New Developments in the Treatment of Eating Disorders
Two years ago, the papers in the eating disorder section in this journal focussed on the classification and treatment of feeding and eating disorders in the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5); one of the conclusions was that despite significant advances in the field, novel treatments are needed and that especially childhood representations are a neglected area. This year, the reviews in the section on eating disorders do address new developments in the treatment of eating disorders and disordered eating. The five papers in this section describe a spectrum of severity of disordered eating over the lifespan, ranging from picky eating in childhood and adolescent anorexia nervosa to severe and enduring eating disorders in adulthood.

Cardona Cano et al. describe that in most cases, picky eating in early childhood can be considered as part of normal development; it has a higher prevalence in preschool children and seems to decrease thereafter, but may persist through to adulthood in some individuals. They suggest that picky eating is a reasonably robust concept, comprising food neophobia, eating a limited variety of food, and other specific features related to food and eating (e.g. low enjoyment of food, slowness in eating, and higher satiety responsiveness). Picky eating is often a major concern for parents of young children, but there is only limited guidance regarding the management of picky eating. The most common approach to the management of picky eating is to start with nutritional education. Educational group programmes for parents of children with non-clinical feeding problems focus on increasing parental knowledge, improving parenting feeding styles, and reducing negative parent–child interactions, such as coercion and parental anxiety. Several treatment options using internet and mobile apps are in development, with some developed by commercial parties.

The three most prominent guidelines – from the UK National Institute for Health and Care Excellence in 2004, from the American Psychiatric Association in 2006, and the most recent guidelines from the Royal Australian and New Zealand College of Psychiatrists in 2014 – all recommend family therapy for adolescent anorexia nervosa. Blessitt et al. describe that there has been a renewed interest in the evaluation of family functioning in adolescent anorexia nervosa, though the focus has moved away from questions of its role in the development of the illness to its potential role as moderator or mediator of treatment outcome. While family therapy for adolescent anorexia nervosa is now generally accepted as an effective treatment, we are only at the beginning of understanding what aspects of the treatment underpin the process of change, who is most likely to respond, and to what extent expertise in the disorder and the service treatment context shapes outcome. Not just for family therapy, but more generally for anorexia nervosa, there is still a strong need for more well designed treatment studies.

This relative lack of evidence base for the treatment of anorexia nervosa is in contrast with the large number of randomized controlled trials (RCTs) and meta-analyses for bulimia nervosa and binge eating disorder (BED). First-line treatment for bulimia nervosa and BED in adults is an individual psychological therapy with the best evidence for cognitive behavioral therapy (CBT), but also interpersonal psychotherapy is a well established therapy for these disorders. A specific trans-diagnostic enhanced therapy (CBT-E) has been found more efficacious than other psychological approaches, although the specificity of CBT-E requires more evidence. Considering that in many countries there are not enough CBT therapists available to serve the needs on a population level, self-help manuals and interventions by the Internet might be helpful strategies for some of the sufferers with an eating disorder. Fairburn and Murphy focus in this issue on recent studies of delivering self-help cognitive behavioural interventions using the Internet (eTherapy). The use of eTherapy as a means of providing treatment for depression and anxiety disorders is already receiving considerable attention, but there has been much less research on its application to eating disorders. Fairburn and Murphy give detailed descriptions of four RCTs of eTherapy for adult participants with an eating disorder (bulimia nervosa or BED) recruited from the community. They found that guided eTherapy interventions of a cognitive behavioural nature are acceptable to adults with a binge eating problem, and that a subgroup improves substantially, at least in the short term, but that more effective eTherapy interventions are needed and also ones for people who do not binge eat.

The most challenging subject for eating disorders is probably the treatment of severe and enduring eating disorders (SEED), and this might be particularly true for severe and enduring anorexia nervosa (SE-AN). For the treatment of SEED, some new strategies are picked up from other fields in psychiatry, especially from findings in the field of schizophrenia. Danner et al. describe cognitive remediation therapy (CRT) as one of these new strategies – adapted from the schizophrenia field. CRT is a behavioural-based training intervention that aims to improve cognitive processes with the goal of durable improvement in functional outcomes. Recent studies of CRT in schizophrenia describe a diversity of positive results, such as improvement in symptoms, cognitive, and psychosocial functioning, and changes in neural activity. CRT for anorexia nervosa tries to improve cognitive flexibility by training set-shifting abilities and central coherence strength. Danner et al. review the first studies using a RCT design, which show an added value of CRT for eating disorders. Patients reported less symptoms and further improvements in quality of life and cognitive flexibility. Furthermore, the acceptability of the intervention was good and attrition rates for CRT itself were low. Danner et al. argue that an important next step is to develop more effective personalized methods of CRT for eating disorders.

A more personalized form of treatment like in a staging model might be beneficial not just for CRT, but for the treatment of SEED in general. Hay and Touyz report on new developments in the conceptualization of recovery and staging models, and treatment of people with SEED. They discuss several approaches to the management of severe and enduring anorexia nervosa and other eating disorders. Hay and Touyz argue that it might be useful for especially anorexia nervosa to apply staging models from other medical fields such as oncology and the recovery model, as understood for schizophrenia. A staging model of anorexia nervosa might range from a pre-syndromal 'high-risk' stage, through early and then full syndromes, to severe enduring illness with markedly impaired quality of life and neurocognitive deficits, and the entrenchment of altered reward habit learning. The recovery model emphasizes functionality with meaning and purpose in life and de-emphasizes symptom remission. While the evidence base for SEED is still weak, there is an emerging consensus that modifications to treatment, particularly to treatment goals, are appropriate in long-standing illness. In anorexia nervosa, these modifications generally comprise de-emphasizing weight gain with improved quality of life and adaptive function taking primacy. Hay and Touyz conclude from their review that a staging model appears to have validity and clinical utility, particularly in anorexia nervosa. Compulsory treatment might be a last option for anorexia nervosa, especially in light of the high mortality rate of 5% per decade for anorexia nervosa. Although there is lot of controversy on compulsory treatment, there are good arguments that in severe cases of anorexia nervosa, where the patient refuses life-saving treatment, compulsory treatment at least needs to be considered.

Overall, these five papers show an active search for new developments for the treatment of eating disorders with some promising new strategies. However, further searches are necessary, considering that persons with eating disorders still face a severe problem of under-detection. The vast majority of individuals with an eating disorder in the community does not enter the healthcare system. Hopefully, the development of new strategies such as the application of social media might be beneficial for the unmet needs of persons with eating disorders in the community.