Eating Disorders Review May/June 2014 Volume 25, Issue 3

Eating Disorders Review
May/June 2014
Volume 25, Issue 3
Scott Crow, Editor-in-Chief
Breaking Down Barriers to Coverage for Eating
Disorders Treatment
Despite widespread awareness of eating disorders, only about a third of those with anorexia nervosa (AN)
and only 6% with bulimia nervosa (BN) receive mental health care (NEDA Statistics). For those who do
manage to get treatment, the cost ranges from $500 to $2,000 per day in the US. A month of inpatient
treatment can easily reach $30,000. The cost of treatment, including therapy and medical monitoring,
can extend to $100,000 or more (NEDA).
Insurance companies use a number of tactics to avoid or minimize the costs of covering eating disorders
treatment. For example, many private employee benefit plans, which cover most Americans and
adolescents, place greater restrictions and limitations on mental illnesses to reduce health care costs.
Some of these restrictions include lower caps on mental health care than on physical health care, limits
on the number of covered therapy sessions, days of residential or inpatient treatment, and dietitian
appointments and lower “life” and annual maximums (Law and Inequality 2014; 31:411).
Some Help from Mental Health Parity Laws
Nearly every state has mental health parity laws, particularly those aimed at coverage for alcoholism and
other chemical dependencies. As a result, some positive changes have occurred in states such as New
Jersey and California. In a well-known California case, the Ninth Circuit Court decided that residential
treatment was medically necessary for eating disorders and therefor [must] be covered under the
California parity law despite an argument from Blue Shield that there is no exact equivalent of residential
treatment for physical illness (Harwick vs. Blue Shield of California. 686F.3d 699, 703 (9th Cir 2012).
The Patient Protection and Affordable Care Act (ACA) was signed into law on March 23, 2010, and its
constitutionality was upheld by the Supreme Court in June 2012. The ACA prohibits insurance companies
from denying coverage to people with preexisting conditions and mandates that individuals purchase
insurance or incur a tax penalty.
But what of eating disorders? The current ACA leaves significant potential treatment gaps for patients
with AN, BN, and feeding and eating disorders not otherwise classified. To attempt to fill those gaps, the
Eating Disorders Coalition advocated for legislative reform through the Federal Response to Eliminate
Eating Disorders Act of 2013, better known as the FREED Act. H.R. 2010. This act, currently in the
Subcommittee on Health, Employment, Labor, and Pensions, would amend the Public Service Act (PHSA)
and would require that “any insurer that provides health coverage for physical illnesses provide coverage
for eating disorders: and require insurers “to follow standards of care as written in the Practice Guidelines
for the Treatment of Eating Disorders by the American Psychiatric Association.” Insurance companies
would be required to cover treatments including residential care, long-term therapy, and dietitians’
appointments. According to the Coalition, the FREED act would provide funding and direction to the
National Institutes of Health for research and surveillance, provide for education and prevention
activities, and improve access to treatment of eating disorders by requiring coverage of eating disorders
be consistent with coverage of medical/surgical benefits.
Under the FREED Act, coverage would be available not only to patients who meet the strict criteria for AN
and BN but also to those with other eating disorders. Thus, patients with binge eating disorder (BED)
would also be eligible for coverage. If passed, the bill would ensure that treatment will be accessible to
low-income Americans by including eating disorders treatment to services already covered by Medicaid.
Eating Disorders Parity
The individual states can require private insurers to cover eating disorders on the same bases as other
health conditions. Beginning this year, mental illness and substance abuse services must be included in
the essential benefits packages sold to individuals and small businesses. Ten states require private
insurers to cover treatment for AN and BN on the same basis as other mental health conditions (CA, CT,
DE, MA, MD, MN, NJ, VA, VT, WA). Eighteen other states do so in a more limited way, in that parity is only
required in certain types of health plans (for example, state employee or group plans), according to the
National Women’s Law Center Health Care Report Card ( .
