Eating Disorders

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Allan S. Kaplan, Katherine A. Halmi: Eating Disorders, 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.9781585622986.265260. Printed 5/10/2009 from www.psychiatryonline.com

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

Eating Disorders

INTRODUCTION

This new fourth edition of Treatments of Psychiatric Disorders has been streamlined, and this

section on eating disorders appropriately reflects this process. The previous edition had eight

chapters in this section; in this current edition, the section has been pared down to four chapters.

Despite the shortening of the content component, these chapters provide comprehensive, concise,

up-to-date summaries of the current state of the art of the interventions reviewed for the treatment

of anorexia nervosa, bulimia nervosa, and binge-eating disorder. These chapters provide

research-based as well as clinical evidence for the efficacy of psychological and pharmacological

treatments, as well as family and intensive therapies. However, recommendations for the treatment

of eating disorders, especially for anorexia nervosa, suffer from a paucity of evidence-based

studies. Even when such evidence exists, such as for the efficacy of cognitive-behavioral therapy

for bulimia nervosa, such interventions are not widely practiced in the community because of a lack

of adequate dissemination and training. Choosing the most effective treatment approach for

someone with an eating disorder should take into account a number of variables, including physical

and psychological risk, motivation, social support, comorbidity, and age.

In regard to anorexia nervosa, the British National Institute for Clinical Excellence (2004) noted

that there were very few randomized controlled trials to guide treatment. Expert committee reports

or opinions and clinical experiences of respected authorities constituted most of the

recommendations from this source. These recommendations stated that intensive treatment for

anorexia nervosa should be in a setting where staff are experienced in treating the disorder and

where they can implement refeeding with careful physical monitoring and provide psychosocial

intervention. They also stated that family intervention that directly addresses the eating disorder

should be offered to children and adolescents. They note that for anorexia nervosa, treatment with

medications to date has been disappointing in influencing the core symptoms of the disorder.

These recommendations differ little from the practice guidelines developed by the American

Psychiatric Association (2006). Practice guidelines from the Royal Australian and New Zealand

College of Psychiatrists (2004) recommend a multidimensional approach for the intensive

treatment of anorexia nervosa, with close attention to medical manifestations and weight

restoration. Dietary advice should be a part of all treatment programs, and family therapy was

mentioned as a valuable part of treatment for children and adolescents. These guidelines also

acknowledge their reliance on expert opinions and not on controlled trials. Finally, the Cochrane

Database of Systematic Reviews noted the high dropout rate in anorexia nervosa treatment trials

and concluded that an urgent need exists for large, well-designed trials assessing treatment in

anorexia nervosa (Hay et al. 2003).

In contradistinction to anorexia nervosa, the evidence for the efficacy of pharmacotherapy and

psychotherapy for bulimia nervosa and binge-eating disorder is more compelling. This evidence is

reviewed by experts in the chapters that follow. In the ensuing paragraphs in this overview, we will

highlight the important points noted in these chapters and provide additional integrative comments

for each of the four chapters that comprise this section of the book.

INTENSIVE TREATMENTS FOR EATING DISORDERS

Randomized controlled trials for severely ill patients with anorexia nervosa have been difficult to

conduct for several reasons. First, these patients are notoriously not motivated for treatment andPrint: Eating Disorders

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therefore do not wish to enter treatment trials. When they do participate, they frequently drop out;

the dropout rates for anorexia nervosa treatment trials in adults range from 30% to 70%. The

medical instability of these patients often requires withdrawal from treatment trials. Second, there

are not enough patients in any one treatment center to constitute an adequate sample size for a

meaningful treatment trial. Thus, collaborative studies are necessary.

In the United States, the clinician has to consider several practical factors, such as insurance

coverage and the availability of appropriate management facilities for intensive treatment of eating

disorders. Currently, managed care companies determine both the type and the duration of

treatment patients may receive (Kaye et al. 1996).

Most patients with bulimia nervosa can be treated effectively in outpatient therapy. Intensive

treatment is necessary when persistent medical emergencies occur from the consequences of

bingeing activities, frequent vomiting and abuse of laxatives and diuretics, which can create serious

electrolyte imbalances and dehydration. Intensive treatment may be necessary for bulimic patients

who are seriously depressed and for those who are no longer able to function due to persistent

bingeing and purging, which can cause a marked deterioration in work performance and social

relationships.

