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Kathleen M. Pike, Christina A. Roberto, Marsha D. Marcus: Chapter 48. Evidence-Based and Innovative Psychological

Treatments, in Gabbard’s Treatments of Psychiatric Disorders, 4th Edition. Edited by Glen O. Gabbard. Copyright ©2009

American Psychiatric Publishing, Inc. DOI: 10.1176/appi.books.9781585622986.262142. Printed 5/10/2009 from

www.psychiatryonline.com

Gabbard’s Treatments of Psychiatric Disorders > Part IX. Eating Disorders >

Chapter 48. Evidence-Based and Innovative Psychological Treatments

INTRODUCTION

The lion’s share of treatment research in the field of eating disorders focuses on the two most

widely recognized eating disorders: anorexia nervosa (AN) and bulimia nervosa (BN). In addition,

with the publication of DSM-IV (American Psychiatric Association 1994), binge-eating disorder

(BED) emerged as a distinct disorder warranting further exploration, and thus a growing database

exists regarding treatment efficacy for BED as well. Because outpatient psychotherapy is the

cornerstone of clinical care for eating disorders, this chapter focuses on evidence-based outpatient

psychotherapies for AN, BN, and BED. The extant knowledge base varies in strength and breadth

across these disorders and across different stages of treatment for these disorders. This chapter

highlights the extent to which the existing knowledge base can inform clinical work. It also

underscores the gaps in the knowledge base that clinical research should aim to fill in the coming

years. This chapter does not address medication or family therapy interventions. The role of

medication in the treatment of eating disorders is discussed in Chapter 47, and the utility of family

therapy is discussed in Chapter 49.

OUTPATIENT PSYCHOTHERAPY FOR ANOREXIA NERVOSA

The hallmark features of AN are extreme food restriction, refusal to maintain a weight healthy for

age and height, and overvaluation of or dysfunctional attitudes regarding weight and shape. Table

48–1 delineates the full DSM-IV-TR (American Psychiatric Association 2000) criteria for AN. One of

the most remarkable features of AN is the nearly universal ego-syntonic nature of the disorder,

which presents profound challenges for treatment engagement, motivation, and outcome. Thus,

despite the long history of AN in the diagnostic nomenclature, the empirical database regarding

clinical treatments is remarkably limited. An extensive clinical literature exists prescribing a range

of outpatient psychotherapy interventions for AN, but it is impossible to rely solely on

evidence-based treatment recommendations in clinical practice due to the very limited extant data.

Empirical support is increasing for family therapy in the treatment of adolescents with

short-duration illness, as discussed in Chapter 49. Preliminary empirical support exists for other

approaches; however, replication studies and studies with larger sample sizes are necessary. The

limited evidence base has significant and practical consequences for clinical care, and a major

initiative is underway to fill these gaps with data generated from controlled clinical trials (Agras et

1. 2003). In the meantime, preliminary data regarding CBT, IPT, supportive psychotherapy, and

cognitive analytic therapy comprise our research base as described below.

Table 48–1. DSM-IV-TR diagnostic criteria for anorexia nervosa

1. 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).

1. Intense fear of gaining weight or becoming fat, even though underweight.
2. 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.

1. In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles.

(A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen,

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Specify type:

Restricting type: during the current episode of anorexia nervosa, the person has not regularly engaged in

binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)

Binge-eating/purging type: during the current episode of anorexia nervosa, the person has regularly

engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics,

or enemas)

Source. Reprinted from American Psychiatric Association: Diagnostic and Statistical Manual of Mental

Disorders, 4th Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000, p. 589.

Copyright 2000, American Psychiatric Association. Used with permission.

Individual Psychotherapy for Adolescents With Anorexia Nervosa

In two studies evaluating the efficacy of family therapy for adolescents, individual psychotherapies

served as the comparison treatments. At the Maudsley Hospital, Gerald Russell and colleagues

conducted a landmark study of treatment for individuals who had successfully completed inpatient

treatment for weight restoration (Russell et al. 1987). This clinical trial included adolescents and

adults and compared family therapy and individual supportive psychotherapy. Concerning the

adolescents (n = 21), findings from this study favored family therapy over individual supportive

therapy for individuals with a short duration of illness (3 years or less) and early onset of AN (prior

to age 18 years). By the end of treatment, 60% (6 of 10) of the family therapy group achieved good

outcome, compared with 9% (1 of 11) of the individual supportive psychotherapy group.

A subsequent study conducted by Robin et al. (1999) compared family therapy and a

psychodynamically oriented psychotherapy for 37 non-weight-restored adolescents with AN.

Results from this trial indicated that the family therapy group (n = 19) and the psychodynamically

oriented psychotherapy group (n = 18) were similar in terms of improvements in eating behavior

and attitudes, depression, and family functioning. Weight gain was greater in the family therapy

group, but this group also had a higher rate of hospitalizations during the course of the treatment

trial. Several additional studies of family therapy for adolescents exist, and the encouraging

findings (as discussed in more detail in Chapter 49) support continued work in this area for young

patients with recent-onset AN. At the same time, the results from the two studies highlighted above

suggest that it is premature to foreclose the development of individual psychotherapy for

adolescents. In the Maudsley study (Russell et al. 1987), no treatment emerged as clearly

beneficial for individuals who had AN for 3 years or more, even if they were young at the time of

onset. In the study by Robin et al. (1999), the outcome for the psychodynamic group was

comparable to that for the family therapy group with the exception of weight gain, a difference that

is uninterpretable because the groups had different hospitalization rates during the trial.