In the Meantime
While proposed legislation slowly progresses and eating disorders coverage parity gradually spreads to
additional states, two experts offer some guidelines to help reduce the chances of having insurance
coverage denied. According to Lisa Kantor, an attorney with Kantor& Kantor Law, and a well-known
advocate for improved insurance coverage for patients with eating disorders, here are several steps to
take. Before admission for treatment, patients and parents should request a copy of their insurance
policy. One way that a treatment facility can be more proactive during admissions or after a denial of
service is to send in all medical and treatment record to the insurance company on time and before any
utilization review or appeals, and to have a patient’s records in front of them during utilization reviews.
Treatment should be documented according to the American Psychiatric Association’s Clinical Practice
Guidelines. Detailed notes of all conversations should be made and confirmation of all conversations
should be in writing, including recording the name and number of the person with whom they spoke at
the insurance company, the time on the phone, was the call transferred from one department to the
other, and so forth. It’s also important, she notes, to document whether the insurance company has a
qualified doctor conduct the review or if it is reviewed by a claims representative.
Dr. Arnold Andersen, a member of EDR Editorial Board, also has published some excellent guidelines to
follow when coping with difficulties getting coverage (see “Ethical Conflicts in the Care of Anorexia
Nervosa Patients,” in the March-April 2008 EDR ; see archives on this website; also see Principles of
Inpatient Psychiatry, edited by Fred Ovsiew and Richard L. Munich, Wolters-Kluwer/Lippincott Williams &
Wilkins, 2009)
Dr. Andersen suggests that patients read their policies and understand what is covered and what is not,
and stresses that it is also important to know the individual state’s  law. California is a good example.
Coverage is mandated by California Assembly Bill 88, the mental health parity law, which now specifically
includes treatment for patients with AN and BN. Other suggestions include keeping excellent records,
including copies of all correspondence, letters and emails, including times, dates, names of persons
contacted, telephone, fax, and e-mail messages.
Dr. Andersen writes that if treatment is denied, the decision should be appealed by phone and a letter
written immediately to the medical director of the insurance company, stressing that if the patient’s
needs are not satisfied, the state insurance commissioner, the media, or an attorney will be contacted.
Lisa Kantor advises that while any legal action is pursued, it is important for the patient to remain in
Other resources may also be available. Dr. Andersen notes that community mental health agencies have
sliding fees, and medical schools and university centers sometimes provide low-fee clinics staffed by
psychiatric residents in training who are supervised by faculty members. If the treatment center is
funded partly by county, state, or federal funds, the center may be required to make appropriate care
Free clinical trials and research programs can also be found on the Internet. Check the websites of the
National Institute of Mental Health, the Academy of Eating Disorders, the clinic at the New York State
Psychiatric Institute, and the American Academy of Child and Adolescent Psychiatry. Finally, scholarships
may also be available for eating disorder treatment, according to Lisa Kantor (see box).
A few places to check for scholarships
UPDATE: Early Weight Gain and Treatment Outcome
among Teens with Anorexia Nervosa
Early partial symptomatic response can be a very useful predictor of long-term treatment outcome. For
example, studies have shown this pattern with cognitive behavioral therapy for bulimia nervosa. Results
of a collaborative study at Stanford University and the University of Chicago suggest that teens with
anorexia nervosa (AN) treated either with family-based treatment (FBT) or individual adolescent
supportive psychotherapy (AFT) and who show early weight gain are more likely to be in remission at the
end of treatment. Dr. Erin Accurso, from the University of Chicago, reported at the 2014 International
Conference on Eating Disorders in New York City that degree of weight gain quite early in treatment (by
session 3 or 4) predicted remission by the end of treatment. Participants in the study included 121
adolescents with AN who were randomly assigned to receive FBT (n=61) or AFT (n=60). The researchers
gauged treatment response using percent of expected body weight (EBW) and the global score on the
Eating Disorder Examination. The earliest predictor of remission at end of treatment was a gain of 5.8 lb
by session 3 among those receiving FBT and a gain of 7.1 lb by session 4 among those receiving AFT.