In Chapter 46, “Intensive Treatments for Eating Disorders,” Marion Olmsted and colleagues discuss

the latest evidence for the efficacy of intensive treatment, criteria for intensive treatment, and

specific therapy strategies. Evidence-based studies on intensive treatments for eating disorders are

urgently needed. Acutely ill eating disorder patients need to be randomly assigned to specialized

inpatient treatment programs and/or different types of intensive day programs. Randomization

studies need to determine criteria of transferring eating disorder inpatients to a step-down day

hospital or partial hospitalization program and a further step down to outpatient therapy. Effective

components of intensive treatments need to be identified.

FAMILY THERAPY AND MARITAL THERAPY

The difficulty and expense of treating individuals with chronic anorexia nervosa who become

increasingly resistant to treatment and who have repeated hospitalizations, with high rates of

suicide and physical and psychological morbidities, are frustrating. Preventing the development of

chronicity through early identification and effective treatment of adolescent anorexia nervosa may

solve this problem. The most effective evidence-based treatment of adolescent anorexia nervosa is

family therapy. However, few randomized controlled trials have assessed different strategies of

family therapy in the treatment of adolescents, and even less evidence is available for family

treatment of adults with eating disorders. In Chapter 49, “Family Therapy and Marital Therapy,”

Daniel Le Grange and James Lock provide a thorough review of the empirical support for family

therapy for eating disorders.

There are many questions to be answered regarding family therapy and eating disorders. For

example, is family therapy effective in the treatment of bulimia nervosa adolescents? How can we

identify adult eating disorder patients who may benefit from family therapy? Does marital therapy

for the parents of an adolescent eating disorder patient have any impact on that adolescent’s

outcome? What is the impact of marital therapy on adult patients with eating disorders? How do

certain characteristics, such as high expressed emotion, interact with specific family therapy

techniques?

Evidence-based studies are necessary to improve the outcome of eating disorders and to provide

guidance to clinicians concerning optimal treatment approaches for eating disorders. From a public

health perspective, development of effective treatments for adolescents could reduce the morbidity,

mortality, and high cost associated with chronic eating disorders.

PHARMACOLOGICAL TREATMENTS FOR EATING DISORDERS

Compared to most other major psychiatric disorders, anorexia nervosa is unique and striking in its

resistance to pharmacological interventions. This is even more surprising considering the fact that

patients with anorexia nervosa share many of the same symptoms as disorders that do respond toPrint: Eating Disorders

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medication, including depression, anxiety, and obsessive-compulsive disorder. The exact

mechanism of this relative resistance to medication is unknown. As noted by James Mitchell and

Scott Crow in Chapter 47, “Psychopharmacological Treatment of Eating Disorders,” one possible

explanation may relate to central neurotransmitter alterations that occur secondary to starvation.

It has been demonstrated that acute tryptophan depletion causes a rapid lowering of brain

serotonin and precipitates clinical depressive symptoms in recovered patients with recurrent major

depression (Smith et al. 1997) and subjective loss of control of eating in recovered subjects with

bulimia nervosa (Smith et al. 1999). Tryptophan depletion as a result of starvation, resulting in a

central hyposerotonergic state, could account for the lack of mood response to selective serotonin

reuptake inhibitors in underweight anorexia nervosa patients. Even in weight-restored anorexic

subjects, a recent study reported a lack of response to the antidepressant effects of fluoxetine

(Walsh et al. 2006).

The evidence for the efficacy of antidepressant pharmacotherapy for bulimia nervosa and

binge-eating disorder is more compelling. Nonetheless, only a minority of patents given

antidepressants will have a dramatic response to these medications, and many will experience loss

of efficacy and breakthrough binge eating over time (Walsh et al. 1991). The exact mechanism for

the relative lack of prophylaxis in the use of antidepressants for bulimia nervosa is unknown.

As described by Mitchell and Crow, other classes of drugs have been studied in the treatment of

anorexia nervosa, bulimia nervosa, and binge-eating disorder. There is a need to “think outside the

box” in pursuing new pharmacological agents for the treatment of eating disorders (Attia et al.

