Editorial The Treatment of Eating Disorders JAMES
E.
MITCHELL, M.D.
Received August 14, 1989; accepted September 14, 1989. Address reprint requests to Dr. Mitchell, DepanmentofPsychiatry, Box 393, University of Minnesota Hospital, Harvard Street at East River Road, Minneapolis, MN
55455. Copyright © 1990 The Academy of Psychosomatic Medicine. VOLUME 31 • NUMBER I • WINTER 1990
DUring the last decade, the literature on the treatment of anorexia nervosa and bulimia nervosa has changed. While once composed primarily ofarticles on theory and anecdotal reports, it now includes an ever-larger number of reports of controlledtreatment trials and large-scale, long-term follow-up studies. This literature is large and diverse and cannot be reviewed in depth here. However, after examining this literature, we can tentatively draw several broad conclusions. First, anorexia nervosa and bulimia nervosa are certainly treatable in the short run. In particular, clinicians can anticipate considerable success in getting low-weight anorexic patients to gain l - 3 and in getting normal-weight bulimic individuals to interrupt their binge-eating and purging cycle,4--7 although neither is easily accomplished. Controlled studies also suggest that both pharmacotherapy and psychotherapy can have a significant impact on these disorders. For example, when treating patients with anorexia nervosa, 8the serotonin antagonist cyproheptadine can improve both the rate of weight gain and the patient's mood, and a variety of heterocyclic antidepressants will suppress core symptoms of bulimia in individuals with bulimia nervosa.9-11 Psychotherapy approaches, particularly those employing cognitive-behavior techniques, can also be very powerful in suppressing bulimic symptoms.6.12.13 The second broad conclusion is less reassuring. The longterm outcome for anorexia nervosa is far from good, and many patients continue to struggle with the disorder for years. 14 The morbidity and mortality for this disorder are probably as high or higher than for any other psychiatric illness. We know much less about the long-term outcome of bulimia nervosa, but the results to date are more encouraging than for anorexia, although bulimic patients are still at a substantial risk of relapse. 15 Therefore, short-term improvement does not necessarily translate into lasting change for either disorder. Third, anorexia nervosa and bulimia nervosa have become more common in recent decades, although not all data support this view. I 6-18 Many attribute this increase to our society's preoccupation with thinness and the particular emphasis placed on slimness as a model of attractiveness. 19 Thus, eating disorders are unusual and unique among psychiatric disorders in that to a large extent, they appear to be culturally determined. When considering the implications of these conclusions, we can discern several areas that will receive increasing research attention over the next decade. Short-term treatment studies need to continue, and much remains to be done. Research has shown that we can treat these conditions, but the important logistical and content variables ofeffective treatment have yet to be delineated. These factors will be identified through dismantling studies, in which various components of
Editorial
therapy are applied in different combinations. Several have already begun. However, I think we must also focus on three separate but related areas that may well become increasingly important to research: what happens before treatment, what happens physiologically during treatment, and what happens after treatment. Events Before Treatment The cultural factors in the development of eating disorders cannot be ignored. 19 The role that culture plays in these disorders suggests that their primary prevention may be possible and that considerable resources should be devoted to the identification of risk factors and to preventive intervention studies in individuals at high risk. This will be difficult, time-consuming, and expensive research, but I believe it should be pursued. Physiological Changes During Treatment Clinically we know that it is possible using a variety of paradigms, most commonly behavioral contingencies, to get patients with anorexia nervosa to gain weight, and using various pharmacological or psychotherapy approaches, to get patients with bulimia nervosa to interrupt their bulimic symptoms. However, we have yet to fully apply the growing medical knowledge on nutritional assessment and refeeding that has been generated primarily in the internal medicine and surgery literature to these disorders. Researchers in eating disorders are only now beginning to examine such variables as resting energy expenditure in patients with eating disorders, and many important questions remain. What is the optimal rate of weight gain for patients with anorexia nervosa? How should the macronutrient content of their diet be structured so that they develop the right proportions of lean body mass and fat? What is the impact of fluid flux between compartments during refeeding? Should phosphate supplementation be used routinely to avoid hypophosphatemia? These arejust a few ofmany physiological questions that need to be addressed, in collaboration with our colleagues in other specialties. Events Following Treatment We know we can get patients to gain weight, but how do we get them to keep the weight on and not relapse? We know we can get patients to interrupt their bulimic behavior, but how do we prevent them from going back to the behaviors after treatment? Considerable attention needs to be devoted to main2
PSYCHOSOMATICS
Editorial
tenance strategies and relapse prevention in both disorders. We must focus not simply on eating and weight issues but also on prevention or amelioration of adverse psychosocial sequelae resulting from these disorders. Again, such studies will be expensive, time consuming, and difficult, but the available follow-up studies strongly suggest that the long-term outcome of these disorders must be improved.
