Chapter 15: Evidence Based Interventions for

Eating Disorders

Peter M. DoyleCatherine ByrneAngela Smyth

Daniel Le Grange

Overview: DSM-5

Anorexia Nervosa: failure to achieve or maintain a minimum weight for age and height, fear of gaining weight although underweight, and disturbance of self-perception of body weight or shape or denial of seriousness of low body weight

Bulimia Nervosa: normal weight, but engaging in regularly occurring episodes of binge eating coupled with compensatory behaviors

Binge Eating Disorder: binge eating but not engaging in any compensatory behaviors

Feeding and Eating Disorder Not Elsewhere Classified: engaging in some sort of disordered eating

Eating Disorder Rates

At age of 20, 0.8% of people in United States will have anorexia2.6% bulimia3.0% binge eating disorder4.8–11.5% feeding and eating disorder not elsewhere

classified

Typical age for onset: 16 to 20 years old

Increasingly younger cases are being seen in the United States

Anorexia: Family Based Treatment

Family-Based Treatment for Anorexia Nervosa (FBT-AN)

Focus: weight restoration and aiming to empower parents and families to elicit change

Primary therapist coordinates treatment team Team: family, therapist, medical provider, psychiatrist

Three phases: 1) Engage the entire family in the eating disorder 2) Control over food decisions is gradually handed back to child/adolescent 3) Help patient and his or her family navigate a return to normal trajectory of

adolescent development

Only treatment that has well-established empirical evidence

Behavioral Family Systems Therapy

Parental involvement and initial control over eating to help patients overcome anorexia

Unlike FBT-AN, BFST does not focus on empowering parents to use their own intuition to facilitate changes to meals and food choiceParents work with a nutritionist

Three phases: 1) Parent training related to implementation of behavioral weight gain

program2) Parents maintain control over eating, but sessions turn to identify

cognitions that are underlying eating disorder3) Patient assumes responsibility for his/her own eating and weight

Evidence indicates this is a promising therapy

Adolescent Focused Psychotherapy (AFP)

Individual psychotherapy from a self-psychology model

Focus: helping patients to identify, tolerate, and more effectively manage their emotions

Three phases: 1) Building rapport between therapist and patient and developing a

mutually understood conceptualization of anorexia2) Enhancing individualization and independence from parents3) Developing appropriate coping strategies to deal with the tasks of

adolescence and engage in independent behaviors

RCT indicated that FBT was significantly superior to AFP

CBT for Bulimia

Cognitive behavioral therapy for bulimia nervosa (CBT-BN)

Three stages1) Establish rapport, increase motivation for treatment2) Address distorted cognitions surrounding food, eating,

weight, shape3) Consolidate treatment gains and develop a relapse

prevention plan

RCT compared CBT to family therapy: CBT showed improvements over family therapy at 6 months, but not 12

Family Based Treatment for Bulimia

Relies on family involvement to address eating disorder symptoms

Three Phases1) Shifts control of eating over to the parents2) Shifting control of eating and food-related decisions back to

adolescent in gradual fashion3) Addresses developmental issues and encourages

communication between parents and adolescents

Two RCTs have provided empirical evidence for FBT-BN

Binge Eating Disorder

No RCTs have been published examining the efficacy of treatment for adolescents with binge eating disorder

In adults, interpersonal psychotherapy, cognitive behavioral therapy, and dialectical behavior therapy are efficacious for binge eating

Parental Involvement: Family Based Treatment of Anorexia

Parent involvement critical and central to this approach

Parents can: Get frustrated with refusal to eat Misinterpret refusal to eat Blame their child for bringing stress on the family Retreat from role and become overly permissive

To be most effective: aligned with one another and sending consistent messages regarding decisions about the child’s meals and activity level

Parental Involvement: Bulimia

Adolescents with bulimia are less likely to need parentsOften more motivated during treatment

Involvement varies based on the case and family dynamics

Can assist with CBT

Younger patients can benefit from reminders to use rational responses to automatic thoughts

Adaptations and Modifications

FBT: age of child/adolescent needs to be taken into consideration, and adaptations made for developmental level

Bulimia: common for adolescents to have a comorbid psychiatric disorder; treatments can include additional mental health professionals to treat these comorbid disorders

Binge Eating Disorder: developmental concerns

Measuring Treatment Effects

Weight: measured weekly

Frequency of binge eating and purging: assessed via self-report

CBT self-monitoring: cognitions about food, weight, shape, or mood state

Gold standard: Eating Disorder ExaminationSemi structured interview conducted by a clinicianMeasures disordered eating over 28-day periodFour subscales: eating concern, shape concern, weight concern,

dietary restraintGlobal score

Clinical Case: Annalise

15-year-old Caucasian female

Assessment: weight started at 115 lbs and at assessment weighed 92 lbs; BMI 2nd percentile; consumes fewer than 1,000 calories per day most days; fears of “becoming fat again”

Diagnosis: GAD, anorexia

Treatment plan: FBT-AN, medication to treat preexisting anxiety symptoms

Outcome: continued to gain weight weekly with help of parents; improvements in eating restraint, eating concern, weight concern, and shape concern; reductions in anxiety