Download Lit Review Eating Disorders

A Resource for
Counsellors and
Psychotherapists Working
with Clients
Suffering from Eating
Disorders
CLASS NAME
STUDENT NAME
ROOM NUMBER
Christine Knauss
Margot J. Schofield
School of Public Health, La Trobe University, Melbourne, Australia
February 2009
© La Trobe University, February 2009
Distributed by PACFA under licence from La Trobe University
This publication is copyright. No part may be reproduced by any process except in
accordance with the provisions of the Copyright Act 1968.
Suggested citation:
Knauss, C. & Schofield, M.J. (2009). A resource for counsellors and psychotherapists
working with clients suffering from eating disorders. Melbourne: PACFA.
Acknowledgments:
The review was generously funded by an anonymous philanthropic body.
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Foreword
This document is a literature review of research prior to 2009 into the
effectiveness of therapeutic approaches for treating eating disorders, intended as a
resource for counsellors and psychotherapists. It was written on behalf of the
PACFA Research Committee. However, this does not imply that PACFA or its
Member Associations endorses any of the particular treatment approaches
described.
The PACFA Research Committee recognises that it is important to counsellors and
psychotherapists that they have access to recent research evidence that
demonstrates the effectiveness of different therapeutic approaches, to assist them
in their practice. This document is one of a series of reviews that was
commissioned by the PACFA Research Committee to support its Member
Associations in their work.
The PACFA Research Committee endorses the American Psychological
Association’s definition of evidence-based practice as ‘the integration of the best
available research evidence with clinical expertise in the context of patient
characteristics, culture and preferences’, although we would prefer to use the
word client or consumer rather than ‘patient'
The PACFA Research Committee recognises that there is overwhelming research
evidence to indicate that, in general, counselling and psychotherapy are effective
and that, furthermore, different methods and approaches show broadly equivalent
effectiveness. The strength of evidence for effectiveness of any specific counselling
and psychotherapy intervention or approach is a function of the number,
independence and quality of available effectiveness studies, and the quality of
these studies is a function of study design, measurements used and the ecological
validity (i.e. its approximation to real life conditions) of the research.
The PACFA Research Committee acknowledges that an absence of evidence for a
particular counselling or psychotherapy intervention does not mean that it is
ineffective or inappropriate. Rather, the scientific evidence showing equivalence of
effect for different counselling and psychotherapy interventions justifies a starting
point assumption of effectiveness.
We recognise the need to improve the evidence-base for the effectiveness of
various therapeutic approaches. The PACFA Research Committee is committed to
supporting our Member Associations and Registrants to develop research
protocols that will help the profession to build the evidence-base to support the
known effectiveness of counselling and psychotherapy.
We hope that you will find this document useful and would welcome your
feedback.
Dr Sally Hunter
Chair of the PACFA Research Committee, 2011
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Contents
1. Introduction ...................................................................................................................................... 1
2. Types of eating disorders ............................................................................................................. 1
2.1 Diagnostic criteria for Anorexia Nervosa ....................................................................... 2
Table 1: Summary Anorexia Nervosa ............................................................................... 2
2.2 Diagnostic criteria for Bulimia Nervosa .......................................................................... 2
Table 2: Summary Bulimia Nervosa .................................................................................. 3
2.3 Diagnostic Criteria for Eating Disorder Not Otherwise Specified......................... 3
Table 3: Summary Binge Eating Disorder ....................................................................... 3
3. Prevalence .......................................................................................................................................... 4
4. Causes and risk factors ................................................................................................................. 4
Table 4: Risk Factors for Eating Disorders ..................................................................... 5
5. Therapeutic interventions ........................................................................................................... 5
5.1 Therapeutic alliance ............................................................................................................... 6
5.2 Therapy for anorexia nervosa............................................................................................. 7
Table 5: Summary therapy for anorexia nervosa ..................................................... 12
5.3 Therapy for bulimia nervosa ............................................................................................ 12
Table 6: Summary therapy for bulimia nervosa ........................................................ 15
5.4 Therapy for eating disorder not otherwise specified ............................................. 15
6. Summary and conclusion .......................................................................................................... 16
Table 7: Internet Resources............................................................................................... 16
References ........................................................................................................................................... 18
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1. Introduction
This literature review is based on available empirical evidence and has been
developed to provide a resource for counsellors and psychotherapists working
with clients who have eating disorders. It is not based on a systematic literature
review but summarizes current evidence base for therapeutic approaches to
working with eating disorders. It has been reviewed by the Research Committee of
PACFA, the PACFA Board, and by international eating disorder experts:
•
Professor Phillippa Hay, Professor and Foundation Chair of Mental Health,
School of Medicine, University of Western Sydney, Sydney;
•
Professor Susan Paxton, Head of the School of Psychological Sciences, La
Trobe University, Melbourne;
This resource gives an overview of types of eating disorders, prevalence, causes,
risk factors and evidence for effective therapy. The review is consistent with
current scholarship on the definition of evidence base in psychological practice
and mental health areas (e.g., APA Presidential Taskforce on Evidence-Based
Practice, 2006). It also provides information about internet links for other
therapeutic resources and guidelines.