References
I. Morgan HG. Purgold J. Wolbourne J: Management and outcome in anorexia nervosa: a standardized prognosis study. Br J Psychiatry 143:282287.1983 2. Silverman J: Anorexia nervosa: clinical observations in a successful treatment program. J Pediatr 84:68-73. 1974 3. Halmi KA: Treatment of anorexia nervosa.J Adolesc Health Care 4:47-50. 1983 4. Fairburn CG: The management of bulimia nervosa. J Psychiatr Res 19:465-472.1985 5. Fairburn CG. Kirk J. O'Connor M. et a1: A comparison oftwo psychological treatments for bulimia nervosa. Behav Res Ther 24:629-643. 1986 6. Lacey JH: Bulimia nervosa. binge-eating. and psychogenic vomiting: a controlled-treatment study and long-term outcome. Br Med J 286:16091613.1983 7. Lee NL. Rush AJ: Cognitive-behavioral group therapy for bulimia.lnternational Journal ofEating Disorders 5:5~ 15. 1986 8. Halmi KA. Eckert E. LaDu TJ. et al: Treatmem efficacy of cyproheptadine and amitriptyline. Arch Gen Psychiatry 43: 177-181. 1986 9. Pope HG Jr. Hudson 11. Jonas JM. et a1: Bulimia treated with imipramine: a placebo-controlled. double-blind study. Am J Psychiatry 140:554-558. 1983 10. Hughes PL. Wells LA. Cunningham CJ. et al: Treating bulimia with desipramine. Arch Gen Psychiatry 43: 182-186. 1986 II. Walsh BT. Stewart 1M. Roose SP. et al: Treatment of bulimia with phenelzine: a double-blind. placebo-controlled study. Arch Gen Psychiatry 41:1105-1109.1984 12. Kirkley BG. Schneider JA. Agras WS. et a1: Comparison of two group treatments for bulimia. J Consult Clin PsychoI53:43-48. 1985 13. Freeman C. Sinclair F. Turnbull J. et a1: Psychotherapy for bulimia: a controlled study. J Psychiatr Res 19:473-478. 1985 14. TheanderS: Outcome and prognosis ofanorexia nervosa and bulimia: some results of previous investigations. compared with those of a Swedish long-term study. J Psychiatr Res 19:493-508. 1985 15. Mitchell JE. Pyle RL. Hatsukami O. et al: A two- to five-year follow-up study of patients treated for bulimia. International Journal of Eating Disorders 8:157-165. 1988 16. Theander S: Anorexia nervosa: a psychiatric investigation of 94 female patients. Acta Psychiatrica Scand 46: 1-194. 1970 17. Jones OJ. Fox MM. Babigian HM. et a1: Epidemiology of anorexia nervosa in Monroe County. New York: 1960-1976. Psychosom Med 42:551-558. 1980 18. Szmukler 11: The epidemiology of anorexia nervosa and bulimia. J Psychiatr Res 19:143-153. 1985 19. Gamer OM. Garfinkel PE. Olmsted MP: An overview of sociocultural factors in the development of anorexia nervosa. in Anorexia Nervosa: Recent Developments in Research. New York. Alan R Liss. 1983. pp 65-82
VOLUME 3\· NUMBER \. WINTER 1990
3
E.