Establishing empirical support for a well-articulated individual psychotherapy for adolescents with

AN would be an enormous contribution to clinical practice and would provide a valid alternative to

family therapy for those cases where family therapy is not an option or has failed.

Individual Psychotherapy for Adults With Anorexia Nervosa

Eight controlled trials comprising a total sample of just under 400 individuals represent the extant

empirical literature informing clinical practice for adult AN. Six studies evaluated a variety of

psychotherapies for outpatient treatment of non-weight-restored individuals, and two studies

compared the relative efficacy of family therapy, individualized supportive psychotherapy, CBT, and

nutritional counseling in the posthospital care of weight-restored individuals with AN.

Outpatient Psychotherapy for Non-Weight-Restored Adults With Anorexia

Nervosa

Hall and Crisp (1987) published one of the first studies evaluating the efficacy of psychotherapy for

non-weight-restored adults with AN approximately 20 years ago. In this study, 30 adult women

with AN (mean age: 19.5 years) participated in 12 sessions of dietary advice or 12 sessions ofPrint: Chapter 48. Evidence-Based and Innovative Psychological Trea… http://www.psychiatryonline.com/popup.aspx?aID=262146&print=yes…

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combined individual and family psychotherapy. Individuals in both treatment conditions reported

modest improvements in terms of weight and global clinical functioning. The psychotherapy group

also reported improvements in psychosocial functioning.

In a study of 24 adult women comparing CBT, behavioral treatment, and routine care, Channon et

1. (1989) reported no differences in treatment outcome and limited efficacy across all treatments.

However, the study did not use standardized treatments, each treatment condition contained only 8

participants, and the intensity of treatment was limited to 24 sessions over the course of 1 year (18

sessions during the first 6 months, followed by 6 sessions at 1-month intervals).

A larger-scale study conducted by Crisp et al. (1991) randomly assigned 90 adult women with AN to

one of four conditions: inpatient treatment, combined outpatient individual and family therapy,

outpatient group therapy for patients and parents, and a no-treatment control group. The inpatient

treatment and no-treatment control group had very high dropout and nonadherence rates.

Individuals in all of the active-treatment groups achieved greater weight gain than those in the

no-treatment control group, and differences among the active-treatment groups were minimal. The

data from this study clearly suggest that active treatment is better than no treatment. More

specifically, the results favor outpatient psychotherapy, given the lower dropout rates associated

with this treatment. However, it is not possible to distill more differentiated recommendations

regarding outpatient psychotherapy based on findings from this study, given the lack of differences

between the outpatient treatments. Another limitation of this study is the lack of manuals

describing the psychotherapies in sufficient detail for replication.

In a subsequent study of 30 adults with AN, Treasure et al. (1995) compared educational

behavioral treatment and cognitive analytical therapy. Educational behavioral treatment includes

behavioral monitoring of food intake and exercise, goal setting regarding weight gain and food

consumption, discussion of weight and shape issues, and education regarding general nutrition and

eating disorders. Cognitive analytic therapy is a psychoanalytically based psychotherapy that

focuses on a collaborative reconstruction of an individual’s history and eating disorder

development. In the course of therapy, a sequential diagrammatic reformulation of behavior

visually displays patterns of thinking, feeling, and behavior that are linked to the eating disorder

and associated problematic behaviors. These patterns become the targets of attention each week.

Treatment outcome was comparable across therapies, with approximately two-thirds of participants

in both groups achieving good or intermediate outcomes.

One of the largest outpatient studies evaluating psychotherapy for non-weight-restored adult AN

compared three active treatments with a control treatment. The trial included 84 individuals who

participated in family therapy, focal psychotherapy, cognitive analytic therapy, or treatment as

usual (Dare et al. 2001). Findings from this trial indicated that participants in the active treatments

generally fared better than did those in the control condition. The family therapy and focal

psychotherapy groups demonstrated significantly more improvement than the control group;

however, the three active treatments were not statistically different from one another.

Approximately one-third of the participants in each of the active conditions achieved a good or

intermediate recovery.

The most recent study of adult outpatient treatment compared 20 sessions of CBT, IPT, and

nonspecific supportive clinical management (NSCM) (McIntosh et al. 2005). This study included 33

women who met criteria for AN and 23 women who met criteria for subthreshold AN (17.5 < BMI <

19.0 kg/m2 ). The NSCM group fared somewhat better than the other two groups, although the

differences between the CBT and the NSCM group were not statistically significant in the

intent-to-treat analysis but only in the completers analysis. In both analyses, NSCM was superior to

IPT.

In summary, none of these studies provide definitive evidence to support the efficacy of any

particular form of psychotherapy in the outpatient treatment of underweight patients with AN.

Outpatient Psychotherapy for Posthospital Treatment of Adults With

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The first controlled clinical trial to evaluate a posthospital treatment for adult AN was the clinical

trial by Russell et al. (1987) that compared family therapy with individual supportive

psychotherapy. This study included 36 weight-restored adults whose mean age at the start of

treatment was 20.6 years. In distinction to the findings for younger and less chronic patients,

results from this study suggested that family therapy was contraindicated for older and/or more

chronic individuals with AN. This group seemed to do slightly better in individual supportive

psychotherapy, but none of the treatments evaluated proved to be tremendously beneficial and the

treatment differences that existed at the end of treatment had diminished at follow-up (Eisler et al.

1997).