2. Types of eating disorders
Individuals who suffer from an eating disorder have problems with their eating,
weight management practices and body image. These problems often lead to
severe, sometimes life-threatening, physiological and psychological consequences.
Severe restriction of food intake can result in depression, social withdrawal,
preoccupation with food, changes in hormone secretion, amenorrhea (i.e. the
absence of at least three consecutive menstrual cycles), decreases in the metabolic
rate and binge eating. Eating disorders, particularly anorexia nervosa, have one of
the highest mortality rates of any mental disorder, with a death rate of 15.6%
(Zipfel, Lowe, Deter, & Herzog, 2000) due to suicide or medical complications
(often cardiac arrest secondary to arrhythmias). Therefore it is particularly
important, as described in the section about therapeutic interventions, to integrate
risk monitoring and management into therapy.
There are three different disorders listed in the Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition, Text Revision (DSM-IV) which can be captured
under the phrase of “eating, weight, and shape-related” disorders: Anorexia
nervosa, Bulimia nervosa and Eating Disorder Not Otherwise Specified. Below are
the diagnostic criteria for the three eating disorders according to the DSM-IV-TR
(American Psychiatric Association, 2000a).
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2.1 Diagnostic criteria for Anorexia Nervosa
A. Refusal to maintain body weight at or above a minimally normal weight for age
and height (e.g., weight loss leading to maintenance of body weight less than 85%
of that expected; or failure to make expected weight gain during period of growth,
leading to body weight less than 85% of that expected).
B. Intense fear of gaining weight or becoming fat, even though underweight.
C. Disturbance in the way in which one’s body weight or shape is experienced,
undue influence of body weight or shape on self-evaluation, or denial of the
seriousness of the current low body weight.
D. In post-menarcheal females, amenorrhea (i.e., the absence of the least three
consecutive menstrual cycles). A woman is considered to have amenorrhea if her
periods occur only following hormone administration.
Table 1: Summary Anorexia Nervosa
Anorexia is characterised by:
A severe restriction of food intake
A loss of body weight to an unhealthy level
A loss of menstrual periods (female)
An intense fear of getting “fat”, and/or losing control of eating
Body image disturbance: regarding the body as fat despite being
underweight.
2.2 Diagnostic criteria for Bulimia Nervosa
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by:
1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount
of food that is larger than most people would eat during a similar period of
time and under similar circumstances;
2. A sense of lack of control over eating during the episode (e.g., a feeling that
one cannot stop eating or control what or how much one is eating).
B. Recurrent, inappropriate compensatory behaviour in order to prevent weight
gain such as: self-induced vomiting; misuse of laxatives, diuretics, enemas, or other
medications; fasting; or excessive exercise.
C. The binge eating and inappropriate compensatory behaviours both occur, on
average, at least twice a week for 3 months.
D. Self-evaluation is unduly influenced by body shape and weight.
E. The disturbance does not occur exclusively during episodes of anorexia nervosa.
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Table 2: Summary Bulimia Nervosa
Bulimia nervosa is characterised by a cycle of binge eating followed by
compensatory behaviour such as purging, laxative abuse or over-exercising to
get rid of the food.
2.3 Diagnostic Criteria for Eating Disorder Not Otherwise Specified
The Eating Disorder Not Otherwise Specified (EDNOS) category is for disorders of
eating that do not meet the criteria for any specific eating disorder. One form of
EDNOS can be binge eating disorder.
Diagnostic Criteria for Binge-Eating Disorder
A. Recurrent episodes of binge eating. An episode of binge eating is characterized
by:
1. Eating, in a discrete period of time (e.g., within any 2-hour period), an
amount of food that is larger than most people would eat during a similar
period of time and under similar circumstances
2. A sense of lack of control over eating during the episode (e.g., a feeling that
one cannot stop eating or control what or how much one is eating).
B. The binge-eating episodes are associated with three (or more) of the following:
1. Eating much more rapidly than normal
2. Eating until feeling uncomfortably full
3. Eating large amounts of food when not feeling physically hungry
4. Eating alone because of being embarrassed by how much one is eating
5. Feeling disgusted with oneself, depressed, or very guilty after overeating.
C. Marked distress regarding binge-eating is present.
D. The binge eating occurs, on average, at least 2 days a week for 6 months.
E. The binge eating is not associated with the regular use of inappropriate
compensatory behaviours (e.g., purging, fasting, excessive exercise) and does not
occur exclusively during the course of anorexia nervosa or bulimia nervosa.
Table 3: Summary Binge Eating Disorder
Binge eating disorder is characterised by periods of binge eating (uncontrolled,
impulsive or continuous eating) without compensatory behaviours such as
vomiting or excessive exercise.
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3. Prevalence
Eating disorders have been reported to be one of the ten leading causes of
disability and distress among young women in Australia (Mathers, Vos, Stevenson,
& Begg, 2000). The prevalence of specific eating disorders such as anorexia
nervosa or bulimia nervosa has been considered relatively low in comparison to
other mental disorders such as affective disorders or anxiety disorders (Piran,
Levine, & Steiner-Addir, 1999). However, when the prevalence rates of various
eating disorders are summed and the higher prevalence rates of sub-clinical eating
disorders or eating disorders not otherwise specified are included, it can be stated
that many individuals, particularly women, suffer from an eating disorder
(Thompson, 2004; Wade, Bergin, Tiggemann, Bulik, & Fairburn, 2006).
