Eating Disorders: Looking Ahead

The wonderful articles by Drs. Anderson, Mitchell, and Kalarchian and Marcus aptly capture key issues in the evolving stories of anorexia nervosa, bulimia nervosa and binge eating disorder at the verge of the millennium. We can all take some comfort in the fact that the last several decades of the 20th century have produced substantial increases in keen clinical observations and in research studies addressing these disturbing conditions.

One measure of the vigor of an intellectual field is the degree to which professions organize around their core problems. In the last few decades the field of eating disorders has spawned a bevy of new scientific journals and newsletters, given birth to several professional societies, and started to command increasing amounts of research funding. The field is alive and well.

I will not repeat the predictions that our visionaries have provided. Instead, I’d like to imagine several additional strong forces that are likely to influence and shape the directions of our etiologic and pathogenetic understanding of eating disorders, our methods of clinical evaluation and assessment, and our treatment interventions.

Biological: Unprecedented insights into molecular genetics are emerging from research laboratories. Already, more than 200 separate genes have been identified that impact eating, satiety, propensities for physical activity, energy expenditure, and related issues. Genes that influence temperament and personality are also being discovered. Closely associated with eating disorders, biological research is similarly booming in obsessive-compulsive disorders and personality traits, mood disorders, anxiety disorders, and other areas in which emotional self-regulation is impaired. Add this research to the recent description and genetic investigations into “thin sow” disease, a naturalistically occurring animal model that bears uncanny similarities to anorexia nervosa, and new biological understandings of altered physiological processes that mediate rat hyperexercise-anorexia models. All of this promises that we can anticipate new biological models and perhaps new pharmacologic approaches to eating disorders. Advances in neuroimaging and other biological technologies may add additional insights and approaches.

Psychosocial: Only in the past few decades have psychosocial interventions been standardized in treatment manuals to the point where some reliability can be assumed when one treatment is compared to another. We are now seeing the emergence of self-guided and therapist-guided treatment manuals applicable to individual and group settings, for cognitive behavior therapies and interpersonal psychotherapies for patients with anorexia nervosa, bulimia nervosa, binge eating disorder and body image problems. New manuals are being developed for specific forms of family therapy that will lend themselves to empirical testing. As these treatments are refined, the trick will be training health providers to use them in wise and sophisticated manners. Several new developments offer promise.

Information technology: We are just beginning to envision opportunities for treatments offered by emerging technologies. Patients and their families may already be way ahead of providers, tapping into information, chat-lines and self-help sources on the world-wide web. The upside is that many become more sophisticated and informed. The downside is that much of the information available is unfiltered, and we do need to do better jobs of developing and disseminating responsible web-based information.

And for the future? First, we can anticipate increased use of computer-based screening and assessment forms to be completed by patients and their families for initial evaluations and follow-up. The purpose of these assessments is not to replace human contact, but to make optimal use of the time available, and to help standardize the information collected. Practitioners will be able to follow up and ask detailed questions about salient issues that very thorough assessment tools have revealed. Second, some practitioners are already using e-mail to enhance office-based sessions with outpatients (anticipate the publication of J. Yager, “E-mail as a Therapeutic Adjunct in the Outpatient Treatment of Anorexia Nervosa,” International Journal of Eating Disorders, in press), and this modality may enhance provider-patient/family contact and involvement. As an extension, we can envision “bots”(personal cyber-space information robots) that prompt and guide patients through difficult periods. Third, PDAs, personal digital assistants, such as palm pilots, may offer untapped capacities to act as therapeutic adjuncts, for diary keeping and for guidance, among other possible uses. Fourth, think “distance learning” with regard to new developments and therapeutic techniques for patients, families, and providers. Professional organizations serving the needs of providers will increasingly turn to distance learning technology to update, upgrade, and uplift. And this is only the beginning.

I invite you all to come back a millennium from now to see how we’re doing.