Anorexia is much harder to treat than previously thought

Stuart Murray, assistant professor of psychiatry at the University of California, San Francisco, has just completed the largest study on anorexia treatments. The results were bleak

Anorexia nervosa is a psychiatric disease that mainly affects young people during their adolescence.

Although anorexia is relatively uncommon and affects approximately 1 percent of the population, it can be lethal. In fact, despite its relatively early onset, anorexia can last several decades in more than half of those affected.

It can lead to many psychiatric and associated medical risk factors, which partly explains why anorexia has the highest mortality rates of any psychiatric disorder.

Those who suffer from anorexia have a great fear of gaining weight and a cruelly distorted self-perception.

As a result, some restrict calorie intake to less than 400 calories per day, which is less than a quarter of what is generally recommended for adolescents.

People with anorexia can quickly become emaciated and lose more than 25 percent of their typical body weight. This rapid loss of weight causes cardiac abnormalities, structural and functional brain alterations, irreparable bone diseases and, in some cases, sudden death.

The effective treatment of anorexia is, therefore, very important.

Stuart Murray, assistant professor of psychiatry at the University of California, San Francisco, has just completed the largest study on anorexia treatments. The results were bleak

Stuart Murray, assistant professor of psychiatry at the University of California, San Francisco, has just completed the largest study on anorexia treatments. The results were bleak

I have specialized in the treatment of anorexia nervosa for 10 years, and my research program funded by the National Institute of Mental Health focuses exclusively on the understanding of the mechanisms of anorexia nervosa, with the aim of reporting precise treatment approaches .

Recently, colleagues and I completed the largest meta-analysis ever done on the results of existing treatments for anorexia. Our analysis revealed major flaws in the way people are currently treated for this disease.

Changing the brain, not the body

We combine the findings of 35 randomized controlled trials between 1980 and 2017, which cumulatively evaluated the results of specialized treatments, such as cognitive behavioral therapy, in more than 2,500 patients with anorexia.

An important aspect of our study was that we examined the results according to the weight and central cognitive symptoms of anorexia, such as the fear of weight gain and the desire for thinness.

This differs from traditional assessments of whether treatments are effective, which have generally focused only on the patient's weight.

It saddens me to say that what we found was grim.

In essence, specialized treatments for anorexia, such as cognitive-behavioral therapy, family-based treatment, and emerging drug treatments, seem to have few advantages over the usual standard control treatment, such as supportive counseling.

In fact, the only advantage of specialized treatments, in relation to the control treatment as usual, was a greater possibility of having a greater weight at the end of the treatment.

No differences were found in body weight between specialized treatments versus controls at follow-up.

In addition, we did not find differences in the central cognitive symptoms of anorexia between specialized treatments versus control treatments at any point.

This means that, even if a treatment helps to regain normal weight, it is common to focus on the thinness and discomfort around the intake, and a relapse into low weight is likely.

Equally important, specialized treatments do not seem to be more tolerable for patients, with comparable rates of patient abandonment to control treatments.

When we analyze the temporal trends within these data over the last four decades, we discover that the results of specialized treatment do not progressively improve over time.

More than weight

These findings are instructive. The notion that our best efforts to advance treatment outcomes over the past four decades have failed to move the needle is a matter of serious concern.

However, an important result of this study lies in giving those of us who study and treat anorexia a better idea of ​​how we can move the needle.

We believe that these findings speak of an urgent need to better understand the neurobiological mechanisms of anorexia.

We can no longer assume that improvements in patient weight should be the ultimate goal of treatment for anorexia, and will confer improvements in cognitive symptoms.

While weight normalization reduces the acute risk of complex medical events, the constant fear of weight gain and food intake probably means future episodes of low weight and starvation.

We have reached a plateau in the treatment of anorexia. Future research efforts should elucidate the precise mechanisms underlying the cognitive symptoms of anorexia, and the alteration of these mechanisms should become the goal of treatment.

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