2005), as currently the majority of patients with eating disorders do not have a clinically significant

response to pharmacotherapy for the core symptoms of their eating disorder.

PSYCHOLOGICAL TREATMENTS FOR EATING DISORDERS

As noted by Kathleen Pike, Christina Roberto, and Marsha Marcus in Chapter 48, “Evidence-Based

and Innovative Psychological Treatments for Eating Disorders,” psychotherapy remains the

cornerstone of treatment for eating disorders. Such psychotherapy needs to include elements of

psychoeducation (Olmsted and Kaplan 1995), nutritional management, cognitive and behavioral

strategies, and motivational enhancement in order to comprehensively address the complex issues

that eating disorder patients bring to the table. Rational psychotherapeutic approaches to anorexia

nervosa are based more on clinical consensus and prevailing practice rather than on empirical

evidence (Kaplan 2002). However, as reviewed in the ensuing chapter, there is convincing research

to support the efficacy of cognitive-behavioral therapy and more limited research evidence to

support the efficacy of interpersonal therapy for bulimia nervosa. There is emerging evidence to

support the efficacy of cognitive-behavioral therapy, interpersonal therapy, and, more recently,

dialectical behavior therapy in the treatment of binge-eating disorder. What remains largely

unknown at this time are the specific mediators, moderators, and predictors of response to

psychotherapy for bulimia nervosa and binge-eating disorder. This should be an important focus of

future research in this area. Finally, for anorexia nervosa, there is a pressing need to develop more

effective psychological treatments, especially for adults, for whom outcomes are generally poor

(Fairburn 2005). As challenging and difficult as these patients may be to treat, they deserve our

collective and committed attention as researchers and clinicians (Kaplan and Garfinkel 1999).

REFERENCES

American Psychiatric Association: Treatment of patients with eating disorders, third edition.

American Psychiatric Association. Am J Psychiatry 163 (suppl 7):4–54, 2006

Attia E, Steinglass J, Appolinario J, et al: Symposium 50, Novel Research Treatments for Eating

Disorders, Annual Meeting, American Psychiatric Association, Atlanta, Syllabus and Proceedings

Book, pp 164–165, May 24, 2005

Fairburn CG: Evidence-based treatment of anorexia nervosa. Int J Eat Disord 37 (suppl):S26–S30,

2005

Hay P, Bacaltchuk J, Claudino A, et al: Individual psychotherapy in the outpatient treatment ofPrint: Eating Disorders

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adults with anorexia nervosa. Cochrane Database Syst Rev (4):CD003909, 2003

Kaplan AS: Psychological treatments for anorexia nervosa: a review of published studies and

promising new directions. Can J Psychiatry 47:235–242, 2002 [PubMed]

Kaplan AS, Garfinkel PE: Difficulties in treating patients with eating disorders: a review of patient

and clinician variables. Can J Psychiatry 44:665–670, 1999 [PubMed]

Kaye W, Kaplan AS, Zucker ML: Treating eating disorders in a managed care environment:

contemporary American issues and Canadian response. Psychiatr Clin North Am 19(4):793–810,

1996 [PubMed]

National Institute for Clinical Excellence: Core interventions in the treatment and management of

anorexia nervosa, bulimia nervosa and related disorders. Clinical Guidelines #9. London, National

Institute for Clinical Excellence, 2004, pp 1–15

Olmsted M, Kaplan AS, Olmsted M, et al: Psychoeducation in the treatment of eating disorders, in

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York, Guilford, 1995, pp 299–305

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Smith KA, Fairburn CG, Cowen PJ: Relapse of depression after rapid depletion of tryptophan. Lancet

349:915–919, 1997 [PubMed]

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Walsh BT, Hadigan CM, Devlin M, et al: Long-term outcome of antidepressant treatment for bulimia

nervosa. Am J Psychiatry 148:1206–1212, 1991 [PubMed]

Walsh BT, Kaplan AS, Attia E, et al: Fluoxetine after weight restoration in anorexia nervosa: a

randomized controlled trial. JAMA 295:2605–2612, 2006 (erratum: JAMA 296:934, 2006)

Copyright © 2009 American Psychiatric Publishing, Inc. All Rights Reserved.