Dear Editor,

We read with great interest the letter by Himmerich et al., “Psychopharmacological Options for Adult Patients with Anorexia Nervosa: The Patients’ And Carers’ Perspective,”Reference Himmerich, Joaquim and Bentley¹ commenting on our paper recently published in CNS Spectrums.Reference Miniati, Mauri, Ciberti, Mariani, Marazziti and Dell’Osso² We found noteworthy their proposal of taking a deeper look at the limitations that anorexia nervosa (AN) patients might have regarding drug treatments, especially those that might increase body weight.

The authors focused on two main problems: (1) the poor compliance of AN patients might derive from scarce educational support and from clinicians’ underestimation of patients’ subjective experience of the illness; and (2) patients’ perceptions of drugs as “unspecific” for AN signs and symptoms and their concerns about weight gain. We agree with Himmerich et al.Reference Himmerich, Joaquim and Bentley¹ that drugs are often described by patients as reducing anxiety and helpful with sleep problems and depressive symptoms but are ineffective in terms of the psychopathological core of AN—namely, their self-perception of body dysmorphia.

Himmerich et al.Reference Himmerich, Joaquim and Bentley¹ summarized the results from a quality improvement (QI) project on a specialist unit for eating disorders (EDs) at the South London and Maudsley National Health Service Foundation Trust. They highlighted the distance between patient’s subjective perception of the illness and that of caregivers regarding both pharmacological options and therapeutic goals. We strongly agree with the authors that systematic adoption of outcome measures focused on effectiveness, safety, and subjective experience of care from a patient’s perspective should be considered for future randomized controlled trials (RCTs). Along these lines, more than 10 years ago (2002)Reference Cassano, Frank and Miniati³ we suggested the use of a “spectrum assessment” as a phenotypic dimensional description of the most important psychiatric disorders, including EDs, directed toward the full extent of the signs, symptoms, and traits experienced by the patient over a lifetime. The rationale for this model was actually twofold: (1) to assess and better understand the course of AN symptomatology, and (2) to highlight the signs and symptoms that patients consider relevant to their “subjective experience of illness.” The phenotypic description of AN within the “spectrum assessment method” can provide a tailored picture of the single patient, and when patients complete the spectrum assessment, they are likely to report feeling that their symptoms are better understood by their clinicians.

We proposed this approach in several studies, mainly with respect to mood and anxiety disorders.Reference Miniati, Rucci and Frank⁴ In the psychopathological area of EDs, we constructed and validated an interview and a self-rating instrument, the Anorexic–Bulimic Spectrum Questionnaire (ABS–SR), within the framework of an Italian multicenter study.Reference Mauri, Borri and Baldassari⁵ The ABS–SR encompassed nine psychopathological domains: (1) attitudes and beliefs; (2) weight history; (3) self-esteem and satisfaction; (4) phobias; (5) avoidant and compulsive behaviors; (6) weight maintenance; (7) eating dyscontrol; (8) associated features and consequences; and (9) interference and level of insight.

The second point of discussion raised by Himmerich et al.Reference Himmerich, Joaquim and Bentley¹ is related to the difficulties experienced by patients in taking drugs that are mainly targeted at anxiety and mood symptoms, such as selective serotonin reuptake inhibitors (SSRIs), or drugs that are perceived as “dangerous” because of feared side effects or weight gain, common with both antipsychotics and SSRIs. Again, we agree with the authors that studies focused on increasing weight had little success, because weight gain is the clinician’s goal, not the patient’s. We also agree on the proposal for a scientific exploration of patients’ goals as part of future RCTs. In line with this idea, we believe that the role of dopamine 1 and 2 receptor antagonists should be reconsidered in a new light, and they should be utilized for the more severe forms of AN, when body image distortion reaches delusional intensity and compliance is limited by poor insight. However, the evidence in this field is still limited. The impact on delusional fear of weight gain or on body image distortion has usually been disregarded. In view of this, the rationale for administration of antipsychotics has been more closely associated with psychomotor hyperactivity control and with induction of weight gain, thus reinforcing the distance between the goals of patients and clinicians. Conversely, in line with Himmerich et al.,Reference Himmerich, Joaquim and Bentley¹ we propose an integrated approach that considers the systematic exploration of a patient’s goals as clinically relevant. We also propose a more refined phenotypic description of the different (and subjectively perceived) forms of AN (with the “spectrum model assessment”) and the adoption of a new rationale for the use of “old drugs” (such as the antipsychotics) that focus on body image distortion rather than on sedation or weight gain.