The accurate prevalence of eating disorders is difficult to assess due to the
sometimes secretive nature of the disorder. The prevalence rates given by the
American Psychiatric Association (2000a) are approximately 0.5% for anorexia
nervosa and between 1% and 3% for bulimia nervosa. Wade and colleagues
(2006) reported in an Australian study a lifetime prevalence of 1.9% for anorexia
nervosa and an additional 2.4% of women who partially met the criteria for
anorexia nervosa (they did not show amenorrhea). Bulimia nervosa was shown by
2.9% of the women and binge eating disorder also by 2.9%; while 5.3% showed an
eating disorder not otherwise specified. It is also notable that there has been an
increase in disordered eating behaviours in Australia between 1995 and 2005
(Hay, Mond, Buttner, & Darby, 2008).
Eating disorders are much less prevalent in men (Hay, Loukas, & Philpott, 2005;
Hoek, 2006; Hoek & Hoeken, 2003) with a ratio of about 10 women to 1 man
(Thompson, 2004). In an Australian study (Hay et al., 2005) the prevalence of
eating disorders in men was 1.2%. Men showed similar symptoms to women.
However, they were less weight concerned or less likely to use self-induced
vomiting as compensatory behaviour.
The onset of eating disorders occurs mostly during adolescence or young
adulthood. Anorexia nervosa typically begins during adolescence and bulimia
nervosa in young adulthood. An eating disorder can, however, also develop in later
years and, if untreated, persist into a person’s adult life.
4. Causes and risk factors
Knowledge about causes of, and risk factors for, eating disorders is still limited
(Field, 2004; Striegel-Moore & Bulik, 2007) due to the lack of longitudinal studies
with large sample sizes. It has been suggested that a complex set of biological,
cultural and psychological factors contribute to the risk of developing an eating
4
disorder. Therefore, the etiology of eating disorders has been described as
complex and multifactorial (Jacobi, Hayward, de Zwaan, Kraemer, & Agras, 2004;
Striegel-Moore & Bulik, 2007). Risk factor research has focused on biological
processes and factors involved in appetite and weight regulation, and cultural
factors that lead to attitudes and behaviours associated with body image and
eating. Higher body mass index has not been found to be a risk factor for eating
disorders (Jacobi et al., 2004). Table 4 shows a list of risk factors for eating
disorders (Pike et al., 2008; RANZCP, 2004; Striegel-Moore & Bulik, 2007). Pike et
al. (2008) have shown that negative affectivity, perfectionism, family discord, and
high parental demands were risk factors for anorexia nervosa.
Socio-cultural models have focused on the influence of the media and beauty ideals
on body image and eating behaviour. The thin body ideal is mostly equated with
beauty or success and has been shown to be a strong influencing factor on body
dissatisfaction and disordered eating. Body dissatisfaction has been found to be a
significant predictor of eating pathology (Stice & Agras, 1998), particularly for
bulimic symptoms (Stice, 2002). The research on genetic risk factors in eating
disorders is still in its early stages. Results of twin studies suggest that there is a
substantial genetic component that contributes to the development of eating
disorders (Striegel-Moore & Bulik, 2007). More sophisticated models need to be
developed and further investigated. These need to incorporate longitudinal study
designs and include the interplay of genes/biological factors and environment.
Table 4: Risk Factors for Eating Disorders
• Being female
• Having a parent with an eating disorder
• Body dissatisfaction, focus on appearance and internalization of the thin
ideal
• Low self-esteem
• Dieting
5. Therapeutic interventions
Many individuals with an eating disorder do not seek or receive appropriate
therapy for their eating problems (Mond, Hay, Rodgers & Owen, 2007). Results of
an Australian study (Hay, Marley, & Lemar, 1998) indicated that only a minority of
individuals with a bulimic disorder sought appropriate therapy. Some key reasons
that people do not seek help include fear of stigma, shame, fear of change and costs
(Hepworth & Paxton, 2007; Hepworth, Paxton, & Williams, 2007). However, the
sooner the disorder is treated, the more likely it is that the disorder can be
overcome. Therefore, it is important to make appropriate therapy available and
more easily accessible for people with an eating disorder. It is also important to
5
focus on active engagement of clients in therapy. The following section
summarizes recommendations and research results from existing literature and
aims to give information about appropriate therapy for anorexia and bulimia. In
this literature review, the focus was exclusively on counselling and
psychotherapeutic approaches, not on drug treatments.
5.1 Therapeutic alliance
A strong and positive therapeutic alliance, in the form of a collaborative, empathic
and accepting bond between client and therapist, is an established predictor of
outcome in psychotherapy (Martin, Garske, & Davis, 2000). This is true for
psychotherapy in general, and specifically for working with clients suffering from
an eating disorder (Constantino, Arnow, Blasey, & Agras, 2005; Brisman, 1994;
Geller, 2006; Toman, 2002; Loeb et al., 2005). This is related to the salience of
issues of trust and control which are important features of eating disorder
conditions (Pyle, 1999). The therapeutic relationship is considered to be the
central factor contributing to therapy outcome (APA, 2005).
