Severe and Enduring Anorexia Nervosa-peer Reviewed and Scholarly Sources

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Severe and Enduring Eating Disorders: Concepts and Management

Submitted: December 7th, 2018 Reviewed: May 22nd, 2019 Published: August 14th, 2019

DOI: ten.5772/intechopen.87004

Abstract

The concept of astringent and enduring mental illness was introduced in 1999 in order to direct resources to patients suffering from long-term serious disorders, and was suggested for eating disorders in 2009. Withal, the term is still restricted to patients with long-term psychosis. In this affiliate, the concept of severe and enduring eating disorder (SEED) is described and its relevance to anorexia nervosa (AN) and bulimia nervosa (BN) is explored. The recovery curve for anorexia nervosa seems to follow an exponential pattern with an asymptote that approaches but does not meet the horizontal, suggesting that recovery is ever possible. Symptoms of AN but non BN seem to worsen later 3 years of illness, perhaps a significant threshold. Symptoms of severe and enduring AN (SEED-AN) are debilitating and longstanding every bit well as potentially fatal. Symptoms of severe and indelible BN (SEED-BN) are also debilitating, especially in social aligning. In both conditions, family difficulties are prominent. A clinical approach to SEED is described based on improving quality of life, the recovery arroyo, (rather than cure) for sufferers and their families is described, although full symptomatic recovery can occur at any stage and clinicians should exist alarm to the possibility in all patients.

Keywords

anorexia nervosa
bulimia
chronic
severe and enduring
recovery model

Paul Robinson*
- Orri, United kingdom of great britain and northern ireland
- University Higher London, U.k.

*Address all correspondence to: drpaulrobinson@gmail.com

1. Introduction

The idea of astringent and enduring mental illness (SEMI) extends dorsum to 1999 when the UK Department of Health published the National Service Framework [1]. In information technology, SEMI was defined equally follows:

" People with recurrent or astringent and enduring mental illness, for example schizophrenia, bipolar affective disorder or organic mental disorder, severe anxiety disorders or severe eating disorders, accept circuitous needs which may require the continuing care of specialist mental health services working finer with other agencies ."

Clearly information technology was intended, rightly, to include non-psychotic disorders such every bit eating disorders and obsessive-compulsive disorder. Since that time policy has changed, possibly because of increasing demands on community psychiatric services due to bed closures and funding restrictions and the almost recent definition is very restrictive. In 2018, the National Found for Clinical and Care Excellence (NICE) [2] released the draft scope for SEMI and stated: "the groups that volition be covered are Adults (aged eighteen years and older) with complex psychosis ". Ruggeri et al. [3] provided 2 sets of criteria that reflect this tension: 1. Diagnosis of psychosis, 2. Duration of service contact ≥2 years, 3. GAF (Global Cess of Operation) score‚ <l and a second model only including the latter two criteria, hence including non-psychotic disorders (including eating disorders).

In this context in which access to services could be restricted past psychiatric teams on the basis that the patient did not take a severe and enduring mental disease, the author wrote a book entitled Severe and Enduring Eating Disorders [4] partly in an attempt to draw attention to the ongoing major bug experienced past people with long term eating disorders. In this chapter we will examine the SEMI concept as applied to eating disorders, review the symptoms experienced by SEED patients and await at the differences between different eating disorders, which have lasted for many years. In the last section, recommendations for management of SEED will be fabricated.

2. Definitions and concepts

Eating disorders have been fully described in the DSM 5 [5] and these definitions will non exist considered here. However, the questions of elapsing and severity do requite rising to controversy and although the term Severe and Enduring" has been practical to eating disorders [4, 6], the precise length of history and severity required are even so undecided.