A subsequent study conducted by Pike et al. (2003b) compared CBT with nutritional counseling as a

first step in proving efficacy of a specific psychotherapy in the posthospital care for adult AN. In

this study, 33 women participated in a year-long outpatient treatment initiated upon successful

weight restoration achieved during inpatient hospitalization. All participants were monitored

medically and were randomly assigned to either CBT for AN or nutritional counseling, and the

results clearly document therapeutic efficacy for CBT. Relapse rates were lower for the CBT group

than for the nutritional counseling group (22% vs. 53%, respectively), and overall treatment

failure (relapse and dropping out combined) was lower for the CBT than for the nutritional

counseling group (22% vs. 73%, respectively). A significantly greater percentage of individuals in

the CBT condition achieved a good outcome or full recovery (44%) compared with those in the

nutritional counseling condition (6.7%), and 77% of the CBT group achieved an intermediate or

better outcome, compared with 26.7% of the nutritional counseling group.

The clinical application of CBT in this study is consistent with the fundamental principles of CBT for

1. However, the applications of CBT for BN and AN diverge in ways that reflect differences

between the disorders (Garner and Bemis 1982, 1985; Guidano and Liotti 1983; Pike et al. 1996,

2003a; Vitousek and Ewald 1993; Vitousek and Hollon 1990). Specifically, this CBT program is a

longer-term intervention than the typical course of CBT for BN. Given the ego-syntonic nature of

AN, CBT for AN focuses more heavily on issues of motivation and resistance and extends beyond the

specific eating disorder symptoms to broader general maladaptive self-schemas. Treatment also

emphasizes the reinforcing and adaptive aspects of the disorder and its role in protecting the

individual from assuming appropriate developmental challenges such as increased independence

and autonomy. Finally, CBT for AN also tends to require greater attention to medical complications

and the effects of starvation on functioning.

Summary of Empirical Support for Cognitive-Behavioral Therapy for

Anorexia Nervosa

Available research on the treatment of AN is limited; most studies have had small sample sizes, and

thus, the ability to draw definitive conclusions is limited. Nevertheless, two studies evaluating the

efficacy of CBT provide preliminary support for its role in the treatment of AN. The posthospital

study conducted by Pike et al. (2003b) was the first study to document the efficacy of any

psychotherapy intervention for adult AN at this stage of treatment. The findings from the New

Zealand outpatient study (McIntosh et al. 2005) suggest that CBT has therapeutic efficacy in the

outpatient care of individuals with AN; however, the specificity and potency of CBT at this stage of

care are less clear. In this study, the nonspecific supportive clinical management (NSCM) group

showed the best overall rates of improvement; however, the differences between the CBT and

NSCM groups were not statistically different in the intent-to-treat analyses. Given the morbidity and

potentially refractory nature of AN, the need for additional research in the psychological treatment

of AN is compelling. However, at this point in time, evidence suggests that CBT may be potentially

useful. CBT manuals are available for the posthospital care of both weight-restored AN (K. M. Pike,

1. B. Vitousek, G. T. Wilson, “Cognitive Behavioral Therapy Treatment Manual for Post-Hospital

Treatment of Anorexia Nervosa,” 1998 [unpublished manuscript available on request from the

authors]) and non-weight-restored AN (McIntosh et al. 2005) and may be used by clinicians to

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OUTPATIENT PSYCHOTHERAPY FOR BULIMIA NERVOSA

Although BN has a shorter history in the psychiatric nomenclature than AN, the empirical database

regarding treatment efficacy is remarkably more extensive than exists for AN. As delineated in

Table 48–2, the core diagnostic features of BN are recurrent binge-eating episodes (i.e., the

consumption of an objectively large amount of food, coupled with subjective feelings of loss of

control), persistent and regular compensatory behaviors, and overvaluation of or dysfunctional

attitudes toward weight and shape. The majority of individuals with BN are normal weight, and

adolescent and young adult women constitute the groups at highest risk for developing BN (Jacobi

et al. 2004). The majority of individuals with BN experience significant distress associated with

their disorder and present for treatment on their own initiative. Thus, although treatment for BN is

sometimes protracted, the issues of motivation and engagement in treatment are typically less

challenging than in the case of AN, and the standard course of treatment is shorter.

Table 48–2. DSM-IV-TR diagnostic criteria for bulimia nervosa

1. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

(1) eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely

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)

1. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced

vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise.

1. The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week

for 3 months.

1. Self-evaluation is unduly influenced by body shape and weight.
2. The disturbance does not occur exclusively during episodes of anorexia nervosa.

Specify type:

Purging type: during the current episode of bulimia nervosa, the person has regularly engaged in

self-induced vomiting or the misuse of laxatives, diuretics, or enemas

Nonpurging type: during the current episode of bulimia nervosa, the person has used other inappropriate

compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced

vomiting or the misuse of laxatives, diuretics, or enemas

Source. Reprinted from American Psychiatric Association: Diagnostic and Statistical Manual of Mental

Disorders, 4th Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000, p. 594.

Copyright 2000, American Psychiatric Association. Used with permission.

Cognitive-Behavioral Therapy for Bulimia Nervosa

Experts in the field of eating disorders recognize cognitive-behavioral therapy (CBT) as the

treatment of choice for BN. Results from a significant number of randomized controlled clinical

trials indicate that CBT is consistently as good as or superior to the treatments to which it is

compared (Agras et al. 1994, 2000; Fairburn et al. 1991; Garner et al. 1993; National Institute for

Clinical Excellence 2004; Walsh et al. 1997). Although a number of antidepressant medications

have proven efficacy for BN, comparisons of CBT to such medications consistently favor CBT

(National Institute for Clinical Excellence 2004; Wilson et al. 2002). Compared to several other

psychotherapy interventions, including supportive psychotherapy, behavioral therapy, interpersonal

therapy (IPT), and supportive-expressive psychotherapy, CBT reliably proves to be the most

effective psychotherapy available. At the end of a course of CBT, approximately 30%–50% of

individuals with BN report complete remission of binge-eating and compensatory behaviors, and

the overall reduction of binge eating and purging is approximately 80%. In addition, assessments

of attitudinal factors associated with weight and shape typically improve, as does generalPrint: Chapter 48. Evidence-Based and Innovative Psychological Trea… http://www.psychiatryonline.com/popup.aspx?aID=262146&print=yes…

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psychiatric functioning (for a review, see Commission on Adolescent Eating Disorders 2005; Wilson

and Pike 2001).