Both clients and therapists have reported that the therapeutic alliance is an
important factor in the quality of the therapy for eating disorders (de la Rie,
Noordenbos, Donker, & van Furth, 2008). From the client’s perspective, trust in the
therapist has been found to be the most important criterion for the quality of the
therapy for eating disorders (de al Rie et al., 2008). Gallop, Kennedy and Stern
(1994) found that clients in an inpatient unit for eating disorders, who stayed in
treatment, reported a stronger therapeutic alliance than clients who left treatment
before completion.
However, therapeutic relationships with clients suffering from an eating disorder
have been described as challenging (Ardovini, 2002), due to the client’s selfharming thoughts and behaviours, the risk of suicide, the influences of cognitions,
emotions and activity level caused by starvation or malnutrition, and the client’s
ambivalence towards recovery and the therapeutic process (Manley & Leichner,
2003). Clients’ characteristics which have been shown to be related to the quality
of the therapeutic relationship in clients suffering from bulimia nervosa included
the severity of symptoms, expected improvement in therapy, and interpersonal
problems at the beginning of therapy (Constantino et al., 2005). A further client
characteristic that may be related to the quality of the therapeutic relationship is
the body mass index of the client (Toman, 2002). Manley and Leichner (2003)
describe the challenges counsellors or psychotherapists have to face in the work
with clients who suffer from an eating disorder and emphasized the importance of
a sound therapeutic relationship. They recommended understanding, empathy and
careful listening as key elements to ensure good therapeutic process.
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5.2 Therapy for anorexia nervosa
What evidence about the efficacy of therapy of anorexia nervosa do we have?
The evidence base for the efficacy of psychotherapeutic interventions for anorexia
nervosa is weak (Bulik, Berkman, Brownley, Sedway, & Lohr, 2007; Fairburn, 2005;
Keel & Haedt, 2008; Steinhausen, 2002; Wilson, Griol, & Vitousek, 2007) and the
quality of the studies has been judged to be mostly poor (Keel & Haedt, 2008; Royal
Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines
Team for Anorexia Nervosa, 2004; Wilson et al., 2007). This lack of empirical
evidence is mostly due to the low prevalence rate and the high morbidity.
Does therapy work?
A review article by Steinhausen (2002), in which 119 studies and 5590 clients
have been included, has shown that nearly 50% of people who suffered from
anorexia and who completed the treatment recovered, one-third improved and
20% remained chronically ill after treatment. A study about effective treatment of
eating disorders in Europe has reported that treatment was successful in 37% of
702 clients with anorexia at 1 year follow-up (Richard, 2005). Vomiting, bulimia,
chronicity of the disorder, onset of the disorder in adulthood and coexisting mental
disorders were factors which influenced the prognosis negatively. Zipfel et al.
(2000) have reported a recovery rate of 50.6% with an additional 20.8% of the
clients having intermediate outcome at 21-years follow-up after inpatient
treatment. One reason for the low success rates in anorexia is the egosyntonic
nature (sufferers do not feel that they have a problem) of this disorder and the fact
that individuals with anorexia often do not have a high motivation to overcome it
(Pike, Devlin, & Loeb, 2004). Positive influences on the prognosis are prompt
therapy after onset of the disorder, a strong motivation to change behaviour and
outpatient treatment in less severely disordered people (RANZCP, 2004;
Steinhausen, 2002). Furthermore, higher initial body weight and a younger age
significantly predicted higher effectiveness of therapy (Richard, 2005). There is
only limited empirical evidence available about the effectiveness of group therapy
for clients with anorexia (American Psychiatric Association, 2006).
Therapy content and aims: What principles guide therapy for anorexia
nervosa?
The following section summarizes recommendations for the therapy of anorexia
nervosa (American Psychiatric Association, 2006; American Psychiatric
Association, 2000b; National Institute for Clinical Excellence, 2004; RANZCP,
2004). Because of the high mortality rate for this disorder and the challenging
nature of treatment, the literature review outlines the broader treatment context
and the need for therapists to work collaboratively with other health professionals
in relation to the wider medical and dietary aspects of treatment.
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Therapy context
•
Therapy is provided by a multidisciplinary team including a general
practitioner, a dietitian and a mental health specialist.
•
Therapy addresses medical, psychological, nutritional and social
components of the disorder.
•
Therapy includes and/or supports family members and friends where
possible.
•
Family-based therapy may be offered to children and adolescents suffering
from anorexia.
•
Outpatient treatment lasts for at least 6 months.
•
If the course of therapy does not lead to significant improvements such as
weight restoration and changes in dysfunctional thinking and behaviours,
more intensive forms of therapy are recommended. Inpatient treatment
and the provision of life-preserving care is indicated if the body mass index
is less than 14 or the weight of the client is less than 75% of the healthy
body weight. Following inpatient treatment, outpatient treatment combined
with physical monitoring lasts for at least 12 months.
Aims and important parts of the therapy for anorexia nervosa
Preventing death by restoring nutrition and regaining weight.
Fostering more positive eating behaviours and attitudes to weight and
shape with encouragement for weight gain and healthy eating.