ii.ane Length of illness

This can exist approached in a number of means. One is to ask the question: At what betoken do eating disorders get significantly harder to treat? This is an important question, because if we knew the respond, we could make all possible efforts to begin treatment before that bespeak. Unfortunately there is rather little evidence to guide us, although it has been suggested [7] that later 3 years of illness, anorexia nervosa may become more than intractable. This is based on a randomised controlled written report of anorexia nervosa [8] in which patients with a length of history of restricting anorexia nervosa of <3 years did significantly amend in family therapy than patients with a longer history. Some other approach is to look at the proportion of patients who still fulfil criteria for the disorder at unlike times after onset. In Table 1, a number of studies in which this proportion is reported are displayed. In each study, the proportion of patients with a "poor outcome" is noted in the 5th column. The proportion includes all deaths, as well as patients with a poor outcome due to reasons other than the eating disorder, and so the measure is somewhat flawed. However, the proportion after 9–24 years (average 13.4 years) ranges from 12 to 59%, average 27.nine%. This tells us that the proportion of patients initially diagnosed every bit having anorexia nervosa and who continue to exercise badly is high, and we can expect effectually a quarter of patients to follow this form. A more conservative guess is shown in the 3rd cavalcade, namely the proportion of patients still fulfilling diagnostic criteria for anorexia nervosa. The range is from 3 to 37% with an average of 14.iv%. The highest gauge in that column, 37% [xiii] is from a national service which accustomed referrals from all over the UK. Hence the severity of disease in patients admitted is likely to exist college and length of illness proportionately longer. Without that centre the average proportion fulfilling criteria at average 14 years is nine.14% which may be a more than representative figure.

Status studied	Length of follow-upwards (years)	Proportion % fulfilling disease criteria	Notes	Poor outcome (ED and other reasons)	Reference
Anorexia nervosa	24	Diagnoses not recorded	Bloodshed 12.8%	29%	Theander et al. [9]
Anorexia nervosa	9	17	Mortality 11%	59%	Deter et al. [10]
Anorexia nervosa	12	19	Bloodshed 7.vii%, BN 9.5%	39.half-dozen%	Fichter et al. [11]
Anorexia nervosa	10	iii	Adolescents, no deaths, v% BN, 23% personality disorder		Herpertz-Dahlmann et al. [12]
Anorexia nervosa	20	37	fifteen% BN, 15% died	36.6%	Ratnasuriya et al. [13]
Anorexia nervosa	15	13	No deaths, 30% rampage eating		Strober et al. [fourteen]
Anorexia nervosa	10	6	Community screening, hateful age onset fourteen	27%	Wentz et al. [15]
Anorexia nervosa	18	6	Aforementioned cohort equally above	12%	Wentz et al. [16]
Average	xiii.four	xiv.four		27.9%

Table 1.

Follow-up studies of anorexia nervosa.

2.one.i The asymptotic pattern of upshot

Four of the in a higher place studies [9, 10, eleven, sixteen] provided data on event of anorexia nervosa at several fourth dimension points which allows us to draw a survival curve (Figure 1).

Figure 1.

Percentage of participants who fulfilled diagnostic criteria at each assessment from four follow-up studies of anorexia nervosa. The curve is exponential, derived from these data points.

This shows that every bit fourth dimension goes on, the number of cases reduces and nigh, but not quite, reaches the horizontal, that is the bend seems to represent an asymptote. It should be noted that at no time does the curve ever stop falling, although the gradient does flatten, showing that anorexia nervosa tin always recover, at any phase. The graph suggests that significant flattening seems to occur between 5 and 10 years, and in that menstruation after diagnosis recovery does get less likely. Effigy one also shows the exponential bend that was derived from the data points shown and this also suggests an asymptotic pattern.

2.1.ii Symptoms may increase in severity later on 3 years

The proposal by Treasure and Russell [7] that a history of more than than 3 years might exist accompanied by a decreased responsiveness to treatment was further examined in a written report past Gardini [17]. In this audit of routine questionnaires, results in patients with anorexia nervosa with under three years history were compared with a grouping of patients with a history of 3–ten years and a further group with over 10 years duration. A comparable written report was performed for patients with a diagnosis of bulimia nervosa and the same durations of disease.

The results were intriguing. For anorexia nervosa (but not for bulimia nervosa), time had a significant bear on on EDE-Q restraint and a deadline significant affect of EDE-Q weight concern and EDE-Q global score. The scores increased between <three and 3–10 years and so declined later 10 years. The results are summarised in Effigy two.

Effigy 2.

