Anorexia Nervosa (AN) is a serious illness associated with substantial morbidity and a mortality rate among the highest of any psychiatric disorder. At the core of the illness is a salient behavioral disturbance - avoidance of eating - which is not satisfactorily addressed by currently available treatments for older adolescents and adults with AN. Re-hospitalization with a year after acute weight restoration is common. Current psychotherapeutic and pharmacological treatments for relapse prevention are inadequate. New and innovative treatments are clearly needed. The diminished food intake by patients with AN, especially of foods with high caloric/high fat content, is associated with high levels of anxiety and avoidance behaviors around meals and with limited motivation to change. These characteristics - anticipatory anxiety, stimulus-related anxiety, feared consequences, and avoidance rituals - strongly resemble core disturbances of anxiety disorders, including phobias and OCD. Techniques successfully employed in the treatment of anxiety disorders have not been systematically employed in the treatment of AN. By addressing fear of food specifically, these techniques may substantially alter patient's eating behavior such that they are able to have increased eating flexibility, thereby improving their ability to maintain weight. Using a new treatment that utilizes such techniques to reduce avoidance of eating while simultaneously enhancing motivation to change, the current application aims to study a novel psychotherapeutic and behavioral treatment for older adolescents and adults with AN, which we have entitled Food Exposure Therapy and Ritual Prevention with Motivational Enhancement for Relapse Prevention in AN (AN-EX/RP). AN-EX/RP consists of in session exposures to feared eating situations without employing avoidance behaviors, as well as formal motivational interviewing techniques. In the initial phase, we will complete manualization of AN-EX/RP and pilot testing with 8 participants. In the subsequent 2.5 years, 30 patients who have successfully re-gained to a normal body weight in our inpatient program will be randomly assigned to receive AN-EX/RP or cognitive behavioral therapy for AN (CBT-AN) in a 6 month, outpatient treatment. This pilot study will determine whether AN-EX/RP reduces avoidance of high fat/high calorie foods and will estimate the impact of this treatment on reducing relapse. Anorexia nervosa is a devastating illness with substantial morbidity and a mortality rate estimated to be 5% per decade of illness, among the highest of any psychiatric illness. Relapse rates are high, with up to 50% of patients re-hospitalized within a year after successful weight restoration. This grant proposes a new and innovative treatment for patients with anorexia nervosa, which if successful, will reduce this high relapse rate and could have implications for acute treatment of anorexia nervosa, as well.
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