MITCHELL, M.D.
Received August 14, 1989; accepted September 14, 1989. Address reprint requests to Dr. Mitchell, DepanmentofPsychiatry, Box 393, University of Minnesota Hospital, Harvard Street at East River Road, Minneapolis, MN
55455. Copyright © 1990 The Academy of Psychosomatic Medicine. VOLUME 31 • NUMBER I • WINTER 1990
DUring the last decade, the literature on the treatment of anorexia nervosa and bulimia nervosa has changed. While once composed primarily ofarticles on theory and anecdotal reports, it now includes an ever-larger number of reports of controlledtreatment trials and large-scale, long-term follow-up studies. This literature is large and diverse and cannot be reviewed in depth here. However, after examining this literature, we can tentatively draw several broad conclusions. First, anorexia nervosa and bulimia nervosa are certainly treatable in the short run. In particular, clinicians can anticipate considerable success in getting low-weight anorexic patients to gain l - 3 and in getting normal-weight bulimic individuals to interrupt their binge-eating and purging cycle,4--7 although neither is easily accomplished. Controlled studies also suggest that both pharmacotherapy and psychotherapy can have a significant impact on these disorders. For example, when treating patients with anorexia nervosa, 8the serotonin antagonist cyproheptadine can improve both the rate of weight gain and the patient's mood, and a variety of heterocyclic antidepressants will suppress core symptoms of bulimia in individuals with bulimia nervosa.9-11 Psychotherapy approaches, particularly those employing cognitive-behavior techniques, can also be very powerful in suppressing bulimic symptoms.6.12.13 The second broad conclusion is less reassuring. The longterm outcome for anorexia nervosa is far from good, and many patients continue to struggle with the disorder for years. 14 The morbidity and mortality for this disorder are probably as high or higher than for any other psychiatric illness. We know much less about the long-term outcome of bulimia nervosa, but the results to date are more encouraging than for anorexia, although bulimic patients are still at a substantial risk of relapse. 15 Therefore, short-term improvement does not necessarily translate into lasting change for either disorder. Third, anorexia nervosa and bulimia nervosa have become more common in recent decades, although not all data support this view. I 6-18 Many attribute this increase to our society's preoccupation with thinness and the particular emphasis placed on slimness as a model of attractiveness. 19 Thus, eating disorders are unusual and unique among psychiatric disorders in that to a large extent, they appear to be culturally determined. When considering the implications of these conclusions, we can discern several areas that will receive increasing research attention over the next decade. Short-term treatment studies need to continue, and much remains to be done. Research has shown that we can treat these conditions, but the important logistical and content variables ofeffective treatment have yet to be delineated. These factors will be identified through dismantling studies, in which various components of
Editorial
therapy are applied in different combinations. Several have already begun. However, I think we must also focus on three separate but related areas that may well become increasingly important to research: what happens before treatment, what happens physiologically during treatment, and what happens after treatment. Events Before Treatment The cultural factors in the development of eating disorders cannot be ignored. 19 The role that culture plays in these disorders suggests that their primary prevention may be possible and that considerable resources should be devoted to the identification of risk factors and to preventive intervention studies in individuals at high risk. This will be difficult, time-consuming, and expensive research, but I believe it should be pursued. Physiological Changes During Treatment Clinically we know that it is possible using a variety of paradigms, most commonly behavioral contingencies, to get patients with anorexia nervosa to gain weight, and using various pharmacological or psychotherapy approaches, to get patients with bulimia nervosa to interrupt their bulimic symptoms. However, we have yet to fully apply the growing medical knowledge on nutritional assessment and refeeding that has been generated primarily in the internal medicine and surgery literature to these disorders. Researchers in eating disorders are only now beginning to examine such variables as resting energy expenditure in patients with eating disorders, and many important questions remain. What is the optimal rate of weight gain for patients with anorexia nervosa? How should the macronutrient content of their diet be structured so that they develop the right proportions of lean body mass and fat? What is the impact of fluid flux between compartments during refeeding? Should phosphate supplementation be used routinely to avoid hypophosphatemia? These arejust a few ofmany physiological questions that need to be addressed, in collaboration with our colleagues in other specialties. Events Following Treatment We know we can get patients to gain weight, but how do we get them to keep the weight on and not relapse? We know we can get patients to interrupt their bulimic behavior, but how do we prevent them from going back to the behaviors after treatment? Considerable attention needs to be devoted to main2
PSYCHOSOMATICS
Editorial
tenance strategies and relapse prevention in both disorders. We must focus not simply on eating and weight issues but also on prevention or amelioration of adverse psychosocial sequelae resulting from these disorders. Again, such studies will be expensive, time consuming, and difficult, but the available follow-up studies strongly suggest that the long-term outcome of these disorders must be improved.