The theoretical and empirical work on CBT is extensive. Although treatment applications vary as a

function of the disorder and treatment setting, the fundamental tenets of CBT (i.e., that the manner

in which an individual cognitively processes information mediates emotional and behavioral

experiences and expressions in a particular situation) remain consistent. Originally developed by

Aaron T. Beck (A. T. Beck 1976; A. T. Beck et al. 1979, 2003), CBT is one of the most influential

models of mental health and illness that currently informs the worlds of psychology and psychiatry.

For a more thorough elaboration of the broad principles of CBT, readers are referred to A. T. Beck

(1976), J. S. Beck (1995), (2005), Hawton et al. (1989), Hollon and Beck (1993), and Young

(1999).

The CBT model for BN that is best articulated and most widely utilized is the Oxford model

originally developed by Christopher Fairburn (1985) and described in a treatment manual by

Fairburn et al. (1993). The program is based on the assumption that dysfunctional attitudes and

beliefs associated with disordered eating serve to maintain the pattern of binge eating and

compensatory behaviors. Accordingly, the treatment focuses on the role of cognitive and behavioral

disturbances that perpetuate current eating disorder pathology. According to this CBT model,

deficits in self-esteem render individuals vulnerable to pernicious messages regarding feminine

beauty ideals and the myth that achieving thinness will assuage feelings of self-loathing and low

self-esteem. Internalized, these beliefs find expression in dysfunctional ideas that overvalue

eating, shape, and weight that cascade into behavioral striving to attain appearance ideals that are

unrealistic or achieved only through the practice of disturbed eating behaviors or weight-control

methods. The intimate link between extreme dietary restraint and binge eating is a central focus of

CBT for BN. Individuals with BN have rigid dietary rules governing when, what, and how much they

should eat. However, individuals are unable to sustain “perfect” eating behavior and the rules

inevitably are broken, and when they are, binge eating will likely ensue, and feelings of loss of

control will intensify commensurately. Ironically, these weight-control efforts, pursued out of

desperation to improve low self-esteem, lead to diminished self-worth and maintenance of the

destructive cycle.

CBT for BN typically consists of 15–20 outpatient sessions over 5 months and is broken down into

three stages. During the first stage, therapists introduce the CBT model described above and work

with clients to personalize the model to their specific experience. Psychoeducation is an important

component at the beginning of treatment, and therapists provide information about nutrition,

energy balance, physical consequences of binge eating and purging, and ineffectiveness of

compensatory behaviors such as vomiting and laxative abuse as weight-control techniques. Clients

develop self-monitoring skills and work on reducing restraint, focus on normalizing eating patterns

and mealtimes, and developing strategies that will enhance their capacity to resist the urges to

binge-eat and purge. The second stage of CBT typically includes a continuing focus on maintaining

normalized eating patterns, but it also expands to emphasize cognitive restructuring work on

dieting and overvaluation of shape and weight. The final stage focuses on relapse prevention. Upon

therapy termination, clients will have worked on setting realistic expectations and will have

delineated plans for coping with potential setbacks in their recovery from BN.

Interpersonal Psychotherapy for Bulimia Nervosa

IPT is a short-term, time-limited psychotherapy that Gerald Klerman and colleagues developed for

depression approximately 20 years ago (Klerman et al. 1984). Adaptations of IPT exist that alter

the mode of delivery (individual vs. group format) and that target a variety of psychological

disorders. Within the field of eating disorders, Fairburn (1997) adapted IPT for use in the treatment

of BN based on the rationale that, similar to individuals with other psychiatric conditions,

individuals with BN often describe significant interpersonal problems that are integral to their

psychopathology, and that in turn serve to maintain the cycle of disordered eating (Fairburn 2002).

IPT typically consists of 12–20 sessions occurring over the course of 3–5 months, and similar toPrint: Chapter 48. Evidence-Based and Innovative Psychological Trea… http://www.psychiatryonline.com/popup.aspx?aID=262146&print=yes…

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CBT for BN, it is broken down into three phases. The first phase, usually lasting up to 4 sessions,

involves a collaborative effort between the therapist and client to identify interpersonal problems

by exploring the interpersonal situations that are integral to contextualizing the emergence and

maintenance of the disorder. In the case of BN, for example, the initial stage of therapy may

examine the interpersonal triggers associated with binge eating. Together, patient and therapist

decide on the problem areas on which to focus throughout treatment. These areas of difficulty

generally fall into one of four categories: interpersonal disputes, role transitions (e.g.,

commencement of new job, marriage, moving out of home), abnormal grief reactions, or

interpersonal deficits (lack of intimate and satisfying relationships). Interpersonal disputes and

role transitions are the most frequent problem areas for individuals in treatment for BN (Fairburn

2002). The second phase of treatment consists of approximately 10 weekly sessions and focuses on

generating solutions to deal with problem areas. The final phase of treatment, comprising the last

3–4 sessions which occur fortnightly, focuses on the future and relapse prevention.