Early weight gain did not predict long-term follow-up outcome for either group.
A Novel Inpatient CBT Program for Adolescents
The approach included an ‘open’ inpatient unit.
While inpatient treatment for anorexia nervosa (AN) often successfully restores body weight, too many
patients have relapses after discharge from the treatment unit. The risk of malnutrition and weight loss is
higher among teens than adults, and if weight restoration is unsuccessful, lasting complications may
Dr. Richard Delle Grave and colleagues at Villa Garda Hospital, Garda, Italy, and Warneford Hospital,
Oxford University, Oxford, UK, sought to reduce the relapse rate by modifying their conventional inpatient
treatment program (Front Psychiatry. 2014; February 12). The team replaced the traditional approach
with one based on “enhanced” cognitive behavioral therapy (CBT-E). The enhanced CBT approach is
designed to address some of the key mechanisms that help maintain eating disorders, such as restricting
intake and promoting underweight, life events and mood, and overvaluing shape and weight.
A 13-week program for adolescents
The new approach was used in 27 adolescent patients 13 to 17 years of age who had severe AN. The
teens were treated over 20 weeks (13 weeks in an inpatient setting and 7 weeks while enrolled in a day
treatment program). The patients were assessed before and after treatment, and then 6 and 12 months
later. CBT-E for eating disorders was “adapted to make it suitable both for an inpatient setting and for
adolescents.” The authors described the treatment as CBT-E “immersion” because the CBT-E program is
designed to operate around the clock. Rather than focusing on eating and weight gain, the treatment is
designed to enhance the patient’s sense of control over his or her eating and life. The young patients
undergo individual sessions with a trained clinical psychologist twice a week during the first 4 weeks and
once a week afterward. More intensive support of eating is provided until patients achieve a body mass
index (BMI) of 18.5 kg/m2. CBT-E based group sessions are held 4 times a week and focus on core issues
such as dietary restraint. Group physical exercise sessions are held twice a week to help the patients
restore muscle mass and improve overall fitness.
Two more elements of the inpatient program include a CBT-E-based family module that includes 6
sessions with the psychologist and 2 with a CBT-E trained dietitian that are designed to help families plan
meals at home. Parents also become involved early in treatment: during the first week of therapy,
parents attend a private session where the psychologist and family assess the family environment, and
parents are educated about their child’s eating disorder and elements that may be maintaining the
disorder. The remaining 5 sessions focus on family communication, crisis management, and modification
of the home environment. Weekly group sessions address adolescent topics such as identity, autonomy,
social skills, and coping with puberty.
The authors believe that three particular strategies may help reduce relapse risk. First, the inpatient unit
is “open,” so patients are exposed to stimuli that may provoke the return of eating disorder
psychopathology. Second, possible triggers for relapse are identified and addressed in the individual CBTE sessions. Finally, the parents and significant others work to develop a more positive and stress-free
home environment.
Was the program successful?
Treatment was well accepted by the patients and they responded well to it. The authors reported that
only 1 patient of the 27 in the study did not complete the program. The 26 who did complete treatment
gained a substantial amount of weight—the mean weight gain from admission to discharge was 11.7 kg.
Twenty-five teens (96.2%) achieved a BMI greater than 18.5. The mean global EDE score decreased by
1.7, and 38.5% of the patients had “minimal residual eating disorder psychopathology,” defined as a
global EDE scoreless than 1 standard deviation above community norms.
Follow-up at 6 and 12 months
Follow-up data were available for 81 and 85% of participants are 6 and 12 months. Twenty-two, or nearly
85%, received some outpatient treatment after discharge. Overall, the changes in BMI and eating
disorders cognitions made while the teens were inpatients were well maintained at 6-month and 1-year
follow-ups. The authors speculate that the good outcome could be traced to several factors. First, CBT-E
may have addressed key mechanisms that maintain eating disorder psychopathology, including inclusion
of parents and the open nature of the unit. According to the authors, future refinements of the CBT-E
approach may include more focused forms of inpatient CBT-E that can address key elements that may
interfere with outpatient CBT-E. Dr. Delle Grave and colleagues suggest that after brief inpatient
treatment with this focus, that outpatient CBT-E could then successfully be resumed.
