Wednesday, December 9, 2015

New Behavioral Treatment Approach Targets Neurobiology of Adults with AN

Family therapy focusing on AN-specific temperament, cognition, and eating behaviors.

Reprinted from Eating Disorders Review
November/December Volume 26, Number 6
©2015 IAEDP
Information about neurobiological factors in AN that may cause the disease to be long-lasting and relapsing continues to grow. A group at the University of California, San Diego, has developed a new treatment approach for adults with AN that attacks the neurobiology of the illness. Neurobiologically Enhanced With Family Eating Disorder Trait Response Treatment (NEW FED TR) aims to reduce core symptoms among adult AN patients by using behavioral approaches to target disease-specific mechanisms. 
Stephanie Knatz, PhD, and her colleagues report that NEW FED TR targets AN-specific temperament, cognition, and eating behaviors because the underlying traits are stable and pervasive, instead of transitory, in individuals with AN (Dialogues Clin Neurosci 2015; 17:229). The NEW FED TR technique is used to teach patients with AN and their families and caregivers (carers) to manage AN symptoms by using these traits in a constructive way. Results from neuroimaging studies suggest that the mechanisms underlying anticipatory anxiety, reward insensitivity, and/or deficits in awareness of homeostatic needs (interoceptive awareness) are major contributors to the illness. 
Establishing a neurobiological basis as the primary etiologic cause of AN reduces blame and increases empathy, both of which are critical for enlisting support of patients and the people caring for them. These psychoeducational activities are then followed by related skills training. Patients are asked to follow a routine, predictable structure for meals and snacks that specifies specific times, foods, food exchanges, and other details surrounding meal times. Using such a highly predictable and repetitive structure makes use of the patient's personality strengths, such as enhanced inhibition and self-control, while taking into account deficits in the ability to tolerate uncertainty and to shift sets.

Two stages of treatment

Treatment is delivered in two phases that are conducted with the patient and her or his carers. The first phase is an intensive course of 5 consecutive days of 8 to 9 hours of treatment daily. This phase involves joint meetings with multiple families, following the theory that intense, repeated and focused live practice is the key to changing biologically driven avoidance behaviors. Learning is maximized by massed practice and close monitoring of compliance. 
The second phase involves weekly outpatient follow-up sessions focused on monitoring weight and symptoms, while helping patients and carers practice skills learned during their 5-day intensive training. Patients are asked to follow a routine and predictable structure for meals and snacks that specify specific times, foods, exchanges and other mealtime details.
The authors explain that the concept of neuroplasticity suggests that increased treatment frequency and intensity are essential to achieve behavioral change. For example, treatment models for anxiety dictate that intensive, repetitive, and focused "live" practice is key to changing biologically driven avoidance behaviors. According to the authors, one possible reason for failure with current treatment approaches for AN is that the once-weekly treatment format is simply not repetitive enough. 

 A program aimed at adults

While family-based therapy is helpful for adolescents because of its focus on weight restoration by empowering the family to take control of refeeding, implementing this is obviously difficult for adults. However, support for carer involvement in adult AN is growing. For example, "Uniting Couples in the Treatment of AN," based on cognitive behavioral couples therapy, is showing promise for improving communication and reducing marital distress. Patients and carers learn about the neurobiology underlying AN and the most effective ways to respond to and manage symptoms. They also learn skills to help reduce dietary restraint and concerns about shape recovery around meals. For example, carers learn to establish a pre-meal routine that will distract the patient from negative internal states that anticipate the effects of food and to help reduce anxiety about exposure to food. Meal coaching helps carers redirect patients from ruminating when anxiety or obsessions invariably occur.
The authors report that a multi-site clinical trial is now under way to develop and test the efficacy of the NEW FEF TR treatment program, with six intensive multifamily programs scheduled throughout 2015. This approach seems to reflect the revised approach to treatment development supported by the National Institutes of Mental Health, in which treatment design is guided by underlying neurobiological or psychophysiologic aspects of illness. NEW FED TR appears to be an early attempt to put this new approach into practice.

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