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The case for early intervention in anorexia nervosa: theoretical exploration of maintaining factors

  • Janet Treasure (a1) and Gerald Russell (a2)


Here we revisit and reinterpret the original study in which the so-called ‘Maudsley (London) model’ of family therapy was compared with individual therapy for anorexia nervosa. Family therapy was more effective in adolescents with a short duration of illness. However, this is only part of the story. A later study describing the 5-year outcome contains important information. Those adolescents randomised to family therapy achieved a better outcome 5 years later. Moreover, the group with an onset in adolescence but who had been ill for over 3 years had a poor response to both family and individual therapy, suggesting that unless effective treatment is given within the first 3 years of illness onset, the outcome is poor. We examine other evidence supporting this conclusion and consider the developmental and neurobiological factors that can account for this.

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Corresponding author

Janet Treasure, Box PO59, Section of Eating Disorders, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF, UK. Email:


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The case for early intervention in anorexia nervosa: theoretical exploration of maintaining factors

  • Janet Treasure (a1) and Gerald Russell (a2)
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Janet Treasure, Professor of Psychiatry
31 August 2011

We thank Professor Morgan for responding to our Editorial and raisingtwo important points. First, he is correct in saying that there was already some evidence favouring the outcome in anorexia nervosa if patients were enrolled in treatment as soon as possible after the onset ofthe illness. This came from his follow-up study of patients treated in Bristol where the emphasis was on local, easily accessible, treatments. The outcome in the Bristol patients was significantly better than in thosetreated in two London hospitals providing “national services” (The Maudsley and St. George’s). This difference favouring Bristol was acknowledged by other experts in the field (1). But in his 1982 article Professor Morgan had already acknowledged the difficulty of assessing different therapeutic approaches in view of the selection of patients. Itis inescapable that an evaluation of the treatment requires randomised controlled trials, as in the studies of family therapy reviewed in our editorial.

Professor Morgan’s second point was to stress that family processesare crucial in contributing to the success of early intervention in anorexia nervosa. He is right in recognising the risks of alienation in the patients’ relatives which undermines their contributions to a successful treatment. Again we welcome his observations enabling us to expand our too brief description of the essential principles of successfulfamily therapy:1.Exonerating parents from causing the illness.2.Getting them to take joint control of their child’s eating so that he/she is enabled to maintain a normal body weight.

These principles need some elaboration. Exonerating the parents requires the therapist to communicate a neutral position regarding the causes of the illness. The medical pioneers in this field of study (eg Gull, Charcot) expressed strongly negative views about relatives’ poor management of the problem, views which should be dispelled. Charcot’s influence was, of course, strongest in France where the “cure d’isolement” has only been abandoned within recent memory.

The second essential requirement is fraught with difficulties. Parents at first resist taking the necessary action. Their experience leads them to believe that they have failed to prevent their child’s poor eating and weight loss. Some parents fear that firmness on their part will lead to a loss of their child’s affection. They may also jumpto the conclusion that an invitation to participate in treatment implies that they are being blamed. This can be combated by expressing the aims of therapy not as “changing the family” but rather as helping them manage a sick family member (2).

Successful management requires an on-going search for emotional and inter-personal factors (eg expressed emotion) which are responsible for maintaining (rather than causing) harmful behaviours. One of us (Treasure) has contributed to a practical manual describing the techniquesfor negotiating successful transactions between carer and adolescent, focussing on rapport, language and problem-solving skills (3 & 4).

(1) Theander, S (1985) Outcome and prognosis in anorexia nervosa and bulimia. Some results of previous investigations, compared with a Swedishlong-term study, Journal of Psychosomatic Research, 19, 493-508.

(2) Russell, G. Anorexia nervosa. New Oxford Textbook of Psychiatry, EDS Gelder, M.G., Andreasen, N.C., Lopez-Ibor, J.J. and Geddes, J.R. Second Edition. Oxford University Press, Oxford, p 788 and pp 790-792.

(3) Treasure, J., Smith G. and Crane, A. (2007). Skills-based learning for caring for a loved one with an eating disorder: The new Maudsley method. Routledge, London and New York.

(4) Goddard, L., Macdonald, P., Neuman, U., Sepulveda, A., Schmidt, U. & Treasure, J. (2011). A cognitive interpersonal maintenance modelof eating disorders: an intervention for carers. British Journal of Psychiatry.

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Conflict of interest: None declared

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Gethin Morgan, Emeritus Professor of Mental Health
19 August 2011

The Correspondence EditorBritish Journal of Psychiatry

6 July 2011

Dear Correspondence Editor,

It is indeed rewarding to see that Treasure and Russell, in their Editorial on early intervention in anorexia nervosa (1), offer much in support of it. Over many years our therapeutic approach in Bristol placed great emphasis on getting patients into treatment as soon as possible after the onset of the anorexic illness. This was supported by evidence from a study which compared outcome in Bristol with two other treatmentcentres (2). In line with this we emphasised the importance of developing local easily accessible treatment facilities.

Given their welcome support for close involvement of relatives in thetreatment process, Treasure and Russell might well have also included family processes along with the several brain mechanisms which they evaluate as possible reasons why early intervention may be important. If the illness continues for any length of time such factors as loss of heart by relatives, and increasing blaming for failure to respond to help can lead to a progressive alienation of an anorexic relative and impairment of the family's ability to contribute constructively to treatment. Though negative attitudes have long been recognized, they remain a serious obstacle to the development of effective treatments of anorexia nervosa. Surely further research is still required into understanding them more fully as well as into their prevention and management, especially when an anorexic illness is at risk of becoming chronic.

1 Janet Treasure and Gerald Russell The case for early intervention in anorexia nervosa: theoretical exploration of maintaining factors B JPsych(2011) 19 5-72 H G Morgan, Joan Purgold and Jill Welbourne. Management and Outcome inAnorexia Nervosa: A Standardised Prognostic Study. B J Psych. (1983) 143 282-287

Yours sincerely


Emeritus Professor of Mental Health, University of Bristol.

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Conflict of interest: None declared

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Early intervention in Anorexia Nervosa

E. Jane B Morris, Psychiatrist
21 July 2011

As a psychiatrist who has worked across the age range and in inpatient,day patient and outpatient settings with people with anorexia nervosa, I wholeheartedly endorse Treasure and Russell's exhortation to usto strenuously pursue effective treatment as soon as the diagnosis of anorexia nervosa is made. We are all too often guilty of delivering healf-hearted or incomplete treatments in the hope that motivation for change will grow as a result of living with the illness. The brain changes hypothesised in this paper provide a powerful counter blast for us to intervene more assertively and then to persist with evidence-based therapy.

When I consider my own recent caseload, however, I am struck by some remarkable recoveries in older women who have been ill for decades, in contrast with pooer outcomes in some much younger women. The difference seems to be that these older sufferers had not previously received specialist treatment and had kept their disorder as private as possible from other people, so that both the treatment team and lay carers came to therapy innocent of the frustration and fatigue that we so often reach in the course of very long and repeated contact with patients.

Whilst it is likely that life with a starved brain, and one which is not available for healthy psychosocial development may well make be associated with poorer prognosis, may I suggest that we should also locatesome of the responsibility in our own brains and those of lay carers. Theauthors of this paper have led the development of the most effective family interventions in the treatment of anorexia nervosa and may be best placed to develop 'remotivating' interventions to counteract despair in both families and treatment teams.
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