EDE-Q scores in three groups of patients with anorexia nervosa (full due north = 87) with length of history of <three years, three–10 years and >10 years. The p values derive from a Manova comparing the three length of history groups. *≤3 years grouping vs. 3–x yr grouping p = 0.048, **≤three years grouping vs. 3–x year group p = 0.017 (mail-hoc tests). EDE-Q-One thousand: global score, EDE-Q-R: restraint, EDE-Q-E: eating concern, EDE-Q-S: shape concern, EDE-Q-Due west: weight business organisation.

This study provides some evidence for the 3 twelvemonth threshold proposed by Treasure and Russell [seven]. Some eating disorder symptoms significantly increase afterwards 3 years illness and this could chronicle to increasing difficulty in helping patients achieve remission. The increased restraint score could reflect increased resistance to the parents encouraging the patient to consume a weight gaining diet, an essential element in family based therapy.

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3. Clinical features of SEED

In this section, SEED-AN symptoms [18] will exist compared with SEED-BN (unpublished information).

3.1 Physical

In SEED-AN, many participants complained of physical problems, but also denied their seriousness:

" The worst thing is going to exist as I am moving in my latter years being osteoporotic just you lot know what, there are some fantastic tablets today ."

" Osteoporosis was diagnosed but I think it'southward controllable … with Calcium and the right diet, and I think information technology's non astute ."

In SEED-BN about participants either did not mutter of whatever physical problem, or felt they were manageable.

iii.two Psychological

In SEED-AN, most participants were depressed, and self esteem was often extremely low:

" I felt like I was a horrible, disgusting, person … I felt like really ugly and disgusting and dirty and therefore to dress myself in things that made me await pretty would be similar, it would be incorrect somehow ."

In SEED-BN low and mood instability were the rule.

" Sometimes I'1000 merely bubbly and happy and in a fun mood and other days I just want to be on my ain ."

" I think a lot of information technology is dealing with your depression ."

3.3 Social

In SEED-AN, social disruption, lack of intimate relationships and social isolation were common.

" I felt I just totally failed and dropped out of life. I was too scared to join upwardly the squash order, I was too scared to socialise with people, I lost all my confidence with job interviews ."

In SEED-BN about participants were not in relationships and were living alone.

" I've got some friends that I have online just I haven't really met them. Because I experience I can totally fake…see information technology kind of doesn't matter what I say because I haven't met them. Do you lot know what I mean? Because it doesn't thing if they disappear, they're not really real friends ."

3.4 Family

In SEED-AN, the patient sometimes ended up every bit their parents' carer.

" I was sort of left; a lot of the family got married and moved away from home ."

In other cases, difficult relationships improved over fourth dimension.

" In the last 2 years the relationship with my family has got amend. I now accept contact with my sister. We often conversation on the telephone. I don't really meet my brothers or hear from them, I oft ask my parents near them, they ask almost me ."

In SEED-BN, family difficulties were frequent. Some felt their families did not accept the eating disorder seriously. One patient subsequently she had confessed her bulimia to her mother, reported that her mother said " yeah I used to do it. It's and so stupid. Yous kind of don't wanna practise that … , " which she did not find helpful. Other patients reported that their families were weight obsessed. When i participant had regained a size 12, a fellow member of her extended family exclaimed " Oh my God what have they been feeding y'all? You lot're enormous !"

3.5 Financial

For SEED-AN, patients were often poor, living on benefits without paid piece of work. They also described clinical frugality, in which they had extreme difficulty spending coin on themselves:

" I find it very difficult spending money. If you walked into my flat, I've got nothing particular there … just very-very bare. My shoes, I wear them until they begin to fall into pieces ."

For SEED-BN, the illness was often very plush because of the large quantity of food consumed. One patient interviewed was seeing a debt counsellor to manage loans from 5 different lenders: " I don't have any savings, and I don't purchase annihilation nice for myself, I merely survive ."

3.vi Occupational

SEED-AN: These patients frequently reported being out of piece of work and surviving on benefits. " I completed i year of that (teaching) course so I had to go into hospital so that came to an stop. … I seemed to lose interest in piece of work and it seemed more important that I planned my meals and my walks ."

