What is the role of Acceptance and Commitment Therapy (ACT) in treating anorexia nervosa?

Role of Acceptance and Commitment Therapy (ACT) in Treating Anorexia Nervosa

Acceptance and Commitment Therapy (ACT) is not currently recommended as a first-line treatment for anorexia nervosa according to the most recent American Psychiatric Association guidelines. Instead, eating disorder-focused psychotherapies are the recommended approach for adults with anorexia nervosa 1.

Current Recommended Treatments for Anorexia Nervosa

The 2023 American Psychiatric Association practice guideline for eating disorders provides clear recommendations for anorexia nervosa treatment:

For Adults:

• APA recommends (1B) that adults with anorexia nervosa be treated with an eating disorder-focused psychotherapy, which should include:
  • Normalizing eating and weight control behaviors
  • Restoring weight
  • Addressing psychological aspects of the disorder (e.g., fear of weight gain, body image disturbance) 1

For Adolescents and Emerging Adults:

• APA recommends (1B) that those with an involved caregiver be treated with eating disorder-focused family-based treatment 1

Evidence-Based Psychotherapies for Anorexia Nervosa

The current evidence supports several specific psychotherapies:

• Enhanced Cognitive Behavioral Therapy (CBT-E): Designed specifically for eating disorders and shows promising results for adults and adolescents with anorexia nervosa in both outpatient and inpatient settings 2

• Family-Based Treatment (FBT): Particularly effective for adolescents and emerging adults 1

• Maudsley Anorexia Treatment for Adults (MANTRA)

• Psychodynamic-oriented psychotherapies

However, comparative efficacy studies show that none of these interventions consistently outperform treatment as usual in terms of BMI improvement or reduction in eating disorder symptoms 3.

Where ACT Fits in the Treatment Landscape

ACT is not specifically mentioned in the current APA guidelines for anorexia nervosa treatment 1. This suggests that while ACT may have theoretical applications to eating disorders, there is insufficient evidence to recommend it as a primary treatment approach.

ACT principles that could potentially benefit anorexia nervosa patients include:

• Acceptance of difficult thoughts and feelings about body image
• Mindfulness to reduce automatic responses to food-related anxiety
• Value-based actions that align with health rather than eating disorder behaviors

Technology-Based Interventions

For patients with limited access to specialized care, technology-based interventions (TBIs) are emerging as potential supplementary approaches:

• Computer and internet-based interventions (CBIs) show promise, especially when guided by therapists 1
• Videoconferencing appears to be a promising approach for delivering therapy remotely 1
• These approaches may help address the unmet need for treatment, as only about one-quarter of eating disorder sufferers seek specific treatment 1

Clinical Algorithm for Anorexia Nervosa Treatment

1. Initial Assessment:

   • Complete medical evaluation including vital signs, weight/BMI, and laboratory tests 1
   • Comprehensive psychiatric evaluation 1
   • Assessment of co-occurring conditions 1

2. Primary Treatment Selection:

   • For adults: Eating disorder-focused psychotherapy (CBT-E, MANTRA) 1, 2
   • For adolescents/emerging adults: Family-based treatment 1

3. Treatment Implementation:

   • Set individualized goals for weekly weight gain and target weight 1
   • Focus on normalizing eating behaviors and addressing psychological aspects 1
   • Monitor physical health parameters throughout treatment 1

4. Consider Adjunctive Approaches:

   • Technology-based interventions for those with access barriers 1
   • ACT principles may be incorporated within the framework of evidence-based treatments, but not as a standalone primary approach

Pitfalls and Caveats

• Treatment Acceptance: Anorexia nervosa has high rates of treatment refusal and dropout 1, 3
• Delayed Treatment: Patients often undergo psychological treatment only after considerable delay 1
• Specialist Shortage: There is a general shortage of specialized therapists and institutions 1
• Singular Treatment Approaches: Using only one treatment modality has historically been associated with poor outcomes 4

Conclusion

While ACT contains principles that may be beneficial for patients with anorexia nervosa, current evidence and guidelines do not support its use as a primary standalone treatment. The APA guidelines clearly recommend eating disorder-focused psychotherapies for adults and family-based treatment for adolescents with anorexia nervosa. Future research may better establish ACT's role in eating disorder treatment, but for now, clinicians should prioritize the evidence-based approaches outlined in current guidelines.