A Review of the Research on Eating Disorders

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Eating disorders are a persistently challenging issue for clinicians. There are, however, a variety of psychotherapy techniques, as well as some medications, used successfully to treat eating disorders. Here is a summary of some of the latest research on psychotherapy and psychopharmacological treatments.

Psychotherapies for ED
Family-Based Therapy (FBT)

FBT is considered the treatment of choice for adolescents with anorexia nervosa. In this approach, parents are encouraged to intervene in their child’s care and be in charge of decisions relating to food. Once weight is restored, the child is slowly given more control over food choices. Literature also supports FBT for treatment of bulimia.

A recent meta-analysis examined the efficacy of family-based treatment for adolescents with eating disorders. Three studies were examined that met strict inclusion criteria. The authors state that while FBT did not initially appear significantly better than individual therapy, positive benefits for FBT were noted at six to 12 month follow up (Couturier J et al, Int J Eat Disord, 2013;46(1):3–11).

Cognitive Behavioral Therapy (CBT)

CBT has the most research support for treatment of bulimia nervosa. While we don’t fully understand what causes bulimia, CBT addresses distorted thoughts and perceptions about weight and body image that appear to lead to and maintain symptoms of bulimia. CBT teaches patients to modify these maladaptive thoughts and develop more constructive and healthier skills for dealing with high emotional states. Patients with bulimia can then develop more consistent approaches to dealing with food.

A 2011 randomized study compared a) traditional CBT (augmented by fluoxetine (Prozac, Sarafem) if indicated) and b) a stepped-care treatment approach designed to enhance treatment effectiveness. The stepped-care treatment approach began with supervised self-help, followed by the addition of fluoxetine (if indicated), followed by full CBT for those not achieving abstinence. In both conditions, fluoxetine was defined as indicated if, by the end of the sixth session, there was less than a 70% reduction in frequency of purging (a measure shown in previous research by this research group to predict poor outcome).

The authors found that the stepped-care approach was more effective at follow-up (one year later) than CBT followed by fluoxetine for those who were predicted to be non-responders. The authors concluded that the superiority of stepped-care over CBT suggests that “treatment may be enhanced by an individualized approach” (Mitchell JE et al, Br J Psychiatry 2011;198(5):391–397).

Dialectical Behavior Therapy (DBT)

DBT combines CBT techniques with mindfulness awareness to regulate emotions. There are four modules used in treatment, including mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness. Through DBT, patients with eating disorders can learn to identify triggers for disordered eating, find effective ways to respond to stress, and develop awareness and acceptance of their behaviors without judgment.

There is some research supporting the use of DBT with binge eating disorder (BED). One clinical trial strived to examine the moderators of DBT for BED (DBT-BED) on the post-treatment outcome of binge frequency. The researchers used the Eating Disorder Examination (a semi-structured interview) to assess binge frequency. A total of 101 adults were randomized into two groups: DBT-BED and an active comparison group control (ACGT). Two factors were found to be associated with significantly poorer outcome for those treated with ACGT versus DBT-BED: having avoidant personality disorder, and having an earlier onset of being overweight and dieting (<15 years old).

The authors contend that individuals with higher baseline pathology appeared to respond better to DBT-BED than to a control (Robinson AH and Safer DL, Int J Eat Disord 2012;45(4):597–602).

Acceptance and Commitment Therapy (ACT)

ACT is a psychological intervention that uses acceptance and mindfulness techniques to help patients with disordered eating. Whereas CBT is about challenging and ultimately controlling maladaptive thoughts, ACT encourages patients to focus on being aware of and accepting of their distressing cognitions about food. This redirects them from feeling out of control.

A study done in 2010 attempted to look at the relative effectiveness of ACT and CBT in reducing subclinical pathology. Subclinical pathology was defined as fasting, using diuretics, using appetite suppressants, and purging, although not fully meeting the DSM-IV criteria for eating disorders. A total of 55 patients from a university counseling center with subclinical pathology were randomly distributed between two groups—ACT and CBT. The outcome measures, which included the Beck Depression Inventory-II, Beck Anxiety Inventory, Global Assessment of Functioning Scale, and Quality of Life Index, were given pre- and post-treatment. The researchers found a significant difference in scores between the CBT group and ACT group. The authors suggest that ACT was superior to CBT in reducing problem eating behavior. A limitation of the study was the fact that patients did not meet the full criteria for an eating disorder (Juarascio EM et al, Behav Modif 2010;34(2):175–190).

