Learning Objectives
- Describe treatment options for anorexia nervosa.
- Describe treatment options for bulimia nervosa.
- Describe treatment options for binge eating disorder.
- Discuss the outcome of treatment for feeding and eating disorders.
Anorexia Nervosa
The immediate goal for the treatment of anorexia nervosa is weight gain and recovery from malnourishment. This is often established via an intensive outpatient program, or if needed, through an inpatient hospitalization program where caloric intake can be managed and controlled. Both the inpatient and outpatient programs use a combination of therapies and support to help restore proper eating habits. Of the most common (and successful) treatments are Cognitive-Behavioral Therapy (CBT) and Family-Based Therapy (FBT).
10.5.1.1. CBT. Because anorexia nervosa requires changes to both eating behaviors as well as thought patterns, CBT strategies have been very effective in producing lasting changes to those suffering from anorexia nervosa. Some of the behavioral strategies include recording eating behaviors—hunger pains, quality and quantity of food—and emotional behaviors—feelings related to the food. In addition to these behavioral strategies, it is also important to address the maladaptive thought patterns associated with their negative body image and desire to control their physical characteristics. Changing the fear related to gaining weight is essential in recovery.
10.5.1.2. Family based therapy (FBT). FBT is also an effective treatment approach, often used as a component of individual CBT, especially for children and adolescents with the disorder. FBT has been shown to elicit 50-60% of weight restoration in one year, as well as weight maintenance 2-4 years post-treatment (Campbell & Peebles, 2014; LeGrange, Lock, Accurso, Agras, Darcy, Forsberg, et al, 2014). Additionally, FBT has been shown to improve rapid weight gain, produce fewer hospitalizations, and is more cost-effective than other types of therapies with family involvement (Agras, Lock, Brandt, Bryson, Dodge, Halmi, et al., 2014).
FBT typically involves 16-18 sessions which are divided into 3 phases: (1) Parents take charge of weight restoration, (2) client’s gradual control of overeating, and (3) addressing developmental issues including fostering autonomy from parents (Chen, et al., 2016). While FBT has shown to be effective in treating adolescents with anorexia nervosa, the application for older eating patients (i.e., college-aged students and above) is still undetermined. As with adolescents, the goal for a family-based treatment program should center around helping the patient separate their feelings and needs from that of their family.
Bulimia Nervosa
Just as anorexia nervosa treatment initially focuses on weight gain, the first goal of bulimia nervosa treatment is to eliminate binge eating episodes and compensatory behaviors. The aim is to replace both negative behaviors with positive eating habits. One of the most effective ways to establish this is through Cognitive Behavioral Therapy (CBT).
10.5.2.1. CBT. Similar to anorexia nervosa, individuals with bulimia nervosa are expected to keep a journal of their eating habits; however, with bulimia nervosa, it is also important that the journal include changes in sensations of hunger and fullness, as well as other feelings surrounding their eating patterns in efforts to identify triggers to their binging episodes (Agras, Fitzsimmons-Craft & Wilfley, 2017). Once these triggers are identified, psychologists will utilize specific behavioral or cognitive techniques to prevent the individual from engaging in binge episodes or compensatory behaviors.
One method for modifying behaviors is through Exposure and Response Prevention. As previously discussed in the OCD chapter, this treatment is very effective in helping individuals stop performing their compulsive behaviors by literally preventing them from engaging in the action, while simultaneously using relaxation strategies to reduce anxiety associated with not engaging in the negative behavior. Therefore, to prevent an individual from purging post-binge episodes, the individual would be encouraged to partake in an activity that directly competes with their ability to purge, e.g., write their thoughts and feelings in a journal at the kitchen table. Research has indicated that this treatment is particularly helpful for individuals suffering from comorbid anxiety disorders (particularly OCD; Agras, Fitzsimmons-Craft & Wilfley, 2017).
In addition to changing behaviors, it is also important to change the maladaptive thoughts toward food, eating, weight, and shape. Negative thoughts such as “I am fat” and “I can’t stop eating when I start” can be modified into more appropriate thoughts such as “My body is healthy” or “I can control my eating habits.” By replacing these negative thoughts with more appropriate, positive thought patterns, individuals begin to control their feelings, which in return, can help them manage their behaviors.