SEED-BN: These individuals were often in work, and some valued the structure of work to help manage their eating disorder: " I feel that going to work in the morn 'wipes the slate clean' if I take binged and vomited the night before ." Others found that the eating disorder had an agin consequence on work: " Final summertime I had to take a number of months off work due to my eating disorder and depression, and I however struggle to fulfill all my commitments when my mood is depression ."

iv. Management

Outcome research in the area of management of SEED is sparse. There are several examples of publications in which clinicians accept expressed their opinion in this expanse [xiv, 19, xx]. Ane question that constantly appears in the surface area of direction is what general approach to use. As already discussed full recovery from an eating disorder is always possible although less likely every bit the years laissez passer. The patient (and the clinician and family) are thus confronted with the question each time therapy is contemplated: Should I get for a full recovery or for the best quality-of-life given that I have a long-term disorder.

From the betoken of view of the clinician, there may be a moral dilemma. Funding for services may depend on inpatient units being total. This applies to both the public and individual wellness sectors. There may therefore be perverse incentives to admit the SEED patient for a prolonged hospital stay in pursuit of weight gain. Most professionals in charge of an inpatient eating disorders service volition be enlightened of these pressures, and how they sometimes conflict with patient care. Infirmary admission is essential in the instance of a patient who presents life threatening concrete illness. However the likelihood of long-term recovery after prolonged admission in someone with a long illness is probably minor and ane is left with a suspicion that some SEED patients may be admitted for long periods without much benefit.

4.1 Cure or care?

It seems to the author evident that all patients with SEED to be offered handling and that fully alleviating disorder. However non all patients benefit from this approach especially if it is provided against the patient's consent and in such cases a harm minimization or recovery approach focused on improving quality of life maybe more than humane and helpful.

iv.ii The recovery approach

This arroyo [21] that originated amongst service users in the United states posits that improved mental and concrete health tin be achieved even though the illness at the root of a person's difficulties cannot be cured. Thus a person with schizophrenia who hears voices, believes he is beingness bugged and has interpersonal difficulties tin can still be helped to deal with the symptoms through individual family unit and social interventions fifty-fifty though medication has had limited impact.

Can a like approach applied to eating disorders? Hither we will become through the unlike realms indicated by meet patients as problematic and place ways to approach them.

4.3 Medication

The role of medication in the eating disorders is limited and the chief group who appear to benefit are those with bulimia nervosa. Antidepressants such as high-dose fluoxetine can be tried with patients who accept had at least one bear witness-based psychological treatment for bulimia nervosa [22]. Of other drugs olanzapine has been tried in anorexia nervosa [23] and although the evidence is currently weak, some eating disorder specialists believe that the drug reduces anxiety and may have an impact in improving weight gain. Adequate randomised trials are awaited.

4.4 Psychological therapy

Patients with anorexia nervosa and bulimia nervosa are in both quantitative and qualitative studies are plant to endure from depression and anxiety. These difficulties oft correlate with the severity of the eating disorder symptoms such as lower weight or frequent bingeing and purging and treatments to reduce those are conspicuously the preferred approach. However patients with SEED have often received one or more courses of psychotherapy and perhaps 1 or more inpatient or day patient episodes. In anorexia nervosa there is little show that whatsoever therapy is meliorate than whatever other although in bulimia nervosa CBT [24] and some other approaches have been establish helpful. In a trial in which two therapies were tested in patients with long-standing anorexia nervosa [6] weight proceeds was modest just significant and at that place were pregnant improvements in depression and eating disorder symptoms. The two therapies were SSCM and cerebral behaviour therapy (CBT). SSCM is Specialist Supportive Clinical Management [25] and is a therapy that tin can be delivered by mental health staff without psychotherapy training. Information technology mostly addresses eating disorder behaviours and has been used as a control therapy in several randomised trials [half-dozen, 26, 27] in which the results were surprisingly good, frequently doing as well as the more complex therapy beingness studied. Hence information technology has earned itself a place in the NICE guidelines [28]. Initially it was designed exclusively for anorexia nervosa and a variant (SSCM-ED) has been used in all eating disorders [29]. SSCM and SSCM-ED take no published manual but a transmission for the latter tin can exist obtained from the writer of this chapter.

