Advances in Psychiatry

Evelyn Attia, MD

Psychiatrists Evelyn Attia, MD, Director of the Center for Eating Disorders at NewYork-Presbyterian, and Joanna Steinglass, MD, Director of Research at the Center for Eating Disorders at NewYork-Presbyterian, are nationally recognized experts in the field of eating disorders, particularly anorexia nervosa. Working in partnership with staff at the New York State Psychiatric Institute (NYSPI), Drs. Attia and Steinglass helped develop Relapse Prevention and Changing Habits (REACH+), a treatment they are studying for anorexia nervosa that specifically addresses persistent maladaptive behaviors and habits.

“Habits are the way that our brains can function more efficiently so that we are not re-learning each and every day how to do something that we’ve done on days before,” says Dr. Attia. “In eating disorders, and specifically in anorexia nervosa, we believe that habit circuitry gets engaged in the service of maintaining the core behaviors of illness. REACH+ was developed to interrupt these sticky behaviors.”

Neural Circuitry and the Development of Habits

Joanna Steinglass, MD

REACH+ evolved from Dr. Steinglass’ research into the brain circuitry associated with eating behaviors central to anorexia nervosa. “The story starts with working with patients on the eating disorders unit and hearing the way they describe their experience of getting stuck,” says Dr. Steinglass. “Something shifts as they undergo weight restoration treatment, but they still find themselves feeling like they must do certain things in certain ways, and some of those things are not so helpful to them anymore.”

Dr. Steinglass explains that, as her team looked at the neuroscience of anorexia nervosa, evidence pointed to neural circuits in the brain, such as the dorsal frontostriatal circuits, playing a role in these maladaptive behaviors. “For the patients, making decisions about eating involves a different set of neural circuits than the parts of the brain that are active for people who have never had an eating disorder,” she says. “When you think about brain circuits for rewarding behavior, you’re used to thinking about the nucleus accumbens and ventral dopamine pathways. When you do something repeatedly, brain activity shifts from that pathway to the dorsal frontostriatal circuit. The shift occurs as the repeated behaviors have developed the characteristics of a habit.”

“Something shifts as they undergo weight restoration treatment, but they still find themselves feeling like they must do certain things in certain ways, and some of those things are not so helpful to them anymore.” — Dr. Joanna Steinglass

The goal of REACH+, according to Dr. Steinglass, is to give people more options, more flexibility, and greater awareness of their own behavior, and increase the ability to choose behaviors that do not reinforce or promote the eating disorder.

The REACH+ Approach

REACH+ is the first study of its kind to focus on changing habits to help with relapse prevention. Through this randomized, interventional study supported by the National Institute of Mental Health (NIMH), New York-Presbyterian and NYSPI staff will target the habitual control of maladaptive behavior to support patients with anorexia nervosa in the six months after acute treatment on a specialized inpatient unit. “We know a lot about how to help people get weight restored. We also know that after acute treatment there’s this incredibly vulnerable period four to six months after leaving a weight restoration program where relapse rates are particularly high,” says Dr. Steinglass. “We wanted to offer individuals with anorexia nervosa a new set of specialized tools specifically for that highly vulnerable phase.”

Each component of REACH+ seeks to identify and optimize a relapse prevention treatment program that balances treatment efficacy and burden. The researchers will first test the acceptability and feasibility of five components that together target habits:

• Behavioral
• Cognitive
• Motivation
• Food Monitoring
• Skill Consolidation

“All of the components are aspects of psychological treatment that have demonstrated some benefit in other research studies,” says Dr. Steinglass. “We are particularly emphasizing behavioral change in this treatment but are well aware that this needs to be addressed in combination with other key features of illness, so the treatment package will have all of these parts. We are using an efficient, state-of-the-art clinical trial design so that we can test different versions of the treatment components. Each participant receives all components, but there are slight differences between these versions.”

The REACH+ team is seeking to recruit 60 adults with a diagnosis of anorexia nervosa who complete the weight restoration program at NYSPI and are medically stable. Participants will be randomly assigned to different versions of each treatment component. The therapeutic interventions take place using telehealth sessions together with resources available on an online platform that participants may access between sessions. Participants will meet with their individual REACH+ therapist twice weekly for the first six weeks of the study and then once weekly after that.

The NewYork-Presbyterian Difference

NewYork-Presbyterian has been providing evidence-based care to individuals with eating disorders for more than four decades. Through NewYork-Presbyterian’s inpatient and outpatient treatment programs, individuals have access to state-of-the-art, evidence-based treatments centered on weight restoration and therapeutic management of cooccurring psychological and behavioral issues.

“Even early on, when many programs were approaching the treatment of individuals with eating disorders in highly eclectic ways that included many ineffective treatment strategies, the program at New York-Presbyterian insisted on offering behaviorally focused treatments for these behavioral disorders,” says Dr. Attia. “Our center has made a practice of training those who are new to the field and delivering the very latest effective treatment techniques to the many adolescents and adults who come to us for help.”

“Our goal is to give people more options for recovery, and better ability to do battle with their eating disorder, including choosing new behaviors rather than those on the well-worn paths driven by their eating disorder,” adds Dr. Steinglass.