, & Strober, 2000), and clients benefit from learning applied behavioral skills in real-life settings (Couturier et al., 2013).

Resources:

  • Marzola E., Nasser, J. A., Hashim, S. A., Shih, P. B., & Kaye, W. H. (2013). Nutritional rehabilitation in anorexia nervosa: Review of the literature and implications for treatment. BMC Psychiatry,13 (290), 1-13. http://www.biomedcentral.com/1471-244X/13/290

Cognitive Behavioral Therapies (CBT)
CBT interventions focus on addressing both cognitive and behavioral components of AN. This includes restructuring of negative cognitive schemas and introduction of thought-stopping techniques to address weight and body image obsessions (Kaye et al., 2000; NIMH, 2013). Individuals with AN can experience functional fixity; cognitive remediation therapy (CRT) may be helpful in addressing this rigidity of thought (Tchanturia, Lloyd, & Lang, 2013). CRT promotes holistic thinking about AN and broadens the treatment approach. Brown et al. (2013) found that, in addition to the establishment of a strong therapeutic alliance, CBT interventions were helpful in assisting with weight gain (see also Stiles-Shields et al., 2013). When exposed to food, individuals with AN experience a negative affective response (Marek, Ben-Porath, Federici, Wisniewski, & Warren, 2013); the technique of exposure and response prevention can be utilized when addressing this and other treatment issues (Brockmeyer & Friederick, 2013).

Enhanced CBT Therapy for Eating Disorders (CBT-E)
A targeted CBT approach, Enhanced CBT Therapy for Eating Disorders (CBT-E) is a treatment intervention developed for broad application across eating disordered behaviors (Fairburn, 2008). CBT-E utilizes individual therapy occurring over the course of four phases and lasting a total of 20 weeks. The first stage (weeks 1–4) includes client participation in treatment plan development, and the second stage (weeks 5–6) is primarily a progress review. The third stage (weeks 7–14) emphasizes cognitive restructuring, which is the main component of the overall treatment. The fourth and final stage (weeks 15–20) targets relapse prevention (Kress & Paylo, 2015).

Resources:

Dialectical Behavior Therapy (DBT)
DBT is a cognitive-behavioral treatment approach that has been successful in addressing the sequelae of AN (and in addressing its comorbidity with anxiety, depressive, and personality disorders). Egan et al. (2013) posit that women with AN have higher rates of anxiety disorders and perfectionism, and that there is a five times higher rate of eating disorders in those with obsessive-compulsive personality disorder (Reas, Ro, Karterud, Hummelen, & Pedersen, 2013).

For individuals with AN, normative eating behaviors need to translate to the real-world environment; DBT’s focus on behavioral change and emotional regulation addresses the complexities of eating disordered behavior (NIMH, 2013).

Resources:

 

REFERENCES

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Berg, K. C., & Peterson, C. B. (2013). Assessment and diagnosis of eating disorders. In L. H. Choate (Ed.). Eating disorders and obesity: A counselor’s guide to prevention and treatment (pp. 91-117). Alexandria, VA: American Counseling Association.

Berg, K. C., Peterson, C. B., & Frazier, P. (2012). Assessment and diagnosis of eating disorders:A guide for professional counselors. Journal of Counseling & Development, 90, 262-269. doi: 10.1002/j.1556-6676.2012.00033.x

 Brockmeyer, T., & Friederick, H-C. (2013). Anxiety-increasing effects of mindful eating exercises may be of benefit—comment on Marek at al. (2013). International Journal of Eating Disorders, 46, 875-876. doi: 10.1002/eat.22182
 
Brown, A., Mountford, V., & Waller, G. (2013). Therapeutic alliance and weight gain during cognitive behavioural therapy for anorexia nervosa. Behaviour Research and Therapy, 51, 216-220. doi: 10.1016/j.brat.2013.01.008

Chavez, M., & Insel, T. (2007). Eating disorders: National Institute of Mental Health’s perspective. American Psychologist, 62, 159-166. doi: 10.1037/0003-066X.62.3.159