4.5 Physical risk monitoring

This is clearly required in anorexia nervosa of any elapsing, because without in patients tin deteriorate and dice from nutritional bug. For bulimia nervosa, the most common serious medical bug are electrolyte disturbances. Who should practise the monitoring is a point of fence. When specialist eating disorder services are scarce and expensive, there is an argument for monitoring to exist based in main care. However, the staff in primary care crave training in monitoring eating disorders and in what to exercise when a worrying finding, such as an abnormal ECG, is uncovered. Some full general practitioners are reluctant to accept on this piece of work, and a possible model in the United kingdom of great britain and northern ireland NHS might be to provide funding for primary care staff to provide this service, and a formal link with an eating disorders specialist to provide support and guidance when abnormalities are discovered. Unfortunately, this has not even so been achieved and care is thus oft a source of tension between chief and specialist care. Methods for monitoring patients with eating disorders accept been documented in MARSIPAN [xxx] and in Treasure [31]. For monitoring of concrete issues which develop over time merely do not usually threaten life, such as osteoporosis, the patient and medico demand to decide on whether and how oft to monitor the conditions. Some accept argued that equally the sole effective handling for osteoporosis due to anorexia nervosa is weight gain, and as we know it will go worse without increment in weight, repeated scans are not required. Others believe that knowing that the condition is deteriorating might provide an incentive to amend weight and secondly alerts patient, dr. and family to the increasing possibility of fractures afterwards lilliputian or no injury.

4.six Family interventions

Many patients with SEED-AN and SEED-BN describe difficulties with their families every bit already described. The problems from the family members' point of view are how to respond to a serious eating disorder which does non seem to be getting better, without suffering from low and other manifestations of stress, and without inadvertently making the eating disorder worse. For these families, collaborative caring [32] has a lot to offering, and has been shown [33] to result in lower distress levels in carers. Single or multiple family therapy might sometimes be indicated to help resolve some difficulties, although naturally the aim of therapy would exist improving family functioning and quality of life, rather than curing the eating disorder, as information technology is in younger, brusque history patients [34].

4.vii Social and occupational interventions

As described to a higher place, social isolation is commonly described in patients with long term anorexia nervosa and bulimia nervosa. Patients are reluctant to eat with others and may pass up invitations to become out, preferring to stay at home and binge-swallow. Attending a day service for handling can be a get-go pace in re-socialising and help to observe advisable voluntary work or educational courses can also exist a useful aid to recreating a social network. Some patients, especially with anorexia nervosa, observe that meeting other patients with the same condition can be more acceptable, because they do not need to explain their behaviour to others. However, while this may be helpful initially, it tin can upshot in further entrenchment of the eating disorder and if possible, wider social networks should be sought. The help of occupational therapy and nursing staff tin be invaluable in this procedure. If a patient already has a career, or is mid manner through a training, the staff can aid them reintegrate and request observer status before going dorsum to piece of work or study. For certain occupations, such as dance or athletics, the patient needs to decide whether pursuing the old career is possible without the eating disorder condign more severe.

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five. Summary and conclusions

A substantial proportion of individuals with eating disorder fail to recover either considering they have non had early admission to handling, or because they take not responded to such treatment. As time goes on the chances of recovery reduce but they never seem to reach zero, suggesting an asymptotic function underlying the chances of recovery with time. There is some testify to advise that over 3 years, anorexia nervosa, simply not, apparently bulimia nervosa, may become more entrenched and resistant to treatment. Both conditions, however, greatly affect quality of life and although the bloodshed is lower in bulimia nervosa, both conditions are associated with widespread disruption of physical health and psychological, family and social functioning. In long term eating disorders each of these realms require attention from professionals and from other informed individuals in families, who require adequate grooming and support, and the general public including ex-sufferers and charities such as BEAT. Severe and enduring eating disorders (SEED) should be recognised by the wider psychiatry community as deserving of attention and resources as much as other severe and indelible mental disorders so that the suffering endured by patients and their families as well as the costs incurred past individuals, families and gild tin be alleviated.

