Eating Disorders (ED) such as anorexia nervosa (AN), bulimia nervosa (BN) and binge eating disorder (BED) are complicated medical and psychiatric illnesses. Patients, families, and clinicians face enormous challenges in their attempts to pursue and support full and lasting recovery. Yet, in spite of the many clinical, societal, and financial challenges, there has been real progress over the past several years in our understanding of these illnesses and in the development of robust, evidence-based treatments. At the same time, regional, national and parent advocacy groups have raised public awareness of ED and have developed important support resources for patients and their families. In many ways we can be optimistic about these trends and hopeful that people with ED can avoid the potential long term, chronic, and often tragic, including deadly consequences of these illnesses. This article will briefly summarize new trends and point out some of the remaining areas of controversy and barriers to comprehensive treatment and recovery.
Over the past several years, the American Psychiatric Association, Society for Adolescent Health and Medicine and the National Institute of Clinical Excellence (UK) have published practice guidelines for ED. Clinicians, insurers, patients and their families can use these resources to familiarize themselves with the current state of the field and to help structure and evaluate treatment options. It is well beyond the scope of this article, but medical monitoring, psychopharmacological treatments and nutritional therapy are all essential components of any multidisciplinary approach to the treatment of ED. The focus in this article will be on where things stand in terms of the best psychotherapeutic approaches.
While there is some considerable variation in the recommendations, there is a consensus about a number of first line treatments for ED. For adults and adolescents with BN, Cognitive Behavioral Therapy (CBT) has the strongest research base. CBT helps patients interrupt their ED symptoms and behaviors and focuses on a quick normalization of eating. Stabilization of eating then yields to a focus on the thoughts, beliefs, and behaviors that perpetuate the ED cycle. Interpersonal Psychotherapy (IPT) has also been shown to be effective with BN, over the longer term. IPT, in contrast to CBT, focuses almost exclusively on the role of relationships and relational disruptions in the etiology and maintenance of the ED.
For children and adolescents, with AN, Family Based Treatment (FBT) is now commonly regarded as a highly effective treatment approach. FBT, formerly known as the Maudsley approach, has long been in use in the UK but has only gained widespread application in the US over the past 5 years. FBT puts families in charge of their child’s eating and nutritional stabilization and provides skills and support around ED, emotional regulation, and adolescent development. While it is a somewhat counterintuitive treatment for many clinicians, FBT has demonstrated effectiveness for approximately fifty percent of adolescents with AN. Indirectly, FBT has also had an impact on the ways in which we understand the families’ role in the etiology of ED. More than any other factor, the development of FBT has cemented our recognition that many of the clinical features of families with a child with an ED may actually be a consequence of the burden of caring for a seriously ill child. In past years, even not very long ago, many clinicians still viewed these clinical features as etiological factors; parents, particularly moms, who were anxious and overly activated were automatically seen as “enmeshed” with their child, rather than appropriately anxious about a real threat. This has been a sea change in our understanding of AN in kids and teens, and represents perhaps, one of the most important positive changes in our approach and understanding of ED. However, as with all treatment modalities appropriate case selection and continuing support from clinicians is very important in order for FBT to be successful.
There are a number of other treatment approaches that are developing a strong research base. Dialectical Behavioral Therapy (DBT), Acceptance and Commitment Therapy (ACT), and a variety of experiential, mindfulness-based approaches all have roles in the comprehensive treatment of ED.
Gaps in Our Understanding and Treatment
The good news is that we have increasingly diverse and well supported evidence-based treatments for ED. But there are still substantial barriers to effective and accessible treatments.
Complexity, Acuity and Comorbidity: Many patients with eating disorders have associated medical and psychiatric co-morbidity. Our best practices treatment guidelines are not specific enough to guide comprehensive treatment planning for patients with ED combined with other conditions such as primary depression and other mood disorders OCD and anxiety spectrum disorders, trauma histories and PTSD, substance abuse, or, for instance, diabetes. Clinicians must adapt these guidelines to fit the needs of individual patients, addressing not only the ED per se but also the patient’s level of acuity and need for therapeutic structure or higher levels of care. Advances in genetics and neuroscience are directing our attention to some of the basic underpinnings of ED. These include both impulsive and dysregulated temperaments, especially in patients with BN and BED and, for patients with AN, temperaments characterized by inhibition, harm avoidance and perfectionism. We also know that ED can cause or exacerbate relational and family difficulties and deciphering, articulating and addressing the relational impact of an ED on a family or vice versa, can be extraordinarily difficult.