Body Image in Young Adult Men
Two studies trace the effects of cultural differences and
attitudes toward sports doping.
Recent research is challenging an old mindset that body image is more important to women than to men.
Results of some studies indicate that body image concerns are equally important among adolescent boys
and girls (Inquiries Sport Phys Edu Psychol Rev. 2013; 11:65), and around two-thirds of adolescent boys
are dissatisfied with their bodies. For young adult males, body image concerns can be equally divided
between losing weight and a desire to gain muscle mass (Int J Behav Nutr Phys Act. 2011; 8:119).
Does country matter?
Cross-cultural differences among young adult males may affect the incidence of body image disorders.
When an international study led by Debra Franko, PhD, of Northeastern University, Boston, examined
adherence to masculine norms, body image, and attitudes toward muscularity, leanness and thinness, the
results revealed significant cultural differences.
As reported at the International Conference on Eating Disorders in New York City this past March, a
survey of more than 500 males showed that males from Australia and the US scored somewhat similarly
on body image concern measures, including the Conformity to Masculine Norms Inventory, the Drive for
Muscularity Scale, the Drive for Leanness/Thinness scales, and the Body Esteem Scale. Males from the
United Kingdoms scored lower than those in Australia and the US. Swedish men had the lowest scores on
all the body image concern measures.
Leniency in sports doping rules and increased body image concerns
In a second study, two Australian researchers uncovered a connection between body dissatisfaction,
weight change behaviors among adolescent males, and supplement use in sports programs that have
more lenient attitudes toward doping. Drs. Zali Yager and Jennifer O’Dea of Victoria University,
Melbourne, Australia, recently reported the results of their study of 1,148 male adolescents 11 to 21
years of age (J Int Soc Sports Nutr. 2014; 11:13). Drs. Yager and O’Dea’s study was funded by the
Australian government and the Australian Anti-doping Research Program.
Young men with higher body dissatisfaction scores were more open to the use of doping in sports.
Current weight loss efforts and consumption of energy drinks and vitamin/mineral supplements were also
correlated with support for doping in sports. Young men who were weight lifters and those who regularly
used powdered protein drinks were not as supportive of doping
Drs. Yager and O’Dea suggest that using a combined prevention approach targeting both body
dissatisfaction and sports doping could have a beneficial effect on the physical and psychological health of
young males.
New Therapy Targets Neuropsychological Functioning
Cognitive remediation therapy targets severe or lasting
eating disorders.
A new therapy based on neuropsychological functioning has recently been tested in patients with severe
or lasting eating disorders. Scientists at the Center for Eating Disorders Ursala, Leidschendam, The
Netherlands, treated 82 patients who were randomly assigned either to cognitive remediation therapy
(CRT) plus intensive treatment as usual or to treatment as usual alone (Psychother Psychosom. 2014;
CRT is a behavioral treatment that uses drill and practice, and compensatory and adaptive strategies to
improve targeted cognitive areas like memory, attention, and problem-solving. Unlike the much better
known cognitive behavior therapy (CBT), which teaches patients to think through emotionally challenging
problems, CRT helps improve the underlying neuropsychological functions that aid thinking, attention,
memory, planning, organization, and abstract thinking. For example, someone with attention and
memory problems may have difficulty following directions from their boss, or may lose track of important
information provided by their friends and family. Other persons who have difficulty being organized and
prioritizing information may find it hard to manage independent living or going to school. CRT
remediation is intended to help people who have experienced a decline in their cognitive skills, or who
were unable to fully develop their skills because of illness. CRT often involves the use of a computer to
provide exercises to improve neuropsychological skills.
Applying CRT to eating disorders
Dr. A.E. Dingemans reported on 82 patients with severe eating disorders who randomly received CRT plus
treatment as usual (41 patients) or treatment as usual (41 patients). Cognitive measures (set-shifting
and central coherence), eating disorder pathology, general psychopathology, motivation, quality of life,
and self-esteem were all measured.
