Chapter 15: Evidence Based Interventions for Eating Disorders

1. Chapter 15: Evidence Based Interventions for Eating Disorders Peter M. Doyle Catherine Byrne Angela Smyth Daniel Le Grange

2. Overview: DSM-5 • Anorexia Nervosa: failure to achieve or maintain a minimum weight for age and height, fear of gaining weight although underweight, and disturbance of self-perception of body weight or shape or denial of seriousness of low body weight • Bulimia Nervosa: normal weight, but engaging in regularly occurring episodes of binge eating coupled with compensatory behaviors • Binge Eating Disorder: binge eating but not engaging in any compensatory behaviors • Feeding and Eating Disorder Not Elsewhere Classified: engaging in some sort of disordered eating

3. Eating Disorder Rates • At age of 20, 0.8% of people in United States will have anorexia • 2.6% bulimia • 3.0% binge eating disorder • 4.8–11.5% feeding and eating disorder not elsewhere classified • Typical age for onset: 16 to 20 years old • Increasingly younger cases are being seen in the United States

4. Anorexia: Family Based Treatment • Family-Based Treatment for Anorexia Nervosa (FBT-AN) • Focus: weight restoration and aiming to empower parents and families to elicit change • Primary therapist coordinates treatment team • Team: family, therapist, medical provider, psychiatrist • Three phases: • 1) Engage the entire family in the eating disorder • 2) Control over food decisions is gradually handed back to child/adolescent • 3) Help patient and his or her family navigate a return to normal trajectory of adolescent development • Only treatment that has well-established empirical evidence

5. Behavioral Family Systems Therapy • Parental involvement and initial control over eating to help patients overcome anorexia • Unlike FBT-AN, BFST does not focus on empowering parents to use their own intuition to facilitate changes to meals and food choice • Parents work with a nutritionist • Three phases: • 1) Parent training related to implementation of behavioral weight gain program • 2) Parents maintain control over eating, but sessions turn to identify cognitions that are underlying eating disorder • 3) Patient assumes responsibility for his/her own eating and weight • Evidence indicates this is a promising therapy

6. Adolescent Focused Psychotherapy (AFP) • Individual psychotherapy from a self-psychology model • Focus: helping patients to identify, tolerate, and more effectively manage their emotions • Three phases: • 1) Building rapport between therapist and patient and developing a mutually understood conceptualization of anorexia • 2) Enhancing individualization and independence from parents • 3) Developing appropriate coping strategies to deal with the tasks of adolescence and engage in independent behaviors • RCT indicated that FBT was significantly superior to AFP

7. CBT for Bulimia • Cognitive behavioral therapy for bulimia nervosa (CBT-BN) • Three stages • 1) Establish rapport, increase motivation for treatment • 2) Address distorted cognitions surrounding food, eating, weight, shape • 3) Consolidate treatment gains and develop a relapse prevention plan • RCT compared CBT to family therapy: CBT showed improvements over family therapy at 6 months, but not 12

8. Family Based Treatment for Bulimia • Relies on family involvement to address eating disorder symptoms • Three Phases • 1) Shifts control of eating over to the parents • 2) Shifting control of eating and food-related decisions back to adolescent in gradual fashion • 3) Addresses developmental issues and encourages communication between parents and adolescents • Two RCTs have provided empirical evidence for FBT-BN

9. Binge Eating Disorder • No RCTs have been published examining the efficacy of treatment for adolescents with binge eating disorder • In adults, interpersonal psychotherapy, cognitive behavioral therapy, and dialectical behavior therapy are efficacious for binge eating

10. Parental Involvement: Family Based Treatment of Anorexia • Parent involvement critical and central to this approach • Parents can: • Get frustrated with refusal to eat • Misinterpret refusal to eat • Blame their child for bringing stress on the family • Retreat from role and become overly permissive • To be most effective: aligned with one another and sending consistent messages regarding decisions about the child’s meals and activity level

11. Parental Involvement: Bulimia • Adolescents with bulimia are less likely to need parents • Often more motivated during treatment • Involvement varies based on the case and family dynamics • Can assist with CBT • Younger patients can benefit from reminders to use rational responses to automatic thoughts

12. Adaptations and Modifications • FBT: age of child/adolescent needs to be taken into consideration, and adaptations made for developmental level • Bulimia: common for adolescents to have a comorbid psychiatric disorder; treatments can include additional mental health professionals to treat these comorbid disorders • Binge Eating Disorder: developmental concerns

13. Measuring Treatment Effects • Weight: measured weekly • Frequency of binge eating and purging: assessed via self-report • CBT self-monitoring: cognitions about food, weight, shape, or mood state • Gold standard: Eating Disorder Examination • Semi structured interview conducted by a clinician • Measures disordered eating over 28-day period • Four subscales: eating concern, shape concern, weight concern, dietary restraint • Global score

14. Clinical Case: Annalise • 15-year-old Caucasian female • Assessment: weight started at 115 lbs and at assessment weighed 92 lbs; BMI 2nd percentile; consumes fewer than 1,000 calories per day most days; fears of “becoming fat again” • Diagnosis: GAD, anorexia • Treatment plan: FBT-AN, medication to treat preexisting anxiety symptoms • Outcome: continued to gain weight weekly with help of parents; improvements in eating restraint, eating concern, weight concern, and shape concern; reductions in anxiety