Cooper, Z., & Fairburn, C. G. (1987). The Eating Disorder Examination: A semistructured interview for the assessment of the specific psychopathology of eating disorders. International Journal of Eating Disorders, 6, 1–8. doi: 10.1002/1098-108X(198701)6:1<1::AID-EAT2260060102>3.0.CO;2-9

Couturier, J., Kimber, M., Jack, S., Niccols, A., Van Blyderreen, S., & McVey, G. (2013). Understanding the uptake of family-based treatment for adolescents with anorexia nervosa: Therapist perspectives. International Journal of Eating Disorders, 46, 177-188. doi: 10.1002/eat.22049

Crow, S. J., Peterson, C. B., Swanson,  S. A., Raymond, N. C., Specker, S., Eckert, E. D., … Mitchell, J. E. (2009). Increased mortality in bulimia nervosa and other eating disorders. American Journal of Psychiatry, 166, 1342-1346. doi: 10.1176/appi.ajp.2009.09020247

Dailey, S. F., Gill, C. S., Karl, S. L., & Barrio Minton, C. A. (2014). DSM-5 learning companion for counselors. Alexandria, VA: American Counseling Association.

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Eisler, I., Simic, M., Russell, G., & Dare, C. (2007). A randomised controlled treatment trial of two forms of family therapy in adolescent anorexia nervosa: A five-year follow-up. Journal of Child Psychology and Psychiatry, 48, 552-560.

Fairborn, C. G. (2008). Cognitive behavior therapy and eating disorders. New York, NY: Guillford.

Fichter, M. M., Quadflieg, N., & Hedlund, S. (2006). Twelve-year course and outcome predictors of anorexia nervosa. International Journal of Eating Disorders, 39, 87-100. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/16231345

Garber, A., Mauldin, K., Michihata, N., Buckelew, S. M., Shafer, M. A., & Moscicki, A. (2013). Higher calorie diets increase rate of weight gain and shorten hospital stay in hospitalized adolescents with anorexia nervosa. Journal of Adolescent Health, 53, 579-584. doi: 10.1016/j.jadohealth.2013.07.014

Garner, D. M., & Garfinkel, P. E. (1979). The eating attitudes test: An index of the symptoms of anorexia nervosa. Psychological Medicine, 9, 273-279. Retrieved from http://eat-26.com/Docs/Garner-EAT-40%201979.pdf

Garner, D. M., Olmsted, M. P., Bohr, Y., & Garfinkel, P. E. (1982). The Eating Attitudes Test: Psychometric features and clinical correlates. Psychological Medicine, 12, 871-878.  Retrieved  from http://www.ncbi.nlm.nih.gov/ pubmed/6961471

Ghoch, M. E., Caluga, S., Pellegrini, M., Milanese, C., Busacci, M., Battistini, N. C . … Grave, R. D. (2013). Measured physical activity in anorexia nervosa: Features and treatment outcomes. International Journal of Eating Disorders, 46, 709-712. doi: 10.1002/eat.22140.

Goddard, E., Salerno. L., Hibbs, R., Ranker, S., Naumann, U., Arcelus, J. …Treasure, J. (2013). Empirical examination of the interpersonal maintenance model of anorexia nervosa. International Journal of Eating Disorders, 46, 867-874. doi: 10.1002/eat.22172.

Harris, E. C., & Barraclough,  B. (1998). Excess mortality of mental disorders. British Journal of Psychiatry, 173, 11-53. doi:10.1192/bjp173.1.11

Hebebrand, J., & Bulik, C. M. (2011). Critical appraisal of the provisional DSM-5 criteria for anorexia nervosa and an alternative proposal. International Journal of Eating Disorders, 44, 665-678. doi: 10.1002/eat.20875.

