Psychological therapies in anorexia nervosa: on the wrong track?

Recently, in a randomised controlled trial, specialist supportive clinical management (SSCM) has proven to be more effective than the Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA), a treatment specially designed to address the disorder according to a rather complex rationale in comparison with SSCM. ¹ Specialist supportive clinical management, originally ‘non-specific supportive clinical management’ administered to a control group in a previous randomised controlled trial, ² was found to be more effective than two specialised treatments - cognitive-behavioural therapy and interpersonal therapy - and was as effective as these treatments at 5-year follow-up. ³

Specialist supportive clinical management was originally defined as clinical management and supportive psychotherapy, as revealed by its original definition:

‘Non-specific supportive clinical management was developed for the present study, and its aim was to mimic outpatient treatment that could be offered to individuals with anorexia nervosa in usual clinical practice. It combined features of clinical management and supportive psychotherapy. Clinical management includes education, care, and support and fostering a therapeutic relationship that promotes adherence to treatment. Supportive psychotherapy aims to assist the patient through use of praise, reassurance and advice. The abnormal nutritional status and dietary patterns typical of anorexia nervosa were central to non-specific supportive clinical management, which emphasised the resumption of normal eating and the restoration of weight and provided information on weight maintenance strategies, energy requirements and relearning to eat normally. Information was provided verbally and as written handouts.’ (p. 742) ²

In contrast, MANTRA claims to be novel in several respects: (a) it is biologically informed and trait-focused, drawing on neuropsychological, social cognitive and personality trait research; (b) it includes both intra- and interpersonal maintaining factors and strategies to address these; and (c) it is modularised with a hierarchy of procedures tailored to the individuals (as described in the authors' online Table DS1). ¹

Current treatment of anorexia nervosa is disheartening. Following successful weight restoration, almost 50% of patients relapse after 1-year follow-up, and pharmacological or psychological treatment persistently fails to neutralise the purported mechanisms underlying anorexia psychopathology. ⁴ Against this backdrop, according to the American Psychological Association Task Force criteria for the Promotion and Dissemination of Psychological Procedures, SSCM could be the first treatment for adult anorexia to attain the consideration of a well-established psychosocial intervention. However, the acronym SSCM disguises the fact that it has entered the stage through the back door of non-specific supportive treatments originally assigned to control groups, and SSMC efficacy over advanced treatments that have a sound theoretical basis raises perplexing questions. Maybe we are on the wrong track by persistently failing to understand either the fundamental features articulating the current concept of the disorder in terms of symptoms, personality traits, psychopathology and neuropsychological profile, or that these features are an epiphenomenon of malnutrition and are thus irrelevant as targets for treatment. Rather than delving into the self, perhaps the focus should be on the starvation side of self-starvation. ⁵