The Case for Early Intervention in Anorexia Nervosa

The toll from anorexia nervosa (AN), including major physical and psychosocial problems, persists long after initial recovery. In one study that followed AN patients for 9 to 14 years, more than 20% were unable to support themselves independently (Br J Psychiatry 2006; 189:428). In another cohort of patients with early-onset AN, more than a fourth had a poor psychosocial outcome by age 35 (Br J Psychiatry 2009; 194:168).

Drs. Janet Treasure and Gerald Russell recently revisited their original study in which results of the “Maudsley model” of family therapy were compared with individual therapy (Br J Psychiatry 2011; 199:5). The researchers found that family therapy was more effective for teens who had been ill for a short time than for those with longstanding illness. However, that was apparently only part of the story. A later study, which analyzed the study outcome 5 years later, showed that the group with onset of AN in adolescence but who had been ill for more than 3 years had a poor response to both family and individual therapy. This suggested that unless patients with AN receive effective treatment within the first 3 years of illness, the outcome will be poor. Recovery from AN becomes much less likely and treatment is much less successful the longer the illness has persisted.

Looking to the brain for clues

What causes inadequately treated AN to persist? Drs. Treasure and Russell note that starvation and stress affect the brain, which is particularly vulnerable in young patients. AN generally develops at a time when the brain is undergoing structural and functional changes. Next, the brain uses about 20% of an individual’s total daily caloric intake and is particularly dependent on glucose, leading to the dysfunctional effects of extreme caloric restriction. Last, the brain plays a major role in the control of eating, through the neural circuits that regulate the drive for food.

Thus, prolonged untreated AN has highly detrimental effects on brain development. As the authors point out, in addition to streamlining connectivity, hormonal changes can have an impact on the development of the so-called social brain. Maturation of the prefrontal areas, which exert self-regulatory control, occurs later than that of the subcortical areas. Thus, the balance between reflection, risk-taking, and impulsive behaviors is in a state of flux. Such transitions in brain organization in adolescents may then contribute to the risk of developing an eating disorder. Also, it is highly likely that poor nutrition, hormonal changes and high levels of stress disrupt brain maturation and may make it more difficult to recover from AN.

The lessons that emerge, according to the authors, are that early recognition and intervention are vitally important for AN patients, and that family therapy can play a special part among young AN patients. The authors noted that the more diversified family therapy that has evolved in the Maudsley model has mobilized parental resources by exonerating parents from blame for the illness and encouraging them to take joint control of their child’s eating until the child can keep his or her body weight at a normal level.