by Michael D. Anestis, M.S.
Last week, a new Miss Australia was crowned. Ordinarily, this occasion does not prompt a whirlwind of international attention; however, this year's winner has inspired a surge of controversy due to her physical stature. The 19-year-old beauty queen stands 5 feet 11 inches tall and weighs only 108 pounds. This means her body mass index (BMI), a standard of measurement used to determine the expected weight for an individual given his or her height, is 15.1. To provide some context, the BMI specifies the following:
< 18.5 = underweight
18.5 - 24.9 = normal weight
25 - 29.9 = overweight
30 and above = obese
So, according to the gold standard approach for determining the appropriateness of an individual's weight, Miss Australia was significantly underweight. To take this point even further, the diagnostic criteria for anorexia nervosa (AN) require that an individual weight less than 85% of her expected body weight, which means a BMI of 17.5 or lower. Fortunately, the decreasing weights of models and beauty pageant contestants has prompted concern and action. For instance, fashion week in Madrid now requires that all models maintain a BMI of no lower than 18. Obviously, the low end of this continuum is still dangerously close to the diagnostic criteria for AN, but a start is better than nothing.
All that being said, the purpose of this article is not to belabor the point that standards of beauty presented in the media are often quite unhealthy, but rather to provide a resource on what we know about the treatment of AN. Quite understandably, stories like the crowning of this year's Miss Australia can prompt significant concern on the part of the families and friends of individuals who might be suffering from AN. In this article, I would like to provide readers with a summary of what we know about AN and, in particular, its treatment. The findings, as you will see, are quite different for adolescents versus adults, in that the empirical support for treatment is better for the former than the latter. For a more thorough review of the various treatments for AN, I suggest consulting Guarda (2008), listed on our references page along with all other studies referenced in articles on PBB.
- Refusal to maintain a normal body weight as evidenced by weight less than 85% of that which is expected given age and height.
- Intense fear of gaining weight
- Disturbance in evaluation of weight and shape.
- Amenorrhea -- the cessation of menstrual cycles for three consecutive months in females who have already begun menstruating. Importantly, this is a symptom, not a cause of severe weight loss.
Additionally, the DSM-IV-TR specifies two subtypes of AN: restrictive type and binge eating/purging type. In the former, highly controlled restriction of dietary intake is exhibited in the absence of binge eating and purging. In the latter, binge eating and purging regularly occur. Approximately 50% of individuals who at one point meet criteria for the restricting subtype of AN ultimately transition to either the binge eating/purging subtype of AN or to bulimia nervosa (BN; Strober, Freeman, & Morrell, 1997). If an individual meets nearly all of the criteria for AN but is either slightly above 85% of expected weight threshold or is not experiencing amenorrhea, she will receive a diagnosis of eating disorder not otherwise specified (EDNOS).
For individuals who do not develop a chronic course of AN, recovery typically happens gradually over a period of years and often involves intermittent periods of increased symptomatology (Eckert, Halmi, Marchi, Grove, & Crosby, 1995). Although effective treatment is pivotal for any mental illness, this is particularly true for AN, which has one of the highest early mortality rates of any mental illness (Sullivan, 1995). This high rate of early mortality is, in large part, due to depleted nutritional states and suicide (Crisp, Callender, Halek, & Hsu, 1992). Some have argued that the increased suicide rate in AN is due to the physical fragility caused by the disorder, which might make typically non-lethal attempts more likely to result in completed suicide. Holm-Denoma and colleagues (2008), however, found quite the opposite. Consistent with Joiner's (2005) interpersonal-psychological theory of suicide, which stipulates that individuals acquire the capability to die by suicide through habituation to physical pain and the fear of death, the authors found that individuals with AN tend to use methods of attempt likely to be lethal regardless of nutritional state. This, they argue, reflects a gradual habituation to pain through chronic exposure to the physical discomfort of self-starvation.
Division 12 of the American Psychological Association (APA) has comprised a list of all treatments that have empirical support for DSM-IV-TR mental illnesses. For AN, two such treatments are listed. Family-based treatment (FBT) for adolescents is listed as having strong research support, whereas cognitive behavioral therapy (CBT) is listed as having modest/controversial research support (see the Division 12 website for a better understanding of the meaning of these labels). It is important to note that the empirical support for FBT is limited to adolescents, meaning the findings do not generalize to all age groups. This makes AN unique in that it is the only DSM-IV-TR disorder for which an earlier age of onset is a better prognostic indicator.
FBT, developed at the Maudsley hospital in London, typically involves 20 sessions over 12 months, with three phases during the course of treatment. A shorter format, 10 sessions over 6 months, has been shown to be equally effective to the full version as well (Lock, Agras, Bryson, & Kraemer, 2005). The primary aim of FBT is to help the parents of adolescents suffering from AN to regain control over their child's eating patterns and weight. Importantly, this is an outpatient treatment approach, which can significantly reduce the substantial financial burden of treatment for AN.
In phase 1 of treatment, control over what and when the adolescent eats is given entirely to the parents. Parents are informed that their child's AN is not their fault, but that they must be responsible for certain aspects of the recovery process. Cooperation between parents is highly encouraged. Phase 1 typically lasts approximately six months, with weight restoration being the primary goal. Phase 2 involves a gradual return over eating habits for the adolescent. Eating out with peers and on dates is acceptable during this phase, although care is taken to ensure that this does not initiate a return to maladaptive patterns of food restriction and weight reduction. In phase 3 of treatment, which lasts only four sessions, control over eating is handed over entirely to the adolescent and treatment focuses significantly on issues tangential to eating, such as the relationship between the adolescent and parents (Rhodes, 2003). In a long term study of the effectiveness of FBT in treating female adolescents diagnosed with AN, Paulson-Karlsson, Engstrom, and Nevonen (2009) reported that 75% of the 32 adolescents who received treatment were in full remission at 36 month follow-up, an extremely encouraging finding.
An important consideration when examining the effectiveness of treatments for AN is the ego-syntonic nature of the disorder. Many individuals with AN either do not believe they need treatment or desire only treatments that will help with affective difficulties without requiring weight restoration (Rieger et al., 2000). As such, treatment compliance is an issue and motivation for treatment is quite frequently low. Bewell and Carter (2008) found that motivation for change mediated the relationship between AN severity and treatment outcome. In other words, although a less severe case of AN is more likely to respond to treatment, this is only because individuals with less severe symptomatology are typically more highly motivated to change. An individual who is highly severe but highly motivated to change is more likely to respond to treatment than is a less severe individual who is ambivalent about treatment. This is an important consideration, as it highlights two significant points. First, because the physical danger of severe AN can require involuntary inpatient hospitalization, a substantial number of individuals in treatment are likely to be unmotivated to change and unlikely to initially respond. Second, although at times involuntary stabilization of physical danger can be necessary, forced interventions appear unlikely to produce long term gains and, as such, should be avoided when possible (see our article on treatments that cause harm for additional examples of this point).
If you would like to learn more about the Maudsley model of family-based treatment for anorexia, we recommend the following link, provided to us by Katie Gordon, Ph.D., an assistant professor at North Dakota State University and an expert researcher on eating disorders (http://www.maudsleyparents.org/). The site provides information for parents whose children suffer from eating disorders and was created by the founders of the Maudsley model of FBT. We also recommend the following products, all of which are available through our online store:
- Treatment Manual for Anorexia Nervosa: A Family-Based Approach
- Eating with Your Anorexic: How My Child Recovered Through Family-Based Treatment and Yours Can Too
- Help Your Teenager Beat an Eating Disorder
Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.
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