By Dr. Stephanie Knatz Peck
As care providers, we do what we do because we want to provide help to people who need it. It’s difficult to watch people show up for mental health treatment, however, knowing that we don’t have adequate options to offer them help.
But this is the treatment landscape for anorexia nervosa. It is in a word bleak. As an article in JAMA noted eloquently last year, we have a crisis in care: a lethal condition with high relapse rates for which there are no FDA-approved treatments.
Anorexia nervosa is an eating disorder that causes people to obsess over food and their weight. It can be profoundly debilitating, and it is surrounded by myths and misapprehensions that I see my patients confront every day.
- Anorexia nervosa is not a new disease. The first documented case goes back to the 1800s, and prevalence rates have remained stable—about 1 percent—ever since. This speaks to the biological predisposition that people with anorexia nervosa have. Changing social ideals only adds complexity and challenge.
- Anorexia nervosa does not discriminate. It’s a life-threatening disease that affects people across gender, race, culture, class, income, and every other demographic.
- Anorexia nervosa does not affect only those at a certain weight. People who have anorexia do not have to weigh a specific amount, nor must they have lost a specific amount of weight. Weight restoration is, of course, a goal of treatment, but in an ideal world there would be more treatments adequately addressing the mental aspects of the illness (instead of just the physical), which would make recovery—even weight recovery—more achievable and sustainable.
- Anorexia nervosa is not a choice. People develop anorexia for many reasons, but not because they choose to. Anorexia is a complex brain disorder with strong genetic, neurobiological, and psychological underpinnings, aggravated by social pressures. And it is “egosyntonic,” which means it feels intertwined with a person’s very sense of self, making it that much harder to escape. Even if a person restores their weight, that doesn’t mean they don’t still have anorexia in their head.
- Anorexia nervosa isn’t about liking or disliking food. For people with anorexia nervosa, eating leads to measurable anxiety and distress: It is observable on brain scans. Restricting food intake reduces anxiety, and recovery requires them to perform an activity that them feel guilt and makes anxious. It’s very hard to routinely do something your neurochemistry will punish you for. This is why recovery can be so difficult and is often unsustainable.
- Anorexia nervosa is often comorbid with other conditionsincluding depression, anxiety, and obsessive-compulsive disorder.
- Anorexia nervosa has some of the highest mortality rates of any mental illness, second only to opioid addiction. Even in less severe outcomes, it negatively impacts a person’s ability to maintain employment or relationships. Anorexia behaviors take priority over everything, hampering all aspects of life.
The truths behind the myths are where we, as providers and researchers, are trying to help. It is alarming that over 30 million people in the US will experience an eating disorder in their lifetime, and yet only 20 percent of those will receive treatment.
We’ve struggled to find effective treatment for people with anorexia nervosa, particularly for adults. Existing treatments are limited, and there are no approved medications to offer patients. Adolescent treatment is often family therapy, which can be effective because, at that stage of life, support structures are often more encompassing, and can have a stronger effect on behaviors. However, there is a growing interest in treatment research, and some promising therapies are beginning to undergo evaluation, including psychedelic-assisted therapies, in which a psychedelic substance like psilocybin is paired with psychological support.
Why psilocybin therapy for anorexia nervosa? It makes sense on several levels. On a biochemical level, a long line of literature suggests that anorexia nervosa is associated with alterations in brain serotonin. The exploration of psilocybin, a serotonergic agonist, is therefore a useful avenue of research.
Psilocybin also has effects at a psychological level. Psilocybin therapy seems to help with psychological flexibility—to help people get out of deeply worn mental patterns: Anorexia nervosa is characterized by obsessive fears and rituals that cause restrictive behaviors. These are primarily related to food, weight, and shape and can feel like a swarm of alarming thoughts that can be relieved only by restriction. If a person doesn’t believe they have the capacity for new behaviors but suddenly has an experience where they see things differently, the experience can help them create new behavioral patterns and pull them out of those deeply worn ruts.
The research is at an early stage. I am a co-investigator in one of the clinical studies evaluating psilocybin-assisted therapy for anorexia nervosa. We will have our first data soon, and that will be a useful guide for what happens next. We hope to see strong signals of efficacy that could then lead to larger clinical trials to generate more data. We need to understand what the effects might be, how long they might last, and whom they might help.
Even if the therapy proves to be extremely effective, it is unlikely to be a cure. We hope that it will be a tool to help us address aspects of anorexia nervosa that we haven’t been able to assist with before. It may be a way, ideally, to undo brain patterns, to dislodge the egosyntonic nature of the illness, and to help people feel more de-identified from the disease.
It’s too early to know, but I’m heartened by the promise and the early signals that we have seen. I do know that we need to be able to offer patients the help and hope that they need and deserve, and we’ll keep going with our research efforts until we can do that.
Dr. Stephanie Knatz Peck
Source: Used with permission
Dr. Stephanie Knatz Peck is a clinical psychologist and associate clinical professor at the University of California, San Diego, where she specializes in eating disorders treatment. She is Director of Intensive Family Treatment programs at the UCSD Eating Disorder Center. Dr. Peck is also involved in novel clinical treatment development. Her recently published treatment manual, Temperament Based Treatment with Supports, describes her work in integrating family support into eating disorders care, and is a strengths-based framework for treatment based on temperament and personality. She is also involved in the development, delivery and evaluation of psychedelic-assisted therapies for eating disorders and is co-investigator on a study evaluating psilocybin-assisted therapy for anorexia nervosa.