Given the perceived relevance of IPT, it served as a comparison treatment to CBT in two major

outpatient psychotherapy trials of BN. Results from these two investigations indicated that at the

end of treatment, the IPT group had improved significantly, but the potency of the effect was not as

great as that for CBT in terms of remission rates and improvements in binge eating and purging

(Agras et al. 2000; Fairburn et al. 1991). However, at 1-year follow-up, the effects of IPT and CBT

were not discernibly different, and this lack of differences appeared to be due to continuing

improvement in the IPT group rather than deterioration in the CBT group. Thus, given that IPT was

not significantly different from CBT at follow-up and that IPT was significantly different from the

behavioral therapy condition in the Fairburn et al. (1991) study, it is generally agreed that IPT has

documented efficacy in the treatment of BN.

A notable and significant shortcoming of IPT in the two clinical trials for BN is that the treatment

precluded discussions of the specific symptoms of the eating disorder after the initial assessment.

Whereas IPT for depression involves a discussion of the depressive symptoms and their link to

interpersonal situations throughout the course of treatment, IPT for BN eliminated this dimension

of IPT to maximize the difference between the different therapy approaches in the study. This

alteration in the delivery of IPT may account for the protracted response rate. It is possible that the

efficacy of IPT in the treatment of BN would be enhanced if IPT for BN reincorporated this aspect of

IPT. By linking the interpersonal problems to the core eating pathology (consistent with the original

conception of IPT), it is possible that individuals would more readily engage in the change process

on both a behavioral and an attitudinal level.

OUTPATIENT PSYCHOTHERAPY FOR BINGE-EATING DISORDER

BED is included in DSM-IV as an example of eating disorder not otherwise specified (EDNOS) and in

an appendix as a proposed diagnosis requiring further study (see Table 48–3 for the complete

research criteria for BED). BED is characterized by recurrent and persistent binge eating in the

absence of regular compensatory behaviors. Given that there is no regular effort to undo the effects

of binge eating, it is unsurprising that most individuals with BED are overweight.

Table 48–3. DSM-IV-TR research criteria for binge-eating disorder

1. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

(1) eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely

larger than most people would eat in a similar period of time under similar circumstances.

(2) a sense of lack of control over eating during the episode (i.e., feeling that one cannot stop eating or

control what or how much one is eating)

1. The binge-eating episodes are associated with three (or more) of the following:

(1) eating much more rapidly than normal

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(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

1. Marked distress regarding binge eating is present.
2. The binge eating occurs, on average, at least 2 days a week for 6 months.

Note: the method of determining frequency differs from that used for bulimia nervosa; future research

should address whether the preferred method of setting a frequency threshold is counting the number of days

on which binges occur or counting the number of episodes of binge eating.

1. The binge eating is not associated with the regular use of inappropriate compensatory behaviors (e.g.,

purging, fasting, excessive exercise) and does not occur exclusively during the course of anorexia nervosa or

bulimia nervosa.

Source. Reprinted from American Psychiatric Association: Diagnostic and Statistical Manual of Mental

Disorders, 4th Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000, p. 787.

Copyright 2000, American Psychiatric Association. Used with permission.

By and large, interventions for BED have been adapted from those that have been shown to be

effective in reducing binge eating among individuals with BN. There is reasonable evidence that

CBT and IPT have utility in reducing the frequency of binge eating and improving the

psychopathology associated with BED. There also is preliminary evidence that dialectical behavior

therapy (DBT) has promise as an alternative treatment for BED and, finally, that behavioral weight

management may be appropriate for some overweight individuals with BED.

CBT for BED has been adapted to reflect important differences between individuals with BN and BED

(Fairburn et al. 1993). Specifically, CBT for BED targets cognitions relating to having a large body

size. Overweight individuals with BED are helped to accept a larger than average body size and to

change unrealistic expectations for weight loss. Another adaptation of CBT for BED relates to

differences in the role of dieting between individuals with BED and those with BN. Although the

treatment of BN stresses the role of dietary restraint in precipitating and maintaining binge

episodes and treatment focuses on decreasing dietary restraint, patients with BED do not

necessarily binge-eat in response to restraint or hunger. Indeed, the preponderance of evidence

suggests that increasing dietary restraint may help to ameliorate binge eating in obese individuals

(Telch and Agras 1993). Thus, CBT for BED does not stress decreased dietary restraint; rather,

treatment encourages the development of a moderate, structured, healthy eating pattern. CBT has

been delivered efficaciously in individual (Marcus et al. 1995; Smith et al. 1992) and group (Wilfley

et al. 1993, 2002) formats.

Klerman and Weissman’s (1984; Weissman et al. 2000) IPT has also received empirical support in

the treatment of individuals with BED. As is the case in the treatment of BN, IPT for BED is based on

an assumption that dysfunctional eating behavior is maintained in the context of interpersonal

difficulties, and treatment focuses on identifying and addressing specific problematic interpersonal

patterns in an effort to ameliorate binge eating. Initial reports (Agras et al. 1997; Wilfley et al.

1993) showed that IPT delivered in a group format is as effective as CBT in reducing binge eating in

BED patients both at posttreatment and at 1 year follow-up. More recently, Wilfley et al. (2002)

compared the outcomes of overweight individuals with BED who received group IPT with the

outcomes of those treated with group CBT. Both treatments were associated with significant

improvements in binge eating, associated eating disorder psychopathology, psychiatric symptoms,

and self-esteem. Changes in binge eating, dietary restraint, and thoughts about shape and weight

also were maintained during the 1-year follow-up period. Thus, CBT and IPT appear to be equally

effective in the treatment of BED, although the mechanisms by which they promote changes in

eating behavior differ.