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Acknowledgments

The author would like to thank Ms. Jessica Jackson, Ms. Maxine Hughes, and Ms. Giulia Guidetti for permission to quote qualitative interview subjects. The author also thanks Professor Elena Tomba and Ms. Valentina Gardini, Academy of Bologna, for permission to quote data in Figure 2 and associated text.

References

1. Department of Wellness and Social Care. A National Service Framework for Mental Wellness: Modern standards and service models. UK: Section of Health; 1999
2. National Institute for Wellness and Care Excellence (Dainty). Draft guideline scope: Rehabilitation in adults with severe and enduring mental illness. 2018. Bachelor from:https://www.prissy.org.u.k./guidance/gid-ng10092/documents/draft-scope
3. Ruggeri M, Leese Thou, Thornicroft G, Bisoffi Yard, Tansella K. Definition and prevalence of severe and persistent mental disease. The British Journal of Psychiatry. 2000;177(two):149-155
4. Robinson P. Astringent and Enduring Eating Disorder (SEED): Direction of Complex Presentations of Anorexia and Bulimia Nervosa. Wiley: Chichester; 2009. p. 184
five. American Psychiatric Association. Diagnostic and Statistical Transmission of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013
6. Touyz South, Le Grange D, Lacey H, Hay P, Smith R, Maguire Due south, et al. Treating severe and indelible anorexia nervosa: A randomized controlled trial. Psychological Medicine. 2013;43(12):2512
7. Treasure J, Russell G. The case for early intervention in anorexia nervosa: Theoretical exploration of maintaining factors. The British Journal of Psychiatry. 2011;199(i):5-7
8. Russell GF, Szmukler GI, Cartel C, Eisler I. An evaluation of family therapy in anorexia nervosa and bulimia nervosa. Athenaeum of General Psychiatry. 1987;44(12):1047-1056
9. Theander S. Outcome and prognosis in anorexia nervosa and bulimia: Some results of previous investigations, compared with those of a Swedish long-term study. Journal of Psychiatric Research. 1985;nineteen(2-3):493-508
x. Deter HC, Herzog W. Anorexia nervosa in a long-term perspective: Results of the Heidelberg-Mannheim study. Psychosomatic Medicine. 1994;56(1):twenty-27
11. Fichter MM, Quadflieg N, Hedlund Due south. Twelve-twelvemonth grade and consequence predictors of anorexia nervosa. The International Journal of Eating Disorders. 2006;39(2):87-100
12. Herpertz-Dahlmann B, Muller B, Herpertz S, Heussen Due north. Prospective 10-twelvemonth follow-up in boyish anorexia nervosa—Course, effect, psychiatric comorbidity, and psychosocial adaptation. Periodical of Child Psychology and Psychiatry. 2001;42(5):603-612
xiii. Ratnasuriya RH, Eisler I, Szmukler GI, Russell GF. Anorexia nervosa: Outcome and prognostic factors later on xx years. The British Journal of Psychiatry. 1991;158:495-502
xiv. Strober M, Freeman R, Morrell W. The long-term class of severe anorexia nervosa in adolescents: Survival assay of recovery, relapse, and consequence predictors over 10-15 years in a prospective report. The International Journal of Eating Disorders. 1997;22(4):339-360
15. Wentz E, Gillberg C, Gillberg IC, Rastam M. X-year follow-up of adolescent-onset anorexia nervosa: Psychiatric disorders and overall operation scales. Journal of Child Psychology and Psychiatry. 2001;42(five):613-622
sixteen. Wentz E, Gillberg IC, Anckarsater H, Gillberg C, Rastam M. Adolescent-onset anorexia nervosa: 18-year event. The British Journal of Psychiatry. 2009;194(ii):168-174
17. Gardini Five. When do Eating Disorders Become Astringent and Enduring?. Unpublished Master degree dissertation, Supervisor Prof. Elena Tomba. Bologna: University of Bologna; 2019
18. Robinson PH, Kukucska R, Guidetti M, Leavey G. Severe and enduring anorexia nervosa (SEED-AN): A qualitative report of patients with 20+ years of anorexia nervosa. European Eating Disorders Review. 2015;23(four):318-326