Interpersonal Psychotherapy (IPT)

IPT is a time-limited therapy that focuses on how interpersonal difficulties may contribute to and maintain an eating disorder. For example, binge eating may be triggered and/or exacerbated by unstable relationships. In addition, poor selfesteem can make patients feel out of control, further deteriorating relationships with others. IPT can help address such issues and facilitate recovery.

One recent research review found IPT to be a leading alternative to CBT for bulimia and BED. However, treatment with IPT may take longer to produce results. The authors reviewed two large trials where CBT was initially deemed superior to IPT. Participants were reevaluated eight to 12 months later and both treatments were noted to be equivalent (Murphy R et al, Clin Psychol Psychother, 2012;19(2):150–158).

Another study demonstrated how adults with anorexia nervosa may benefit from any of the major psychotherapies, but concluded no particular therapy approach is best. For example, when anorexia nervosa patients were divided into three groups of specialist supportive clinical management, IPT, or CBT, there were no significant differences found on outcome after five years (Carter FA et al, Int J Eating Disord 2011;44(7):647–654).

Overall, despite some data supportive of certain psychotherapies for eating disorders being superior to other therapies, those data are limited. Indeed, a recent meta-analysis on comparative therapy trials examining CBT vs. other legitimate (non-placebo) psychotherapies did not yield much of a difference in favor of CBT—and the small advantage for CBT was tempered by the underlying studies potentially being biased in design (Spielmans GI et al, Clin Psychol Rev in press).

Pharmacotherapy in the Treatment of ED
Medications to Treat Anorexia Nervosa

Medications continue to play a small role in the treatment of anorexia nervosa. They typically serve as an adjunct to psychotherapy and nutritional rehabilitation. However, recent studies have examined the role of atypical antipsychotics, particularly olanzapine (Zyprexa), in the treatment of anorexia.

One study reviewed the results of five randomized controlled trials and found that olanzapine was superior to placebo (three studies), aripiprazole (Abilify) (one study), and chlorpromazine (one study). The author notes that olanzapine appears to have a significant effect on weight gain compared to placebo in an outpatient setting, where there is less structure and limited or no concurrent psychotherapy. When olanzapine and other antipsychotic agents are taken in the context of an intense therapeutic environment (ie, inpatient treatment), it does not appear to offer any added benefit for weight gain.

This information can be helpful in determining which patients would benefit from olanzapine in clinical practice. The author acknowledges that it can be very difficult to convince patients to take olanzapine given the nature of the eating disorder. He encourages prescribers to start adults at 1.25 mg at bedtime so as to diffuse anxiety and avoid sedation (Brewerton TD, Curr Psychiatry Rep 2012;14(4):398–405).

Medications to Treat Bulimia Nervosa or Binge Eating Disorder

Pharmacotherapy may be used in patients with bulimia nervosa or BED as a way to optimize treatment, along with psychotherapy and nutritional counseling. This is especially true in cases where patients may respond inadequately to psychotherapy, or in patients with comorbid psychiatric illness. For bulimia, there is no consistent evidence for any particular agent other than high dose fluoxetine, the only medication that is currently FDA-approved for treating bulimia. In this case, 60 mg is considered the appropriate dose in treatment.

Studies have looked at another medication, topiramate (Topamax), which appears to be effective in decreasing binge eating. However, side effects limit its usefulness (McElroy SL et al, Expert Opin Pharmacother 2012;13(14):2015–2026).

TCRBH’s Take: Considering the available research and given the difficulty of treating eating disorders and the health risks associated with the disorders, it appears that a comprehensive treatment approach is essential. That approach includes psychotherapy, health monitoring, nutritional counseling/rehabilitation, and, as needed, pharmacotherapy. For adolescents with anorexia nervosa, family-based therapy can play an important part in that comprehensive approach. Currently, the only medication that is FDA-approved for the treatment of an eating disorder is fluoxetine (for bulimia). Pharmacotherapy, relative to other treatments for eating disorders, often plays only an adjunctive role. Nonetheless, there are several medications that may be a beneficial part of treatment, addressing symptoms of eating disorders and comorbid conditions (such as depression and anxiety).