Because the majority of individuals with BED are also overweight and want to lose weight, and

because obesity is associated with significant medical and psychosocial consequences, weight lossPrint: Chapter 48. Evidence-Based and Innovative Psychological Trea… http://www.psychiatryonline.com/popup.aspx?aID=262146&print=yes…

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is a potentially important outcome in the treatment of BED. Numerous studies have documented

that calorie restriction does not exacerbate binge eating in BED patients (Agras et al. 1994; Marcus

et al. 1995; Raymond et al. 2002; Wadden et al. 1992). Moreover, participation in behavioral

weight-control programs that focus on calorie restriction, provide education about sound nutritional

principles, and promote physical activity may lead to moderate weight loss, decrease binge eating,

and improve mood in BED patients.

In summary, available research indicates that individuals with BED can be helped with specified

psychotherapeutic approaches targeting disordered eating, and for overweight individuals who

desire weight loss, a behavioral weight management program is helpful. A careful assessment,

review of the benefits and disadvantages of the different therapies, and consideration of the

availability of trained clinicians should guide the choice of treatment for an individual with BED.

OTHER PSYCHOLOGICAL TREATMENTS

A substantial number of eating disorder patients fail to benefit from first-line treatments (Wilson

1996), and there is widespread agreement that there is a need to enhance the impact of currently

available treatments and develop alternative approaches to care. There have been thoughtful

descriptions (de Groot and Rodin 1998; Steiger and Israel 1999) and observational reports (Kächele

et al. 2001) documenting the potential utility of psychodynamic approaches in the treatment of

eating disorders, but empirical support is scant.

A small randomized trial conducted by Fairburn et al. (1986) compared CBT with short-term focal

psychotherapy (STP) for patients with BN. Patients in both treatment conditions made significant

improvements over time, which were sustained throughout follow-up, though the CBT group

achieved several additional gains on psychological measures and overall clinical state. Garner et al.

(1993) also compared individual CBT to a brief psychodynamic therapy (supportive expressive

therapy) for women with BN. Both treatments had a significant impact on the symptom areas

measured, including an equal reduction in binge-eating frequency. However, those in the CBT

condition showed a trend toward more weight gain and had a greater decrease in vomiting

frequency. CBT also led to significantly greater improvement on a variety of eating disorder

measures and improvements in depression, self-esteem, general psychological distress, and certain

personality traits. In a small (n = 33) randomized controlled trial (Bachar et al. 1999), self

psychological treatment was associated with significant improvement in patients with BN and AN in

comparison to cognitive-oriented treatment or nutrition counseling only; however, the small sample

size precludes definitive conclusions. In another small study noted above, Dare et al. (2001) found

that focal psychoanalytic therapy (a standardized 1-year psychoanalytic psychotherapy),

cognitive-analytic therapy (a 7-month intervention that combines components of cognitive therapy

and brief psychodynamic psychotherapy), and family therapy (1 year) were superior to usual care

(1 year) in the treatment of adults with AN. Although all of the specialist treatments were superior

to usual care, there were no differences among the three psychotherapies, which is unsurprising in

light of the small size of the sample. Gowers et al. (1994) analyzed data from a subgroup of 20

patients with AN who were participating in a larger multitreatment outcome study. The authors

compared patients receiving individual outpatient treatment emphasizing psychodynamic issues

with a no-treatment control group. At 2-year follow-up, the treatment group had significantly more

weight gain than the control condition. Upon termination, the 12 patients receiving individual

psychotherapy were classified as “well or nearly well” based on Morgan-Russell outcome criteria

(Morgan and Russell 1975), compared to only 4 individuals in the untreated group. Again,

conclusions were limited because of the utilization of CBT elements in therapy as well as a tendency

of patients to seek alternative treatment when assigned to the control group.

Taken together, the empirical evidence for psychodynamic approaches is somewhat fragmented and

does not provide a clear set of recommendations. When compared with CBT, psychodynamic

approaches appear to achieve more modest gains on some core attitudinal and behavioral

symptoms. Nonetheless, the extant findings also report significant improvements with

psychodynamic approaches, and the renewed emphasis among behavioral researchers on thePrint: Chapter 48. Evidence-Based and Innovative Psychological Trea… http://www.psychiatryonline.com/popup.aspx?aID=262146&print=yes…

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importance of the therapeutic relationship and the function and meaning of symptoms (Hayes et al.

2004) suggests that certain psychodynamic approaches or elements of psychodynamic therapy may

have specific and significant potency. Recent psychodynamic approaches reflect an evolution in the

theoretical underpinnings and clinical practice of psychodynamic psychotherapy. In particular,

these treatments are more active, interpersonally focused, and detailed in their application. Such

advances will allow for continuing investigations of the role of psychodynamic therapy in the

treatment of eating disorders, which are necessary to provide the information needed to guide

clinical care.

The last decade has seen the development of what has been termed the “third generation” of

behavior therapies (Hayes 2004). First-generation (behavior therapies) and second-generation

(cognitive-behavioral therapies) approaches are characterized by the clearly specified and

rigorously tested applied technologies that focus on relief of symptoms. In contrast,

third-generation approaches such as DBT (Linehan 1993a, 1993b), acceptance and commitment

therapy (Hayes 2004), and functional analytic therapy (Hopko and Hopko 1999) emphasize

experiential change and focus on the context and function of psychological phenomena in service of

clinically relevant and meaningful change (Hayes 2004). Accordingly, these interventions

incorporate a focus on intervention components such as mindfulness, acceptance, meditation, and

spirituality and renew an earlier emphasis on the therapeutic relationship.

