Anorexia nervosa

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Abstract
How good is the evidence for managing anorexia nervosa?Ironically, this most lethal of psychiatric disorders is the Cinderella of research. It is hard to engage patients with anorexia for treatment, let alone research. Furthermore, the complexity of coordinated approaches used in most specialist centres may overwhelm conventional research methods.High quality evidence on the effects of starvation on the body is available to guide physical aspects of care.2 Genetic studies, including twin and family studies,3 and more recently gene analysis, have shed some light on causes, but few randomised controlled trials of treatment exist. In contrast, many randomised controlled trials are found on the management of normal weight bulimia nervosa.4 Unfortunately, these interventions have a poor response in anorexia nervosa.This review is based on searches in PubMed, Medline, and PsycLIT for treatment of anorexia nervosa and related eating disorders, and the National Institute for Health and Clinical Excellence (NICE) clinical guideline.5 We found no category A evidence (at least one randomised controlled trial as part of a high quality and consistent body of literature (evidence level 1)), and only family interventions met category B criteria (well conducted clinical studies but no randomised controlled trials (evidence levels 2 and 3) or extrapolated from level I evidence). NICE uses category C recommendations (expert committee reports or clinical experience of respected authorities (evidence level 4) or extrapolation from level 2 or 3) to provide guidance where high quality formal evidence is absent. Two Cochrane reviews cover antidepressant treatment for anorexia nervosa6 and individual psychotherapy for adults with the disorder.7 The reviews are based on only seven and six small studies, respectively, all of which had major methodological limitations. A further electronic and hand search of papers published more recently is supplemented by work in press, conference presentations, and some personal communications with the relatively small group of international experts in the field.