Supporting clients to reassess and change dysfunctional thoughts, attitudes,
feelings and behaviours.
Integrating an understanding of the client’s disorders of self-esteem, selfregulation, psychodynamic conflicts, cognitive development, traumas and
family relationships.
Educating and providing information on the nature, course and treatment
of anorexia nervosa to the client and carers (where appropriate).
In most cases, the aims of therapy include helping the client to have an
average weight gain of 0.5 kg in an outpatient setting. Controlled weight
gain could result from a nutritional rehabilitation program.
Medical management including the monitoring of weight (weighing once or
twice per week), vital signs and dietary intake, to monitor the medical risk
and the treatment response but also to avoid the ‘re-feeding syndrome.’
(Re-feeding after recent, rapid weight loss can lead to weakness, peripheral
oedema, seizures, coma, visual and auditory hallucinations or sudden
death). Detailed information about risk assessment and risk monitoring can
be found in Waller et al. (2007) and in a guide to the medical risk
assessment for eating disorders by Treasure (2004) which is available on
8
the internet (see Table 8).
Addressing comorbid disorders, such as depression or anxiety following
best practice for those issues.
Facilitating psychological and physical recovery and preventing relapse.
Management of physical risks and complications of anorexia nervosa
•
Physical risk in clients with anorexia nervosa needs to be monitored
regularly by a medical specialist throughout treatment. Physical symptoms
associated with starvation need to be treated.
•
Clients with anorexia and their carers need to be informed about the
physical risk.
•
Health care professionals treating clients with anorexia nervosa need to be
aware of the increased risk of self-harm and suicide, and implement
behavioural contracting with clients.
Monitoring of the process
•
It is important to monitor the level of risk to the client’s mental and physical
health during therapy. The physical state of the client needs to be
monitored regularly, including weight gain/loss and other specific
indicators of increased physical risk.
•
Responsibility for the monitoring of progress and of risk needs to be
discussed and agreed by all involved health care professionals and the client.
Inpatient or outpatient treatment?
The National Institute for Clinical Excellence (NICE, 2004) recommends that the
majority of people suffering from anorexia nervosa should be treated in an
outpatient setting with psychological treatment provided by a service that is
competent in giving specific treatment for this disorder and in assessing the
physical risks. Inpatient treatment is necessary if the medical risks for outpatient
treatment are too high and rapid weight loss or physical deterioration occurs
(Beumont, Hay, & Beumont, 2003). Clients with a weight below 75% of healthy
body weight or with rapid and severe weight loss can be too severely compromised
to be treated in a weekly outpatient psychotherapy setting and it may be necessary
to treat in an intensive outpatient or inpatient setting (American Psychiatric
Association, 2000b), where malnutrition can be corrected and regular monitoring
of the medical risk can be assured. However, not only weight, but also the client’s
overall physical condition, rate of weight loss, cardiac function, psychological
condition and the social circumstances should be considered in determining the
appropriate level of care (American Psychiatric Association, 2006).
9
What kind of therapeutic approach?
At this point, no specific psychotherapeutic approach can be considered to be
superior to other approaches for the treatment of anorexia nervosa (Hay,
Bacaltchuk, Byrnes, Claudino, Ekmejian, & Yong, 2003; PYNICE, 2004; RANZCP,
2004). It has been recommended that dietary advice should be part of the
treatment when combined with individual or family psychotherapy (RANZCP,
2004). Psychotherapies used for the treatment of anorexia nervosa include CBT,
family therapy, psychodynamic therapy, art therapy and interpersonal therapy.
Other therapeutic approaches increasingly used in the treatment of anorexia
nervosa are motivational enhancement therapy, dialectical behavioural therapy
(Kotler, Boudreau, & Devlin, 2003) and mindfulness and acceptance-based
approaches (Baer, Fischer, & Huss, 2005). Yager (2003) has suggested the use of email as an adjunct to outpatient treatment of anorexia nervosa.
Cognitive behavioural therapy
CBT for anorexia nervosa is the individual therapy most often evaluated in
research studies. However, CBT has not been shown to be significantly more
effective than other psychotherapies (Channon, De Silva, Hemsley & Perkins, 1989;
Wilson et al., 2007). Pike, Walsh, Vitousek, Wilson and Bauer (2003) have reported
in their randomized controlled trial in which they compared CBT to nutritional
counselling that clients who received CBT showed significantly better outcome and
were less likely to relapse than clients who received nutritional counselling. Of the
clients who had received CBT, 44% had good outcome compared to 7% of the
nutritional counselling group. Details about CBT for eating disorders can be found
in a comprehensive treatment guide by Waller and colleagues (2007).
Family therapy
Review articles indicate that most research about the efficacy of treatment for
anorexia in adolescents has been undertaken on family therapy (Wilson et al.,
2007). The evidence base for the Maudsley model of family-based therapy for the
treatment of anorexia nervosa in adolescents is strongest (Keel & Haedt, 2008;
Wilson et al., 2007). Details about the Maudsley model and the treatment process
can be found in the published manual (Lock, le Grange, Agras, & Dare, 2001).
