We are excited to have another guest blog post today. Dr Mandy Goldstein is a clinical psychologist with 10 years’ experience in the treatment of eating disorders and trauma, across inpatient and outpatient settings. She is the Principal Clinical Psychologist at Mandy Goldstein Psychology, and works as an Associate at The Redleaf Practice. Mandy completed her Doctorate in Clinical Psychology at Macquarie University, where her research was focused on enhancing the treatment of eating disorders. She has a particular interest in both the use of evidence based treatment, and its dissemination beyond research environments, making effective treatment more accessible to clinicians and patients alike.
Is weight recovery enough?
A recent article in the Journal of Eating Disorders by Murray, Loeb and Le Grange (2018) has made a call to change the way we investigate or report on change following treatment for anorexia nervosa (AN). The article, titled 'Treatment outcome reporting in anorexia nervosa: time for a paradigm shift?' and found here, raises the debate about whether weight restoration alone is enough to draw the conclusion someone with an eating disorder (ED) has recovered.
Patients with AN typically restrict weight, and experience various symptoms associated with, or exacerbated by, what we now know to be part of a syndrome of starvation. These can include an increasingly obsessive focus on food to the exclusion of other aspects of life, rigidness in thinking, and difficulty seeing the big picture or having the flexibility to behave differently when the situation calls for it. Patients can experience increased irritability, even leading to significant mood difficulties, such as depression or anxiety, which might not have been there before becoming underweight. Starvation and underweight can also put sufferers at risk of increased psychological and serious medical difficulties. It’s no surprise then, that most clinicians working with people with AN agree, that reversing starvation must be the first aim of treatment. But is that enough to consider a patient recovered? The article suggests, no. As the authors point out, if we consider weight restoration alone as an outcome, we stand to neglect core cognitive and body image related aspects of the illness, and if we are not focusing on these as measures of good treatment outcome, we stand to miss treating these parts of the illness. The numbers don’t stack up either. An apparent “good outcome” of around 60% of patients being considered “recovered” based on weight restoration alone, falls quickly to a much lower percentage (40%), when a broader definition of recovery, including reduced disordered thoughts and feelings related to the ED, is used. This fits with our clinical experience in that, while not true for every case, it is not uncommon for weight restoration to mark the very beginning, rather than the end, of a treatment journey. It makes good sense that once out of starvation, patients are able to think more flexibly and clearly, as well as having more access to their feelings. It is often only once weight is restored, that sufferers are more ready, and have the tools available, to embark on the journey of addressing their thoughts, feelings and body image concerns stemming from the ED and often responsible for keeping it going.
So if weight as an outcome from treatment is not enough, what might be? Some have bundled descriptions of weight and cognitive recovery into a united category, describing whether the patient has made a good, intermediary or poor outcome. But again, as the authors point out, this kind of reporting means we lose focus on the specific contribution that each patient’s weight and cognitive difficulties might make to their ED and makes it tough to provide more targeted treatments to each individual. Not surprisingly, another issue that springs from the confusion about how we report outcomes for EDs, is that there has not been a lot of agreement about this in the research field, leading to difficulties comparing different pieces of research to understand how effective treatments really are. The paper therefore calls for weight restoration and cognitive markers of recovery to be considered distinct entities, measured separately, and reported as independent indices, each contributing to a mark of recovery. That way, clinicians may have the opportunity to focus on specific targets of treatment for each of their clients; and researchers might be better able to compare the results of treatments they are investigating. Interestingly, say the authors, making this shift in how we report on treatment outcome, stands to impact how we use research to influence the development of new, more targetted treatments for AN, the importance of which is likely a whole other blog topic.
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