Participants were assessed at baseline, after 6 weeks of treatment, and finally 6 months after treatment
ended. Those who had the combination therapy had significantly improved quality of life at the end of
treatment, as well as fewer eating disorder symptoms, compared to those who had received treatment as
usual. Patients with poor set-shifting abilities prior to treatment benefited more from CRT than did those
without set-shifting deficits and their quality of life was also higher.
Oxytocin Studied as a Possible Treatment for Anorexia
Early inroads to therapy with the so-called love
Results of a series of pilot studies led by Drs. Janet Treasure, of King’s College, London, and Youl-Ri Kim,
of Seoul’s Paik Hospital, are beginning to tease out the potential roles of oxytocin, sometimes called “the
love hormone,” and its receptor to see if the hormone might provide a new treatment for anorexia
nervosa (Plos One. March 2014, e90721).
Why oxytocin?
Oxytocin (from the Greek, “quick birth”) is a hormone produced by the hypothalamus that is stored by
and released from the pituitary gland. Oxytocin is released naturally during social recognition, bonding,
sex, childbirth, and breastfeeding, and in its synthetic form has been tested as a treatment for numerous
psychiatric disorders. Because it is digested in the gastrointestinal tract when taken orally, oxytocin is
usually administered as a nasal spray.
Problems in social and emotional development have been linked to the oxytocin systems, and
abnormalities in the oxytocin receptor gene have been linked to empathy, trust, and maternal behavior,
stress reduction, anxiety and depression. As Dr. Kim and his colleagues have noted, patients with AN
experience a range of social difficulties that sometimes occur before the onset of AN. The researchers
theorize that oxytocin function might explain some of these changes. Other authors have reported that
patients with AN have low cerebrospinal fluid oxytocin levels, and that greater abnormalities are reported
as eating disorders symptoms worsen.
The authors designed two studies to chart the effects of oxytocin. In the first double-blind, placebocontrolled study, 31 women with AN and 33 healthy controls were given either a dose of oxytocin,
delivered in a nasal spray, or a placebo. The study participants then viewed sequences of images relating
to food (high- and low-calorie foods), body shape (fat and thin), and weight, as shown on scales. When
the images flashed across the screen, the researchers measured how quickly the women identified the
individual images. The women also completed several self-report questionnaires, including the Eating
Disorder Examination Questionnaire (EDE-Q). After testing was complete, the women were offered apple
juice and asked to drink as much as they could. Receiving oxytocin diminished the degree to which
participants focused on eating and shape stimuli, even though the intake of juice was unchanged.
Oxytocin may moderate social difficulties
In the second study, which included the same group of women, a similar test was done before and after
oxytocin or placebo was given. However, this time the researchers observed the women’s reactions to
facial expressions, such as anger, disgust, or happiness. After receiving a dose of oxytocin, patients with
AN were less likely to focus on the expressions of ‘disgust’ and were less likely to avoid angry faces;
instead, they became more vigilant to the angry faces.
In a separate survey, the authors also examined the methylation status of the oxytocin receptor gene
(OXTR) in patients with AN (PLoS One 9:e88673 doi:10.1371). Methylation is a common epigenetic
mechanism that diminishes gene expression. The authors studied average methylation levels between the
two groups of women (15 with AN and 46 healthy controls). The researchers found that individuals with
AN had methylation at 5 of 6 sites within the OXTR gene. Normal healthy women had low or intermediate
levels of methylation. The authors suggest that epigenetic mechanisms in the OXTR gene may play a role
in the pathophysiology of AN.
Tracing Growth and Risks among Children of Mothers
with Eating Disorders
British researchers track potential associations between
a mother’s eating disorder and her child’s growth.
In the first large study of its type, a team of British researchers have analyzed the long-term effects of
maternal eating disorders upon their children’s growth patterns. The team not only found that the
children’s growth trajectories were affected by their mothers’ eating disorders, but also that such children
themselves may be at increased risk of developing disordered eating patterns (BMJ Open. April 3, 2014).
