|
The past 3 decades have seen dramatic changes in
our approach to eating disorders. These changes include marked improvements
in the recognition and understanding of the disorders and in the
reduction of the morbidity and mortality due to anorexia nervosa
(AN) and bulimia nervosa (BN). These gains, including those in the
level of knowledge and appreciation by the public, have been transmitted
to the benefit of patients; however, there remain significant difficulties
in treating people with eating disorders. Critical research may
address gaps in knowledge and lead to more efficacious treatments.
To highlight how care in this area has changed, Professors Walsh
(1,13) and Kaplan (2) focus in this issue on specific aspects of
treatment. Walsh provides a thorough review of the pharmacologic
approaches to AN, BN, and the newly emerging binge eating disorder
(BED). Use of medication for AN has been disappointing, but there
are always new medications appearing, and the recent case reports
of the benefits of olanzapine are worth pursuing. However, to date,
medications have added little to overall management. More promising
are the relapse-prevention approaches that use medications such
as selective serotonin reuptake inhibitors (SSRIs) to prevent weight
loss and recurrence of anorexic psychopathology after weight restoration.
Much more work has been done on BN—for reasons well-documented—and
this literature shows value in the SSRIs, especially when combined
with psychotherapy. They may be particularly useful in relapse prevention
(3). Here again, novel medications are being tried (for example,
in the recent study of the value of ondansetron [4]). The evidence
for treating BED is less well developed, but again, there is an
emerging literature on the benefits of antidepressant medication,
as well as on novel approaches such as the use of anticonvulsant
(topiramate) and weight-loss (sibutramine) agents in obese patients
with BED.
Kaplan (2) focuses his review on controlled treatment trials for
AN and concludes that this area is limited by the following: few
studies (though most of these have come out in the last decade and
more are under way), small sample sizes, the life-threatening nature
of the disorder, and high dropout rates. He also examines denial
and treatment resistance as an important dimension for consideration.
While the controlled treatment studies are few, there are enough
data to point to promising areas for future clinical research. At
the same time, treatment approaches are dramatically different.
In the 1960s, it was common to have treatment for AN based on a
long-term psychoanalytic model, which was ineffective, or on combinations
of potentially harmful medications. Today, there is general acceptance
of the value of nutritional restoration or stabilization before
people can meaningfully benefit from psychotherapy. The types of
psychotherapy that are useful vary. Cognitive analytic therapy has
been shown to benefit in AN (5). Work from the Maudsley Hospital
has documented the value of family therapy for the young restricting
patient with AN (6). Older patients with AN and BN benefit from
cognitive-behavioural therapy, but this has been much more carefully
described for BN. The latter group has also been shown to benefit
from interpersonal therapy (7). As noted, the antidepressant drugs,
including the SSRIs, have also been useful for BN sufferers, although
in controlled studies they are not as useful as the psychological
treatments (1). As a result of these advances in understanding and
in care, AN mortality may have been reduced, and more patients are
completely well at follow-up (8). In contrast, BN has a much lower
mortality and a more variable course (9).
|
|
Clinical science has had a real bearing on these
improvements. The randomized controlled trial, first applied to
evaluating the efficacy of antibiotics in tuberculosis and pneumococcal
pneumonia, quickly led to comparative studies of psychotropic agents
in the early 1950s. Progress in psychotherapy research was greatly
enhanced more recently (in the late 1980s) when developed for studies
on depression. This research has since been adapted to treatments
for BN. Controlled trials for AN are rare and are much more difficult
to conduct—but are imperative for the field to advance.
Understanding the ego-syntonic nature of the primary
symptoms in AN is significant in this regard. Recent work on motivational
enhancement, adapted from the addictions field, may provide significant
benefits but requires careful evaluation (5). It is also important
to develop lines of research on treating comorbid states. Whether
it is drug dependency or depression, the lack of demonstrable treatments—and
facilities prepared to undertake combined treatments—is a serious
impediment to enabling the more chronically ill to develop lives
with meaning and dignity. Further, trials aimed at preventing complications
are also warranted. Studies of relapse prevention—in both AN
and BN— are currently under way and are most welcome.
Regardless of clinical trial benefits, there will be a significant
group of people suffering from these disorders who will continue
to display the complications of chronic illness. Eating disorders
disrupt the individual at many levels. Recognizing these complications
in both the psychosocial and physiological domains and developing
interventions to minimize them will require significant treatment
and research efforts in the coming years. For example, recent epidemiologic
work has described the high frequency of comorbidity for affective
disorders, anxiety disorders, and alcoholism (10,11). This may account
for some proportion of the psychosocial impairment. Understanding
the nature of these associated conditions and decreasing their impact
will have an important effect on patients with eating disorders.
A second example relates to improved understanding of the osteoporosis
that is frequently a complication of AN. Two characteristic features
of AN—low body weight and amenorrhea—serve as important
risk factors for developing osteoporosis. In recent years, with
the increased frequency of eating disorders and their not infrequent
chronicity, attention has been given to the problem of bone demineralization.
Several alarming reports have documented the presence of severe
osteoporosis and pathologic fractures in these patients (12). There
remains, however, a relative lack of understanding about the mechanisms
responsible for the demineralization of bone. Several factors may
contribute, including low body weight, repeated vomiting and purging,
low estrogen levels and amenorrhea, high levels of cortisol and
growth hormone, as well as alterations in somatomedin. The approach
to treating osteoporosis in eating disorders has not been worked
out well.
For patients who have been continuously ill for 10 or more years,
coercive hospital treatment with overly ambitious goals is rarely
helpful and may precipitate depression and suicide. A more realistic
approach to managing this type of patient involves brief, time-limited
admissions to hospital to help work on continuing weight loss or
metabolic complications. This should be associated with supportive
psychotherapy, either individually or in a group. In the future,
much more thought must be given to the ongoing care of this particular
patient group, with respect to both brief hospital stays and ongoing
management, so that these patients can lead lives of dignity with
minimal sequelae and intrusion by the illness.
References
|
