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

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

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

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

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

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

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

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

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

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

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

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

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

Clinical Case: Annalise 15-year-old Caucasian female Assessment: weight started at 115 lbs and at assessment weighed 92 lbs; BMI 2 nd 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