Dr. Abigail Easter and colleagues at Kings College and the University of Bristol investigated growth and
body mass index from birth until 10 years of age in children of women with and without lifetime eating
disorders. Associations of growth with general psychopathology and to gender were then evaluated. The
team used data from the Avon Longitudinal Study of Parents and Children (ALSPAC), a large, longitudinal
birth cohort study (Int J Epidemiol. 2012; 42:111). At 12 weeks’ gestation, mothers were asked if they
had a history of psychiatric problems, including AN, BN and other disorders.
Data were available for 10,190 children (4962 girls, 5228 boys); 1.6% of mothers reported a history of
anorexia nervosa (AN),1.6% reported a history of bulimia nervosa (BN), 0.7% reported a history of AN
and BN, and 9% reported histories of other types of psychiatric disorders. Pre-pregnancy body mass
indexes (BMI, kg/m2) of 21.3 and 21.5, respectively, for women with AN and AN plus BN were lower than
those of women in the control group.
Growth patterns were affected by type of disorder and gender
Male children of women with BN were taller than control group children, while male children of women
with a history of AN and BN and female children of women with AN were shorter. Female children of
women with AN had a lower mean BMI, -0.35 kg/m2 at 2 years of age, compared with the control
children, but did not differ by age 10.
While some prior studies have suggested that children of women with BN may be at risk of becoming
overweight or obese (J Pediatr. 2009; 154:55), in this study higher weight was observed for male
children in all maternal ED diagnoses. Conversely, female children of women with AN grew more slowly in
early childhood.
The study produced several new findings about growth patterns of children of mothers with eating
disorders. Specifically, female children of women with AN had an increased risk of reduced growth during
early childhood, while the risk of more rapid growth was more apparent in male children of mothers with
eating disorders. With the worldwide rise in obesity, and the fact that early childhood growth has been
found to predict weight gain in adolescence and adulthood, the authors stressed the importance of
associations between maternal eating disorders and their children’s growth patterns. The authors
stressed the potential importance of carefully monitoring growth of children of mothers with eating
disorders. They also suggest that a better understanding of what causes the observed growth differences
may help in better understanding obesity.
Exploring Disordered Eating During Early Adolescence
A large study underscores the importance of early
identification and prevention.
Early adolescence is a time of major changes and transitions. The Avon Longitudinal Study of Parents and
Children (ALSPAC) is a population-based study that follows 14,541 women and their children, beginning
at the child’s birth. This study recently provided helpful information on the frequency and patterns of
eating disorder symptoms in 13-year-old girls and boys. The results underscore the importance of
identifying disordered eating early, to help prevent obesity and eating disorders.
Drs. Nadia Micali, Janet Treasure, and colleagues at University College, the London School of Hygiene and
Tropical Medicine, and King’s College, London, mailed questionnaires to the parents of 10,135 ALSPAC
participants with children who were then 13 years of age and 479 children who were enrolled in a second
phase of the study (J Adolesc Health. 2014; 54:574). The researchers sought information on disordered
eating behavior and cognitions, such as fear of gaining weight and evidence of distress about weight and
shape. They also looked for patterns of avoidance of fattening foods, food restriction, excess exercising
for weight loss, binge eating and purging.
Parents provided data on binge eating by their children, and the teens were asked how eating patterns
and concerns about weight and shape had interfered with getting along with other family members,
making and keeping friends, and learning at school. Parents also filled out a separate questionnaire for all
other mental health disorders. All children still enrolled in the study were re-evaluated when they reached
15 years of age.
Differences by gender emerged at age 13
The sample was comprised of 49.0% boys and 50.1% girls, and the participants were similar on all
sociodemographic and childhood characteristics, with the exception of slightly higher birth weights for
boys, which was expected. DSM-IV/ICD-10 emotional disorders at age 13 were similar between the sexes
(2.0% vs. 1.9%) but DSM-IV/ICD behavioral disorders were more common among boys than among girls
(4.0% vs 2.9%, respectively).