Family-based therapy involves 10-20 sessions over 6-12 months with all family
members. In the first phase of therapy, the role of the parents is to take complete
control over their child’s eating and weight. In later stages of therapy, the client
regains autonomy and engages in age-appropriate individuation from the parents
which is related to recovery.
Eisler (2005) has given an overview of empirical evidence for family therapy and
its effectiveness for the treatment of anorexia nervosa in adolescents and a
description of a treatment model. Recovery rates for adolescents have been shown
to be slightly higher after family therapy than for individual therapy (Wilson et al.,
10
2007). Eisler et al. (2000) have shown that after receiving family therapy 38% had
a good and 25% had an intermediate outcome. It has also been shown that
although outcomes of family therapy were comparable to outcomes after
individual therapy (Robin et al., 1999; Robin, Siegel, & Moye, 1995), adolescents
who received family therapy recovered faster (Robin et al., 1999).
In a randomized controlled trial by Schmidt et al. (2007) in which family therapy
was compared to CBT guided self-care, the two treatment outcomes did not
significantly differ from each other after 12 months. Furthermore, there is no
supportive evidence for the effectiveness of family therapy in adults and
individuals who have suffered from the disorder for a longer period of time.
Therefore, family therapy has been shown to be more effective for adolescent
clients than for adult individuals (Bulik et al., 2007). It has been suggested that for
clients with a late onset of anorexia nervosa, individual therapy could be a better
therapeutic intervention than family therapy (Beumont et al., 2003). It can be
concluded that children and adolescents with anorexia nervosa should be offered
family interventions, as also recommended by the NICE guideline (NICE, 2004).
Psychodynamic therapy
Kächele and colleagues (2001) found in their study of the outcome of
psychodynamic inpatient treatment of eating disorders in Germany that 33% of
the clients who had suffered from anorexia nervosa were free of symptoms at the
two and a half year follow-up. In a study about the effectiveness of focal
psychoanalytic psychotherapy, cognitive-analytic therapy and family therapy, one
third of the clients no longer showed symptoms at the end of therapy (Dare, Eisler,
Russell, Treasure, & Dodge, 2001). However, the sample sizes in this study were
small. Therefore, reduced power due to small sample sizes made it impossible to
differentiate between the three psychotherapy approaches. The effectiveness of
psychodynamic therapy for the treatment of anorexia nervosa has only been
investigated to a limited extent.
Interpersonal therapy
Interpersonal therapy has mostly been investigated with individuals who suffer
from bulimia nervosa. Little empirical evidence exists about the efficacy of this
therapy for anorexia nervosa. In a study by McIntosh and colleagues (2005), CBT,
interpersonal therapy and a treatment combining specialist supportive clinical
management (psycho-education and supportive psychotherapy) were compared in
clients with anorexia nervosa. The specialist supportive clinical management and
CBT were more effective than interpersonal therapy. However, sample sizes were
small and overall outcome was low (9% of the clients had a very good outcome and
21% showed improvements).
11
Art therapy
To our knowledge, there is no empirically based study that has investigated the
efficacy of art therapy as a therapeutic intervention for eating disorder. However,
narrative reports on the use of this approach for the treatment of eating disorders
imply positive outcomes (Frisch, Franko, & Herzog, 2006). This therapeutic
approach combines non-verbal and verbal elements and is frequently used in
combination with other psychotherapeutic approaches (Matto, 1997). Art therapy
can help clients to work on cognitive distortions related to their body or their
eating patterns, facilitate the expression of emotions or the exploration of conflicts
and problems, and can help to develop new coping strategies. Levens (1995)
describes treatment of eating disorders through art therapy and how the art
therapist can facilitate the client’s treatment process.
Table 5: Summary therapy for anorexia nervosa
Based on the currently available research results it can be concluded that
psychotherapeutic treatment is significantly more effective than no treatment
(Dare et al., 2001) or dietary advice on its own (Pike et al., 2003). Family
therapy is the most widely tested and efficient method for adolescents.
Furthermore, a multidimensional and multidisciplinary treatment approach
including thorough assessment, ongoing risk management, and integration of
multiple treatment modalities is recommended.
5.3 Therapy for bulimia nervosa
What evidence about the efficacy of therapy of bulimia nervosa do we have?
The empirical evidence for psychological treatment of bulimia nervosa is strong
(NICE, 2004; Shapiro et al., 2007), particularly for CBT and interpersonal therapy
(Wilson et al., 2007). Studies about the efficacy of alternative treatment
approaches are rare.
Does therapy work?
Review studies about the efficacy of treatment for bulimia nervosa have concluded
that a high percentage of clients still suffer from the disorder after treatment
(Mitchell, Hoberman, Peterson, Mussell, & Pyle, 1996). Results of a European
collaborative study in which treatment outcomes from several European countries
have been combined indicated that 40% of the 981 clients with bulimia showed
positive outcome at a one year follow-up (Richard, 2005). This success rate was
relatively low compared to other studies.