Hudson, J. I., Hiripi, E., Pope, H. G., & Kessler, R. C. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 61, 348-358. Retrieved  from http://www.ncbi.nlm.nih.gov/pubmed/16815322

Kaye, W. H., Klump, K. L., Frank, G. K. W., & Strober, M. (2000). Anorexia and bulimia nervosa. Annual Review of Medicine, 41, 299-313. doi: 10.1146/annurev.med.51.1.299

Kress, V. E., & Paylo, M. (2015). Treating those with mental disorders: A comprehensive approach to case conceptualization and treatment. Columbus, OH: Pearson.

Leclerc, A., Turrini, T., Sherwood, K., & Katzman, D. K. (2013). Evaluation of a nutrition rehabilitation protocol in hospitalized adolescents with restrictive eating disorders. Journal of Adolescent Health, 53, 585-589. doi: 10.1016/j.jadohealth.2013.06.001.

Lindberg, L., & Hjem, A. (2003). Risk factors for anorexia nervosa: A national cohort study. International Journal of Eating Disorders, 34, 397-408. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/14566927

Linna, M. S., Raevuori, A., Haukka, J., Suvisaari, J. M., Suokas, J. T., & Gissler, M. (2013). Reproductive health outcomes in eating disorders. International Journal of Eating Disorders, 46, 826-833. doi: 10.1002/eat.22179.

Linville, D., Stice, E., Gau, J., & O’Neil, M. (2011). Predictive effects of mother and peer influences on increase in adolescent eating disorder risk factors and symptoms: A 3-year longitudinal study. International Journal of Eating Disorders 44, 745-751. doi: 10.1002/eat.20907.

Lock, J., Agras, W. S., Le Grange, D., Couturier, J., Safer, C., & Bryson, S. W. (2013). Do end of treatment assessments predict outcome at follow-up in eating disorders? International Journal of Eating Disorders, 46, 771-778. doi: 10.1002/eat.22175.

Lock, J., & Le Grange, D. (2012). Treatment manual for anorexia nervosa: A family-based approach (2nd ed.). New York, NY: Guilford.

Marek, R. J., Ben-Porath, D. D., Federici, A., Wisniewski, L., & Warren, M. (2013). Targeting premeal anxiety in eating disordered clients and normal controls: A preliminary investigation into the use of mindful eating vs. distraction during food exposure. International Journal of Eating Disorders, 46, 582-585. doi: 10.1002/eat.22152.

Marzola, E., Nasser, J. A., Hashim, S. A., Shih, P. B., & Kaye, W. H. (2013). Nutritional rehabilitation in anorexia nervosa: Review of the literature and implications for treatment. BMC Psychiatry, 13 (290), 1-13. Retrieved from: http://www.biomedcentral.com/1471-244X/13/290

National Institute of Mental Health. (2013). Eating disorders. Retrieved from:
http://www.nimh.nih.gov/helath/topics/eating-disorders/index.shtml

Oudijn, M. S., Storosum, J. G., Nelis, E., & Denis, D. (2013). Is deep brain stimulation an option for anorexia nervosa? BMC Psychiatry, 13, 277, 1-10. Retrieved from: http://www.biomedcentral.com/1471-244X/13/277

Racine, S. E., & Wildes, J. E. (2013). Emotion dysregulation and symptoms of anorexia nervosa:
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Reas, D. L., Ro, O., Karterud, S., Hummelen, B., & Pedersen, G. (2013). Eating disorders in a large clinical sample of men and women with personality disorders. International Journal of Eating Disorders, 46, 801-809. doi: 10.1002/eat.22176.

Stiles-Shields, C., Touyz, S., Hay, P., Lacey, H., Crosby, R. D., Reiger, E. … Le Grange, D. (2013). Therapeutic alliance in two treatments for adults with severe and enduring anorexia nervosa. International Journal of Eating Disorders, 46, 783-789. doi: 10.1002/eat.22187.

Tchanturia, K., Lloyd, S., & Lang, K. (2013). Cognitive remediation therapy for anorexia nervosa: Current evidence and future research directions. International Journal of Eating Disorders, 46, 492-495. doi: 10.1002/eat.22106

Published: December 2014
Updated: December 2014

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