In the case of eating disorder behavior and cognitions, however, things were quite different. By 13 years
of age, 63.2% of the girls were afraid of gaining weight or “getting fat” and 11.5% were extremely afraid
or terrified of gaining weight or becoming fat. Fewer than 5% of the boys expressed such concerns. A
significant difference was also seen in food restriction, where girls were more than twice as likely as boys
to restrict their food intake. More boys than girls were using more intensive exercise to lose weight.
Purging and binge eating were rare in both girls and boys.
At age 15, binge eating or overeating were associated with impairment at school and home for the girls.
Among boys, binge eating or overeating was similarly associated with impairment but also with burden
on their parents. At age 15, binge eating/overeating among the girls was strongly associated with a
higher body mass index (BMI, or kg/m2), and contributed to an expected .24 increase in BMI z-scores A
similarly strong association with bingeing/overeating and increased BMI z-scores was reported among
boys. Food restriction predicted lower BMIs by age 15. Binge eating/overeating was associated with
emotional and behavioral disorders across genders.
These results emphasize the importance of disordered eating behaviors in early adolescence for later
disordered eating, overweight, and obesity.
BOOK REVIEW: Food and Addiction, a Comprehensive
(Kelly D. Brownell and Mark S. Gold, Eds. Oxford University Press, 2014; $55.)
The interface between food intake, weight, eating behavior, and addiction has been a topic of increasing
interest in recent years. For example, there was some consideration given to including obesity in the
DSM-5, with proponents of such inclusion in part arguing for an addiction model. Twelve-step group
approaches to earning disorder and obesity treatment have been tried, and in some areas are quite
popular. Recently there has been increasing interest in the role of the concept of reward in disordered
eating behavior; and much of this research is focused not only on the consumption food, but also on the
consumption of drugs. Thus, the interface of food and addiction is currently quite topical. Still,
discrepancies and significant uncertainties remain in this area. For example, there is real controversy
about the idea that some foods could be addictive. In addition, the model of abstinence holds sway in the
field of substance use, but such a model is not readily applicable to food intake.
A new volume, Food and Addiction, a Comprehensive Handbook edited by Drs. Kelly D. Brownell and
Mark S. Gold, is a very useful contribution to the literature in this area. The book covers a wide scope of
topics related to this field. Sections examine the neurobiology of addiction, regulation of eating
behaviors, and the interface of food intake and addiction. Thereafter, the clinical, public health, and legal
implications of this literature are considered. The book contains contributions from leaders in the field.
Coverage is concise, thoughtful, and authoritative. One particularly appealing aspect of the book is that
the chapters are of very manageable length (66 chapters in about 450 pages). This affords the reader the
ability to pick and choose topics of particular interest, which can be easily accessed; alternatively, the
book taken as a whole provides a broad and thorough view of this area.
Regardless of whether or not one considers food intake to be an addictive behavior, the interface between
addiction and food is one that arises frequently, and as such this book is of real value to the field.
— SC
Outpatient Approaches for Anorexia Nervosa
Selected patients were successfully treated as
Anorexia nervosa (AN) is still the most deadly psychiatric disease, with mortality rates reaching 20% in
some studies. Adult women with AN that is not too severe can be successfully treated on an outpatient
basis, according to early results from a large-scale German trial. The Anorexia Nervosa Treatment of
Outpatients (ANTOP), directed by Professors Wolfgang Herzog and Stephan Zipfel (Lancet. 2014;
3843:127), compared new outpatient approaches involving manual-based approaches with optimized
treatment as usual.
The randomized, controlled, efficacy trial of adults included patients from 10 university hospitals in
Germany; 242 women with AN were randomized to 10 months of one of three treatments: (1) focal
psychodynamic therapy (80 patients), (2) enhanced cognitive behavioral therapy (80 patients), or (3)
optimized treatment as usual (82 patients), including outpatient psychotherapy and structured care by a
family physician.