A study of the long term course of bulimia nervosa (Fichter & Quadflieg, 1997)
showed that six years after treatment, 60% achieved a good outcome, and 29% an
12
intermediate outcome. Thompson-Brenner, Glass, and Westen (2003) conducted a
meta-analysis of psychotherapy for bulimia nervosa, in which they included 26
clinical trials (N = 1427) of different therapeutic approaches. They found that of the
clients who completed therapy, 40.1% were classified as recovered post-treatment
(recovery rate for intention-to-treat sample was 32.6%). The recovery rate after
treatment for individual CBT was on average 48% for completers. Follow-up data
has been available for seven studies. After the average follow-up time of 12.75
months, 43.7% of clients were recovered (across different treatments).
The recovery rate for individual therapies was significantly higher than for group
therapies. Frequency of binge eating, age, psychological distress and family
relationships were factors that were related to the effectiveness of therapy
(Richard, 2005).
Therapy content and aims: What principles guide therapy for bulimia nervosa?
In the following section, standards of treatment for bulimia nervosa are
summarised (American Psychiatric Association, 2006; American Psychiatric
Association, 2000b; NICE, 2004; RANZCP, 2004):
Therapy context
•
Inpatient treatment should be considered for clients with risk of suicide or
risk of severe self-harm only. The majority of clients can be treated in an
outpatient setting.
•
Therapy addresses the reduction of binge eating and purging behaviour.
•
Fluid and electrolyte balance should be monitored throughout treatment,
particularly in clients who are vomiting frequently or using large quantities
of laxatives.
•
Dietary advice in combination with other treatment approaches can be
useful to establish healthy eating patterns and reduce eating disorder
behaviour such as vomiting.
•
Eating disorder symptoms and the client’s medical condition should be
assessed and monitored throughout the treatment.
•
Family therapy could be considered for adolescents.
Cognitive-behavioural therapy for bulimia nervosa
The NICE guideline (NICE, 2004) recommends that adults suffering from bulimia
nervosa should be offered CBT for 16 to 20 sessions over 4 to 5 months. Hay,
Bacaltchuk and Stefano (2004 found CBT to be an efficacious treatment in their
Cochrane review. This therapeutic approach is the most investigated evidencebased treatment with the most evidence of efficacy and has been recommended as
the therapy of choice for bulimia nervosa (Pike et al., 2004; Wilson et al., 2007).
About 30% to 50% of the clients typically overcome binge eating and purging after
13
they receive CBT (Anderson & Maloney, 2001; Wilson et al., 2007). Ghaderi (2006)
found that a more individualized CBT treatment, instead of a strictly manual-based
treatment, was slightly more beneficial particularly in terms of drop-outs. At posttreatment, 62% (n = 32) of the clients did not show binge episodes or compensatory
behaviour. The treatment of bulimia nervosa with CBT has been described in
Fairburn (2002).
Interpersonal psychotherapy for bulimia nervosa
Interpersonal therapy (IPT) is an alternative therapeutic approach recommended
by the NICE guideline (2004) for the treatment of bulimia nervosa. However, it
usually takes 8-12 months to reach results comparable with CBT. Reviews about
IPT (Tantleff-Dunn, Gkee-LaRose, & Peterson, 2004) have provided evidence for
the efficacy of interpersonal therapy in the treatment of bulimia. Some studies
found CBT was more effective than IPT - in some studies CBT was as effective as
IPT and in others CBT was more effective at the end of therapy. However both
therapeutic interventions showed comparable outcomes at follow-up (TantleffDunn et al., 2004).
Psychodynamic therapy for bulimia nervosa
There is little empirical evidence for the effectiveness of psychodynamic
treatments for bulimia nervosa. Murphy, Russell and Waller (2005) have shown in
their study that after psychodynamic treatment 50% of the sample (N = 14) was
symptom-free at three and six month follow-ups.
Guided self-help and self-help for the treatment of bulimia nervosa
Guided self-help (GSH) has been recommended as a valuable and effective first step
in the treatment process of bulimia (NICE, 2004). In guided self-help, a self-help
manual based on CBT is introduced to the client by the therapist. The client works
through the manual independently, learns about the disorder, how to change
behaviour and cognitions and about new skills and problem solving techniques. In
the sessions with the therapist, the client gets support, encouragement and
assistance in working through the manual. GSH has been found to be an effective
treatment approach for the treatment of bulimia nervosa. It has been evaluated in
comparison with waiting list controls, CBT, family therapy and pure self-help
treatment (Grilo, 2000; Mitchell, Agras, & Wonderlich, 2007; Shapiro et al., 2007;
Stefano, Bacaltchuk, Blay, & Hay, 2006). An Australian study (Banasiak, Paxton, &
Hay, 2005) found that 28% of the GSH group compared to 11% of the delayed
treatment group showed absolute remission from binge eating and all
compensatory behaviours. An overview of guided self-help manuals has been given
in Paxton, Knauss and Shelton (in press).
A CD-ROM-based CBT self-help intervention has also been described as a valuable
first step in treatment for clients who have no access to face-to-face treatment
(Bara-Carril et al., 2004).
14
Table 6: Summary therapy for bulimia nervosa
Based on current available research, CBT can be considered as the treatment of
choice for the treatment of bulimia nervosa, with interpersonal therapy as an
alternative approach for clients who do not respond to CBT. CBT currently has
stronger and more consistent empirical support than interpersonal therapy and
results in more rapid alleviation of symptoms. To increase global outcome it may
be helpful to use CBT in combination with other psychotherapies. Family therapy
should be considered for adolescents. Guided self-help is an effective approach
as a first step in the treatment process and may be an effective treatment in
some cases.