10.5.2.2. Interpersonal Psychotherapy (IPT). IPT has also been established as an effective treatment for those with bulimia nervosa, particularly if an individual has not been successful with CBT treatment. The goal of IPT is to improve interpersonal functioning in those with eating disorders. Originally a treatment for depression, IPT-E was adapted to address the social isolation and self-esteem problems that contribute to the maintenance of negative eating behaviors.
IPT-E has 3 phases typically covered in weekly sessions over 4-5 months. Phase One consists of engaging the patient in treatment and providing psychoeducation about their disease and the treatment program. This phase also includes identifying interpersonal problems that are maintaining the disease.
Phase Two is the main treatment component. In this phase, the primary focus is on problem-solving interpersonal issues. The most common types of interpersonal issues are lack of intimacy and interpersonal deficits, interpersonal role disputes, role transitions, grief, and life goals. Once the main interpersonal problem is identified, the clinician supports the patient in their pursuit to identify ways to change. A key component of IPT-E is the supportive role of the clinician, as opposed to the teaching role in other treatments. The idea is that by having the patient make changes, they can better understand their problems, and as a result, make more profound changes (Murphy, Straebler, Basden, Cooper, & Fairburn, 2012).
Phase Three is the final stage. The goals of this phase are to ensure that the changes made in Phase two are maintained. To achieve this, treatment sessions are spaced out, allowing patients more time to engage in their changed behavior. Additionally, relapse prevention (i.e., problem-solving ways not to relapse) is also discussed to ensure long term results. In doing this, the patient reviews the progress they have made throughout treatment, as well as identifying potential interpersonal issues that may arise, and how their treatment can be adapted to address those issues.
Support for IPT-E is limited; however, two extensive studies suggest that IPT-E is effective in treating bulimia nervosa, and possibly BED. While treatment is initially slower than CBT, it is equally effective in long-term follow-up and maintenance of disorder (Fairburn, Marcus, & Wilson, 1993).
Binge Eating Disorder
Given the similar presentations of BED and bulimia nervosa, it should not be surprising that the most effective treatments for BED are similar to that of bulimia nervosa. CBT, along with antidepressant medications, are among the most effective in treating BED. Interpersonal therapy, as well as dialectical behavioral therapy, have also been effective in reducing binge-eating episodes; however, they have not been effective in weight loss (Guerdjikova, Mori, Casuto, & McElroy, 2017). Goals of treatment are, of course, to eliminate binge eating episodes, as well as reduce body weight as most individuals with BED are overweight. Seeing as BED has only recently been established as a separate eating disorder, treatment research specific to this disorder is expected to grow.
10.5.3.1. Antidepressant medications. Given the high comorbidity between eating disorders and depressive symptoms, antidepressants have been a primary method of treatment for years. While they have been shown to improve depressive symptoms, which may help individuals make gains in their eating disorder treatment, research has not supported antidepressants as an effective treatment strategy for treating the eating disorder itself.
Outcome of Treatment
Now that we have discussed treatments for eating disorders, how effective are they? Research has indicated favorable prognostic features for anorexia nervosa are early age of onset and a short history of the disorder. Conversely, unfavorable features are a long history of symptoms prior to treatment, severe weight loss, and binge eating and vomiting. The mortality rate over the first 10 years from presentation is about 10%. Most of these deaths are from medical complications due to the disorder or suicide.
Unfortunately, research has not identified any consistent predictors of positive outcomes for bulimia nervosa. However, there is some speculation that individuals with childhood obesity, low self-esteem, and those with a personality disorder have worse treatment outcomes. While treatment outcome for BED is still in its infancy, initial findings suggest that remission rates of BED are much higher than that for anorexia nervosa and bulimia nervosa.
Key Takeaways
You should have learned the following in this section:
- Treatment options for anorexia nervosa include CBT and FBT.
- Treatment options for bulimia nervosa include CBT, exposure and response prevention, and the three phases of interpersonal psychotherapy.
- Treatment options for BED include the taking of antidepressants to manage depressive symptoms, CBT, and interpersonal therapy.
Review Questions
- What is the initial (main) goal of treatment for anorexia?
- What are the three phases of family-based treatment?
- What is the goal for interpersonal psychotherapy? Discuss the three phases of IPT.
- What is the overall treatment effectiveness of eating disorders?
Module Recap
Module 10 covered eating disorders in terms of their clinical presentation, epidemiology, comorbidity, etiology, and treatment options. In Module 11, we will discuss substance-related and addictive disorders, which will conclude this part.