DBT is an exemplar of a third-generation approach. DBT is a comprehensive treatment program

based on cognitive and behavioral principles and complemented by the use of mindfulness

strategies derived primarily from Zen Buddhism. DBT provides an explicit framework for balancing

an ongoing focus on the need to change maladaptive symptom behaviors with an emphasis on

validation of the patient’s point of view and acceptance of the difficulty of change. In the DBT

framework, eating disorder behaviors are conceptualized as an attempt on the part of the patient to

regulate or avoid aversive or overwhelming emotions. Thus, behaviors such as calorie restriction,

purging, or overexercise enable the patient to effectively numb, soothe, or avoid negative affect.

There is an explicit acknowledgment that symptom behaviors serve a meaningful function and

represent a legitimate effort to deal with life circumstances. However, because symptoms also are

associated with significant morbidity, there is an emphasis on recovery, and therapists are trained

to pull for change by utilizing the complete compendium of cognitive and behavioral techniques. In

summary, DBT balances the focus on change and recovery with acceptance and validation of the

patient’s choices given the circumstances.

DBT was initially developed by Marsha Linehan (1993a, 1993b) for the treatment of patients with

borderline personality disorder (BPD) and parasuicidal behaviors. Because of its demonstrated

utility for BPD (Linehan et al. 1991, 1993), the use of DBT has expanded to include other patients

suffering from chronic or refractory behavioral health problems. Telch et al. (2000), (2001) adapted

and tested a group-based version of DBT designed for individuals with BED. This program appears

to be effective in decreasing binge-eating behavior and maladaptive attitudes about eating, shape,

and weight. In one study (Telch et al. 2001), 89% of the women with BED who completed the

20-week DBT group treatment were abstinent from binge eating, compared to only 13% of those in

the wait-list group, and more than half of the women who received DBT maintained their

binge-eating abstinence in the 6 months following the end of treatment. Additional controlled trials

with longer follow-up periods are needed to document the efficacy of DBT, but initial studies

suggest its utility in the treatment of BED. Moreover, one study has suggested its potential utility in

the treatment of BN (Safer et al. 2001), and other investigators have suggested further study of

DBT in the management of patients with chronic or treatment-refractory AN (McCabe and Marcus

2002; Palmer et al. 2003).

Data suggesting the positive effects of interventions that balance the need for change with

acceptance and validation of the patient and the quality and nature of the therapeutic relationship

are intriguing in light of the results of the previously described study by McIntosh et al. (2005). The

results of this study suggested the potential efficacy of NSCM in the treatment of acutely ill adults

with AN. NSCM, developed specifically for the trial, incorporates elements of supportivePrint: Chapter 48. Evidence-Based and Innovative Psychological Trea… http://www.psychiatryonline.com/popup.aspx?aID=262146&print=yes…

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psychotherapy, a focus on the quality of the therapeutic relationship, and acceptance and validation

of patients’ agendas for treatment. Although these initial results require confirmation in larger

studies, the findings suggest that interventions that include elements of third-generation

interventions have promise in the management of eating disorders.

SELF-HELP AND INNOVATIVE THERAPIES FOR EATING DISORDERS:

SELF-HELP FOR BULIMIA NERVOSA AND BINGE-EATING DISORDER

Although numerous research studies have validated the effectiveness of CBT for individuals with BN

and BED, it is not a treatment that is easily accessible for everyone. There are a limited number of

therapists specially trained in CBT, and for some individuals the time commitment and financial

costs pose significant obstacles to treatment. Though not unique to CBT, these limitations have

prompted researchers to explore the benefits of developing self-help treatments based on the

principles of CBT for individuals with BN and BED. Given the ego-syntonic nature of AN and the

medical complications associated with starvation, self-help programs have not been pursued for

1.  

A series of randomized trials of self-help interventions have reported positive findings (Carter et al.

2003; Cooper et al. 1994, 1996; Huon 1985), and a variety of self-help manuals and books are

available (Fairburn 1995). The results of some of these studies suggest that self-help yields

improvements comparable to those produced by CBT and certainly is more helpful for patients than

a wait-list control condition (Treasure et al. 1994).

Results from two studies suggest that providing minimal support and guidance enhances the

benefits of self-help manuals (Loeb et al. 2000; Thiels et al. 1998). Loeb et al. (2000) examined this

idea by comparing a guided self-help (GSH) group and an unguided self-help (USH) group. Both

groups improved (68% for GSH vs. 55% for USH), though GSH led to significantly more

improvement, including higher rates of reduction in objective binge-eating frequency. Bailer et al.

(2004) found that both guided self-help treatment and group CBT sessions reduced binge-eating

and vomiting frequency and improved Eating Disorder Inventory and Beck Depression Inventory

scores, and that these improvements persisted throughout 1-year follow-up. Peterson et al. (1998)

investigated the utility of self-help interventions that incorporated the use of a videotape in a

self-help program based on the principles of CBT. The study included three separate conditions: a

therapist-led self-help group, a partial self-help group (psychoeducational videotape plus a

therapist), and a structured self-help group (psychoeducational videotape plus group member–led

discussion). All three conditions surpassed a wait-list control group, and binge-episode frequency

decreased in all treatment groups, but there were no significant differences between groups. A

subsequent study by the authors employed this same design with an additional 1-year follow-up

and found that improvements were maintained at follow-up, although roughly 50% of patients

remained symptomatic.