There is a lack of clinical trials which include therapeutic approaches other than
CBT or interpersonal therapy (Thompson-Brenner et al., 2003). Cognitivebehavioural therapy is currently the treatment of choice for bulimia nervosa, but
further studies that include different therapeutic approaches are necessary to be
able to draw a more precise conclusion about the efficacy of other treatment
approaches.
5.4 Therapy for eating disorder not otherwise specified
A high percentage of clients with eating disorders do not fully meet the diagnostic
criteria for anorexia nervosa or bulimia nervosa but clearly suffer from disordered
eating. This group of clients fall under the DSM-IV-TR category eating disorders
not otherwise specified (EDNOS). The required therapeutic intervention depends
on symptoms and severity of impairment (APA, 2000b). Treatment strategies for
the reported problems such as binge eating, unhealthy dieting behaviour and body
dissatisfaction can be nutritional counselling and dietary management combined
with cognitive-behavioural, interpersonal or psychodynamic psychotherapy (APA,
2000b). The APA (2006) also recommends dialectical behavioural therapy for the
treatment of binge eating disorders.
In a review article about the effectiveness of the treatment of binge eating
disorders it has been concluded that evidence of the efficacy of treatments for
binge eating disorders is still limited (Brownely, Berkman, Sedway, Lohr, & Bulik,
2007). It can be helpful to use a ‘non-diet’ approach with a focus on self- and body
acceptance, exercise and improvement of nutrition and health. Guided self-help
can be a valuable treatment approach particularly for binge eating disorders
(Paxton, Knauss, & Shelton, in press). For overweight clients with binge eating
disorder, CBT and behaviour weight loss therapy have both been found effective
(Munsch, Biedert, Meyer, Michael, Schlup, Tuch, & Margraf, 2007). A guided selfhelp manual for the treatment of disordered eating is accessible on the internet
(Fursland, Byrne, & Nathan, 2007; see Table 8).
15
6. Summary and conclusion
The success rate of treatment of anorexia nervosa is still low. Available and
empirically evaluated therapeutic approaches have not shown to be as effective as
one would wish. Risk monitoring and management is an important part of the
therapeutic process. Important aims of therapy are weight gain, change of eating
behaviour, of attitudes to weight and shape and of dysfunctional thoughts and
feelings.
There is a strong evidence-base for the treatment of bulimia nervosa showing that
CBT is the most effective treatment approach and that interpersonal therapy can
be considered as an alternative approach. Guided self-help which is based on CBT
can be recommended as a first step in the treatment process for bulimia nervosa
and can also be considered as helpful in the treatment of binge eating disorders.
For the treatment of EDNOS and binge eating disorders nutritional counselling,
exercise and dietary management combined with psychotherapy can be
recommended. Guided self-help can also be a valuable treatment approach for
binge eating disorders.
Table 7: Internet Resources
American Psychiatric Association Practice Guidelines. (2006). Treatment of
patients with eating disorders, 3rd edn. Retrieved on 12th February 2009 from:
http://www.psychiatryonline.com/content.aspx?aID=138866
Eating Disorder Interstate Contact List 2008. Retrieved on 12th February 2009
from:
http://www.eatingdisorders.org.au/documents/interstate%20list%200808.p
df
Fursland, A.., Byrne, S., & Nathan, P. (2007). Overcoming disordered eating.
Perth, WA: Centre for Clinical Interventions. Guided self-help manual
retrieved on 12th February from:
http://www.cci.health.wa.gov.au/resources/infopax.cfm?Info_ID=48 and
http://www.cci.health.wa.gov.au/resources/infopax.cfm?Info_ID=49
National Institute for Health and Clinical Excellence (NICE). (2004). Eating
disorders: Core interventions in the treatment and management of anorexia
nervosa, bulimia nervosa and related eating disorders. Clinical guideline 9.
Retrieved on 12th February 2009 from:
http://www.nice.org.uk/CG009NICEguideline
16
Royal Australian and New Zealand College of Psychiatrists Clinical Practice
Guidelines Team for Anorexia Nervosa. (2004). Australian and New Zealand
clinical practice guideline for the treatment of anorexia nervosa. Australian and
New Zealand Journal of Psychiatry, 38, 569-670. Retrieved on 12th February
2009 from http://www.ranzcp.org/images/stories/ranzcpattachments/Resources/Publications/CPG/Clinician/CPG_Clinician_Full_Anor
exia.pdf
Royal Australian and New Zealand College of Psychiatrists. (2005). Anorexia
Nervosa: Australian treatment guide for consumers and carers. Melbourne:
Author. Retrieved on 12th February 2009 from:
http://www.ranzcp.org/images/stories/ranzcpattachments/Resources/Publications/CPG/Australian_Versions/AUS_Anorexi
a_nervosa.pdf
Treasure, J. (2004). A guide to the medical risk assessment for eating disorders.
London: King’s College London, Eating Disorders Unit. Retrieved on 12th
February 2009 from: http://www.iop.kcl.ac.uk/sites/edu/?id=73#item03
17
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