19. Yager J. Management of patients with chronic, intractable eating disorders. In: Yager PS, editor. Clinical Manual of Eating Disorders. London: American Psychiatric Publishing; 2007
20. Wonderlich S, Mitchell JE, Crosby RD, Myers TC, Kadlec K, Lahaise 1000, et al. Minimizing and treating chronicity in the eating disorders: A clinical overview. The International Journal of Eating Disorders. 2012;45(four):467-475
21. Slade M. Mental disease and well-beingness: The central importance of positive psychology and recovery approaches. BMC Health Services Enquiry. 2010;10:26
22. Walsh BT, Wilson GT, Loeb KL, Devlin MJ, Expressway KM, Roose SP, et al. Medication and psychotherapy in the treatment of bulimia nervosa. The American Periodical of Psychiatry. 1997;154(4):523-531
23. Norris ML, Spettigue West, Buchholz A, Henderson KA, Gomez R, Maras D, et al. Olanzapine use for the adjunctive treatment of adolescents with anorexia nervosa. Journal of Child and Adolescent Psychopharmacology. 2011;21(3):213-220
24. Fairburn CG, Cooper Z, Doll HA, O'Connor ME, Bohn K, Hawker DM, et al. Transdiagnostic cognitive-behavioral therapy for patients with eating disorders: A two-site trial with sixty-week follow-up. The American Journal of Psychiatry. 2009;166(3):311-319
25. McIntosh VV, Jordan J, Luty SE, Carter FA, McKenzie JM, Bulik CM, et al. Specialist supportive clinical management for anorexia nervosa. The International Periodical of Eating Disorders. 2006;39(viii):625-632
26. Schmidt U, Renwick B, Lose A, Kenyon M, Dejong H, Broadbent H, et al. The MOSAIC study: Comparing of the Maudsley model of treatment for adults with anorexia nervosa (MANTRA) with Specialist Supportive Clinical Management (SSCM) in outpatients with anorexia nervosa or eating disorder not otherwise specified, anorexia nervosa type: Study protocol for a randomized controlled trial. Trials. 2013;xiv:160
27. McIntosh VV, Jordan J, Carter JD, Frampton CM, McKenzie JM, Latner JD, et al. Psychotherapy for transdiagnostic rampage eating: A randomized controlled trial of cognitive-behavioural therapy, ambition-focused cognitive-behavioural therapy, and schema therapy. Psychiatry Research. 2016;240:412-420
28. National Institute for Health and Care Excellence. Eating disorders: Recognition and treatment. NG69; 2017
29. Robinson P, Hellier J, Barrett B, Barzdaitiene D, Bateman A, Bogaardt A, et al. The NOURISHED randomised controlled trial comparing mentalisation-based treatment for eating disorders (MBT-ED) with specialist supportive clinical management (SSCM-ED) for patients with eating disorders and symptoms of borderline personality disorder. Trials. 2016;17(1):549
30. Royal College of Psychiatrists. MARSIPAN CR189. London; 2014
31. Treasure J. A Guide to the Medical Risk Assessment for Eating Disorders. 2009; Available from:https://www.kcl.ac.uk/ioppn/depts/pm/research/eatingdisorders/resources/GUIDETOMEDICALRISKASSESSMENT.pdf[Accessed: March 31, 2019]
32. Treasure J, Sepulveda AR, Whitaker W, Todd Grand, Lopez C, Whitney J. Collaborative care between professionals and non-professionals in the management of eating disorders: A description of workshops focussed on interpersonal maintaining factors. European Eating Disorders Review. 2007;15(1):24-34
33. Whitney J, Murphy T, Landau S, Gavan K, Todd K, Whitaker W, et al. A practical comparison of two types of family intervention: An exploratory RCT of family mean solar day workshops and individual family work as a supplement to inpatient care for adults with anorexia nervosa. European Eating Disorders Review. 2012;20(two):142-150
34. Blessitt East, Voulgari Due south, Eisler I. Family therapy for adolescent anorexia nervosa. Current Opinion in Psychiatry. 2015;28(6):455-460