Focal psychodynamic therapy addressed the associations of interpersonal relationships, and the working
relationship of the therapist and patient (therapeutic alliance) was emphasized. The form of CBT-E
followed Fairburn’s model (Psychiatr Clin North Am. 2010; 33:611) and used aspects of both the focused
and broad versions; regular eating and weight gain were emphasized. In addition, these patients were
assigned “homework” by the therapists. The final approach, optimized treatment as usual, was provided
by experienced psychotherapists selected by the patients themselves. The patients’ family physicians
were also included in the treatment process. Participants in the optimized treatment as usual group
visited their respective study centers 5 times during the study.
The main outcome was weight gain, measured as increased body mass index (BMI, or kg/m2) at the end
of the 10 months of treatment. Therapists were extensively trained and closely supervised. The women in
the focal psychodynamic therapy and CBT groups had 40 outpatient individual therapy sessions during
the 10 months of the study, and all were followed for 12 months after treatment ended.
Patients in all three treatment groups had significant weight gains at the end of treatment, and again at
the end of follow-up. At the end of treatment and follow-up, their BMIs had increased an average of 1.4
BMI points, or the equivalent of 3.8 kg (8.3 lb).
According to the authors, optimized treatment as usual, combining psychotherapy and structured care
from a family doctor, should be regarded as solid baseline treatment for adult outpatients with AN. Focal
psychodynamic therapy was advantageous in terms of recovery at 12-month follow-up, and enhanced
CBT therapy was more effective than the other approaches with respect to speed of weight gain and
improvements in eating disorder psychopathology. Longer-term outcome data will be helpful to adapt and
improve these novel manual-based treatment methods.
Q & A: An Anorexic Patient Driven to Exercise
Q. I know it is not unusual for patients with anorexia nervosa to use exercise to maintain and increase
their weight loss. However, one of my patients, a 22-year-old college student, seems particularly
obsessed with exercising. Has any new research looked into this problem? (DB, Portland)
A. The problem of excessive exercise in these patients is always a perplexing and challenging problem.
Several recent studies have investigated an underlying drive for activity (DFA) or driven exercise (DE)
that may underlie hyperactivity and increased physical activity.
Dr. L. Sternheim and colleagues at Altrech Eating Disorders Rintveld, The Netherlands, investigated DFA
levels in 240 female patients with AN to see if there was any relation between DFA and severity of the
disease (In J Eat Disord. 2014 Mar 29. Doi:10.10002/eat.22272[Epub ahead of print]. They also looked
at the effects of one aspect of negative affect (anxiety) on DFA rates. Higher DFA was correlated with
EDE scores and with anxiety. The authors believe that the results suggest DFA could be considered a core
feature in AN.
In a second study, Drs. C. Stiles-Shields and researchers at Northwestern University’s Feinberg School of
Medicine and The University of Chicago examined DE in adolescents with bulimia nervosa (BN) and AN
(Int J Eat Disord. 2014 Apr 11. doi: 10.1002/eat.22281 [Epub ahead of print].
The study group included 201 teens with eating disorders (80 with BN and 121 with AN) who were being
treated at two outpatient specialty clinics. Levels of DE were measured at baseline and correlated with
the outcome of treatment.
DE was common (66.3% of adolescents with BN and 23.1% of adolescents with AN). DE predicted worse
outcomes for AN but not BN. Thus, DE appears to be common among adolescents with eating disorders
and may influence outcomes in those with AN.
One challenge in treating people with driven exercise and AN is anticipating their true energy needs. It is
well known that restriction can suppress resting energy expenditure. Does driven exercise significantly
increase energy expenditure (and thus caloric needs for weight restoration)? Zipfel and colleagues
(Lancet. 2014; 3843: 217) suggest that high levels of exercise do significantly increase total daily energy
The authors suggest that clinicians assess the amount of exercise with a single question from the Eating
Disorder Inventory: “What percentage of your exercise is aimed at controlling your weight?”
— SC
Reprinted from: Eating Disorders Review