Effective treatment requires clinicians to embrace conceptual complexity. We must adapt our treatments to address differences in temperament and learning, as noted above, but also to address things as basic as gender and age. Male patients, a fast growing subset of patients with ED, have some important differences in clinical presentation and treatment focus. Similarly, older women with ED, those above 30 years old for instance, are facing very different developmental and social demands than adolescent women.
Treatment Acceptability: Even our most effective treatments, FBT and CBT for example, help only about half of patients achieve full symptom remission. Many patients find these front line treatments helpful, but many others actually drop out of treatment early. Whether this is due to a negative response to the actual treatment or a reflection of the ambivalence they might feel about recovery, we, as a field, still lack treatments that most patients find acceptable. This is particularly true for adults with AN, for whom there is no current evidence-based treatment. However, there is a strong consensus that full restoration of healthy weight is essential for recovery.
Training and Dissemination of EBT: The dissemination of evidence-based treatments (EBT) is a common dilemma in health care and it remains a significant issue within the ED field. While training in treatments such as CBT, DBT and FBT are increasingly available, the vast majority of clinicians may not have access to specialized applications for ED. Just recently, there is an emerging focus on the actual study of best practices for dissemination; essentially a search for evidence-based training for evidence based treatments. One of the less obvious issues is clinician attitudes towards evidence-based manuals and guidelines. There is a significant debate about the pros and cons of specific guidelines; many clinicians feel that clinical researchers lack an appreciation for the complexity of front line treatment realities. Researchers, to caricature a bit, are prone to seeing clinicians as anti-science artisans who overvalue clinical intuition. The ongoing challenge for many will be weaving evidence-based treatments into a clinical framework which takes maximum advantage of both relevant research and the beneficial nature of the clinician-patient relationship. ED professional organizations such as the Academy for Eating Disorders (AED) and the International Association of Eating Disorder Professionals (IAEDP) have both developed task forces to help address this ongoing and fundamental debate.
Treatment Accessibility: This is an underappreciated factor in our current treatment models. Most patients and families will struggle to identify, access and afford high quality treatment. Clinical recommendations for treatment intensity and level of care can, and in fact often do, exceed the treatment authorized by insurers. This is not a simple issue; patients and families want the best treatment possible, but insurers find it difficult to assess whether the treatment being provided is appropriate or effective. The burden falls, at least in part, on the clinical research community to develop better and more efficient therapies for ED as well as documenting the treatment strategies and programs that are effective.
Definitions of Recovery: How do we know when our patients are truly recovered from their ED? The answer to this question has important implications for treatment, the patient’s quality of life, research, and insurance coverage. While some may see symptom remission, weight restoration and cessation of overt ED behaviors, as the threshold for recovery, many clinicians and researchers point to the importance of addressing key maintaining factors that can leave even symptom free patients highly vulnerable to relapse. These may include psychiatric and medical co morbidities, issues around emotional regulation, cognitive and learning factors, a number of personality and temperamental factors, and one’s living and work environment. In our opinion, a full and lasting recovery from an ED requires more than simple symptom remission, at least for the majority of patients, and our treatment models and conceptualizations of these disorders must be complex enough to cover these numerous bases.
It is an exciting time in the ED field. Advances in our understanding of these complex disorders have generated optimism about improving treatment and treatment outcomes. There is a growing awareness of the role of evidence-based treatments and, hopefully, increasing ability for patient and families to access specialized care. At the same time, we have to continue to embrace complexity and avoid the false security of reductionistic models of formulation, treatment and recovery. We need to address issues of age, gender, culture and ethnicity. In our opinion treatments must shift their focus from a search for etiological factors to a focus on the factors that perpetuate and maintain the disorders. New research is investigating the common underlying maintaining factors across multiple general psychiatric disorders, and this work may help us better address common transdiagnostic factors like emotional and experiential avoidance, temperament and mood dysregulation. Clinicians, researchers, patients and families all have a role in developing, studying, disseminating and advocating for high quality treatments for patients with ED.