References
I. Morgan HG. Purgold J. Wolbourne J: Management and outcome in anorexia nervosa: a standardized prognosis study. Br J Psychiatry 143:282287.1983 2. Silverman J: Anorexia nervosa: clinical observations in a successful treatment program. J Pediatr 84:68-73. 1974 3. Halmi KA: Treatment of anorexia nervosa.J Adolesc Health Care 4:47-50. 1983 4. Fairburn CG: The management of bulimia nervosa. J Psychiatr Res 19:465-472.1985 5. Fairburn CG. Kirk J. O'Connor M. et a1: A comparison oftwo psychological treatments for bulimia nervosa. Behav Res Ther 24:629-643. 1986 6. Lacey JH: Bulimia nervosa. binge-eating. and psychogenic vomiting: a controlled-treatment study and long-term outcome. Br Med J 286:16091613.1983 7. Lee NL. Rush AJ: Cognitive-behavioral group therapy for bulimia.lnternational Journal ofEating Disorders 5:5~ 15. 1986 8. Halmi KA. Eckert E. LaDu TJ. et al: Treatmem efficacy of cyproheptadine and amitriptyline. Arch Gen Psychiatry 43: 177-181. 1986 9. Pope HG Jr. Hudson 11. Jonas JM. et a1: Bulimia treated with imipramine: a placebo-controlled. double-blind study. Am J Psychiatry 140:554-558. 1983 10. Hughes PL. Wells LA. Cunningham CJ. et al: Treating bulimia with desipramine. Arch Gen Psychiatry 43: 182-186. 1986 II. Walsh BT. Stewart 1M. Roose SP. et al: Treatment of bulimia with phenelzine: a double-blind. placebo-controlled study. Arch Gen Psychiatry 41:1105-1109.1984 12. Kirkley BG. Schneider JA. Agras WS. et a1: Comparison of two group treatments for bulimia. J Consult Clin PsychoI53:43-48. 1985 13. Freeman C. Sinclair F. Turnbull J. et a1: Psychotherapy for bulimia: a controlled study. J Psychiatr Res 19:473-478. 1985 14. TheanderS: Outcome and prognosis ofanorexia nervosa and bulimia: some results of previous investigations. compared with those of a Swedish long-term study. J Psychiatr Res 19:493-508. 1985 15. Mitchell JE. Pyle RL. Hatsukami O. et al: A two- to five-year follow-up study of patients treated for bulimia. International Journal of Eating Disorders 8:157-165. 1988 16. Theander S: Anorexia nervosa: a psychiatric investigation of 94 female patients. Acta Psychiatrica Scand 46: 1-194. 1970 17. Jones OJ. Fox MM. Babigian HM. et a1: Epidemiology of anorexia nervosa in Monroe County. New York: 1960-1976. Psychosom Med 42:551-558. 1980 18. Szmukler 11: The epidemiology of anorexia nervosa and bulimia. J Psychiatr Res 19:143-153. 1985 19. Gamer OM. Garfinkel PE. Olmsted MP: An overview of sociocultural factors in the development of anorexia nervosa. in Anorexia Nervosa: Recent Developments in Research. New York. Alan R Liss. 1983. pp 65-82
VOLUME 3\· NUMBER \. WINTER 1990
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