With promising results from guided self-help studies that indicate such treatment is superior to

waiting lists, and in some cases comparable to CBT, Walsh et al. (2004) sought to examine the

effectiveness of the treatment in an even more accessible setting. Patients received treatment from

general medicine internists and nurses (who were given brief training by study investigators)

rather than at a specialized eating disorders clinic. Patients in the study were randomly assigned to

one of four treatment options: placebo alone, fluoxetine alone, placebo combined with guided

self-help, or fluoxetine combined with guided self-help. The results from this trial suggest that

disseminating treatments into the community raises significant challenges in delivery and efficacy.

Dropout rates were high, and the self-help intervention did not appear to have a significant impact

on symptoms.

ALTERNATIVE DELIVERY SYSTEMS FOR EATING DISORDER

PSYCHOLOGICAL TREATMENT

Several innovative approaches to eating disorders care have been developed in recent years. One

area that is expanding as rapidly as technology allows is the delivery of psychotherapy via

telemedicine. There is growing interest in the use of telemedicine techniques, particularly becausePrint: Chapter 48. Evidence-Based and Innovative Psychological Trea… http://www.psychiatryonline.com/popup.aspx?aID=262146&print=yes…

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they allow patients in rural areas and with limited funds opportunities to access appropriate and

affordable health care by eliminating the need for patient and doctor to be in the same location.

Although telemedicine is an exciting and innovative strategy for expanding care, its disadvantages

are notable. Suboptimal technology can result in poor or choppy visual images as well as audio

delays. Also, this technology presents challenges to developing trust and building a therapeutic

alliance (Myers et al. 2004). Additionally, the use of this kind of technology poses a potential threat

to confidentiality.

In a thorough summary of telemedicine technologies, Myers et al. (2004) described a study

conducted by Nelson et al. (2003) that compared eight CBT sessions delivered face-to-face or via

telemedicine. Patients were 28 children suffering from depression. Results found that children in

both conditions improved, but there were more rapid gains made in the telemedicine condition

compared to face-to-face. Findings from this study suggest that telemedicine may be a viable

treatment delivery approach and may in some cases even offer advantages over more conventional

types of treatment delivery.

Bakke et al. (2001) also described the successful treatment of two women with BN via

telemedicine, providing pilot data supporting the use of telemedicine in the treatment of eating

disorders. Other studies have shown improvements in eating disorder symptoms after participating

in telephone therapy, and preliminary findings suggest that patients who would not seek treatment

otherwise may avail themselves of telemedicine help.

E-mail is a widely available technology that may have applications for clinical care. According to

Myers et al. (2004), pilot studies of individuals who used e-mail in communicating with their

therapists suggest that many individuals feel more comfortable contacting their therapists via

e-mail as compared with phone contact, because they think it is less bothersome and intrusive.

Although e-mail may have certain advantages worth exploiting, it is accompanied by potential

worries, including messages containing inappropriate content, patients getting upset when

therapists fail to reply promptly, and concerns regarding confidentiality. The Internet as a potential

tool for health care delivery is generating numerous innovative initiatives. Palmtop computers

utilizing a paradigm known as ecological momentary assessment (EMA) have been successfully

used in the treatment of BN (Norton et al. 2003), and studies of this approach are ongoing. Pilot

studies of electronic bulletin boards, chat rooms, and prevention programs over the Internet are

also under way. CD-ROM treatment programs and virtual reality programs to address problems of

body image are exciting and potentially accessible treatments that will be implemented in addition

to or in lieu of more traditional therapies. Results from these initiatives will likely contribute

significantly to shaping the delivery of psychotherapy in the twenty-first century.

CONCLUSION AND RECOMMENDATIONS

The empirical database for eating disorders is sufficient to guide clinical decision making and

treatment planning for certain stages of care and with differing degrees of confidence, depending

on the particular eating disorder. There is strong evidence that CBT and IPT are effective

treatments for BN, and available research suggests their utility in the management of BED. In

addition, behavioral weight management also may be useful for some overweight BED patients. The

evidence base is much weaker in the treatment of AN, although small well-conducted studies raise

hope that a CBT intervention adapted for AN patients will be efficacious. Despite the availability of

effective interventions for BN and BED, a significant number of patients fail to benefit from initial

interventions, and thus the need for strategies to help chronic or refractory patients and for

additional therapeutic approaches is clear.

The gaps in the treatment literature provide clear direction for clinical researchers in the field.

Research to evaluate interventions for AN in adults is sorely needed, but progress is hampered by

difficulties in recruiting, engaging, and retaining patients in research studies. Given the serious

morbidity and mortality associated with AN, the need to develop efficacious treatments for the

older and more severely ill individual is a critical challenge for the future. New complementary and

alternative approaches to treatment are being investigated in the field of eating disorders. ForPrint: Chapter 48. Evidence-Based and Innovative Psychological Trea… http://www.psychiatryonline.com/popup.aspx?aID=262146&print=yes…

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example, a revived interest in developing an efficacious psychodynamic treatment is evident in the

field, and studies of DBT and other third-generation cognitive-behavioral therapies are emerging

with the potential to enhance treatment efficacy. In addition, significant efforts are being made to

disseminate treatment to a broader segment of the population of individuals who suffer from eating

disorders through the development of a variety of self-help and telemedicine initiatives that may

have far-reaching implications.

Currently, it is impossible for clinicians to rely solely on the extant evidence to guide their decision

making and clinical practice. However, the database is sufficient to guide many clinical decisions,

and it is incumbent upon clinicians in the field to heed the data and implement the empirical

findings in their clinical practice. It is also essential that clinical research continue to evolve and

expand so that clinicians can be more confident and effective in their work and ultimately increase

the likelihood that individuals achieve recovery from their eating disorders.

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