Anxiety in anorexia nervosa and its management using family-based treatment

Eating and Weight Disorders Program, Department of Psychiatry, Mount Sinai School of Medicine, New York, NY 10029, USA.
European Eating Disorders Review (Impact Factor: 2.46). 01/2012; 20(1):e1-16. DOI: 10.1002/erv.1071
Source: PubMed


Anorexia nervosa (AN) is characterized by its similarity to anxiety disorders, especially obsessive-compulsive disorder (OCD). Family-based treatment (FBT) has shown promising initial results for treatment of AN in adolescents, yet the precise mechanisms of action are unknown. We present a theoretical argument and model, suggesting that FBT may work via exposure (and habituation) to food and its consumption. First, we review the evidence for pathological anxiety in AN, and suggest a framework for identifying specific anxious triggers, emotions (fear and worry) and avoidance strategies. Second, we briefly review evidence indicating that cognitive-behavioural therapy (CBT) and specifically exposure in its various forms is most effective for treating anxiety disorders in youth. Third, we consider distinct approaches to exposure therapy based on the pattern of triggers, anxious emotions and avoidance. We conclude that the interventions utilized in FBT share clear similarities to exposure with response prevention, a type of exposure therapy commonly used with OCD, and may work via facilitating habituation to food and eating in one's natural environment. We also highlight how parents facilitate this process in between sessions by effectively coaching their children and facilitating naturalistic exposure to food and related triggers. Options for future research are considered.

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Available from: Tom B Hildebrandt, Jan 28, 2015
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    • "This may be an important adaptation for FBT in the context of muscle dysmorphia, given that those with muscle dysmorphia typically report greater distress around body composition and shape rather than body weight per se (Murray, Rieger, & Touyz, 2011). While the agnostic stance to aetiology adopted in FBT has shifted the clinical focus away from the precise mechanism of change throughout FBT, recent research has contested that cognitive symptoms remit through a process of parent-led exposure and response prevention (Hildebrandt et al., 2012). The ego-syntonic and subjectively experienced positive effect of symptoms in muscle dysmorphia (in bringing one closer to one's weight and muscularity-related goals) may also necessitate parental involvement in ensuring exposure and response prevention given the commonly reported admiration of symptoms (Griffiths, Murray, Mond, & Touyz, in review) and fear of symptom remission (Fussell, 1991), although the present case study suggests that similar mechanisms may be equally effective in muscle dysmorphia. "
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    • "In terms of chronology, anxiety problems have been found to precede ED onset (Deep et al. 1995; Bulik et al. 1997; Godart et al. 2002, 2006; Hildebrandt et al. 2012; Swinbourne et al. 2012) and to predict later development of ED (Kaye et al. 2004; Lilenfeld et al. 2006; Jacobs et al. 2009; Mazzeo and Bulik 2009; Micali et al. 2011). Contributions from longitudinal studies also seem to confirm that child ''emotional'' characteristics are associated with eating behaviours (Martin et al. 2000; Haycraft et al. 2011) indicating that internalizing characteristics in childhood could predispose to eating disorder later on in life. "
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    ABSTRACT: Using a sister-pair design, we aimed to investigate the role of maternal anxiety in pregnancy and parental overprotection as risk factors for anorexia nervosa (AN) and bulimia nervosa (BN). We were also interested in investigating anxious personality traits in patients with AN and BN compared to their healthy sisters, and their possible association to overprotection. One-hundred-and-fifty-seven females (AN = 94; BN = 63) and their healthy sisters from four European centres were recruited. Data on temperament and childhood characteristics were obtained from cases and their sisters using the Temperament and Character Interview Revised (TCI-R) and the Oxford Risk Factor Interview (ORFI); maternal anxiety and overprotection were obtained from retrospective parental report. Both AN and BN women displayed significantly higher levels of separation anxiety in childhood in comparison to their sisters, but only women with AN showed anxious temperamental traits. Mothers of women with AN reported higher levels of anxiety during the index pregnancy (p < .01), compared to when pregnant with the healthy daughter. The age in months at which women with AN were first left with another adult for a night was also higher compared to their sisters (respectively medians: 12 (range 1–120), 9 (range 1–96), p < .05). This was not the case for women with BN. Maternal overprotection was not associated with index daughter temperament. This finding is suggestive of an association between AN and maternal stress and anxiety in utero and later overprotective care, whilst BN was not associated with maternal anxiety or overprotection.
    Cognitive Therapy and Research 08/2013; 37(4). DOI:10.1007/s10608-012-9518-8 · 1.70 Impact Factor
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    • "In the present study, we used a symptom-provocation fMRI paradigm that has been used in investigations of Obsessive Compulsive Disorder (OCD) [35], an anxiety disorder that is highly comorbid with AN [86] . In the previous study of those with OCD, participants were cognitively engaged when they were shown anxiogenic pictures related to their disorder. "
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    ABSTRACT: Women with anorexia nervosa (AN) have aberrant cognitions about food and altered activity in prefrontal cortical and somatosensory regions to food images. However, differential effects on the brain when thinking about eating food between healthy women and those with AN is unknown. Functional magnetic resonance imaging (fMRI) examined neural activation when 42 women thought about eating the food shown in images: 18 with AN (11 RAN, 7 BPAN) and 24 age-matched controls (HC). Group contrasts between HC and AN revealed reduced activation in AN in the bilateral cerebellar vermis, and increased activation in the right visual cortex. Preliminary comparisons between AN subtypes and healthy controls suggest differences in cortical and limbic regions. These preliminary data suggest that thinking about eating food shown in images increases visual and prefrontal cortical neural responses in females with AN, which may underlie cognitive biases towards food stimuli and ruminations about controlling food intake. Future studies are needed to explicitly test how thinking about eating activates restraint cognitions, specifically in those with restricting vs. binge-purging AN subtypes.
    PLoS ONE 03/2012; 7(3):e34000. DOI:10.1371/journal.pone.0034000 · 3.23 Impact Factor
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