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Treating eating disorders: a review of the evidence
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  1. Rano Bhadoria1,
  2. Kate Webb2,
  3. John F Morgan3
  1. 1Specialist Registrar in Psychiatry, Yorkshire Centre for Eating Disorders, Newsam Centre, Seacroft Hospital, Leeds, UK
  2. 2Specialist Registrar in Psychiatry, Runnymede CMHT, St Peters Hospital, Chertsey and Honorary Research Assistant, Eating Disorders Team, St George’s University of London, London, UK
  3. 3Consultant Psychiatrist, Yorkshire Centre for Eating Disorders, Newsam Centre, Seacroft Hospital, Leeds, UK
  1. Dr J F Morgan, Yorkshire Centre for Eating Disorders, Newsam Centre, Seacroft Hospital, Leeds LS14 6WB, UK; john.morgan{at}leedspft.nhs.uk

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The assessment and management of patients with eating disorders can cause significant anxiety for all involved in their care, particularly as many patients are ambivalent about treatment and may develop concerning physical complications. Anorexia nervosa has the highest standardised mortality rate of any psychiatric disorder and all eating disorders cause significant short and long term psychological and physical morbidity. In this article, we provide an overview of the current psychological, pharmacological and physical evidence based management of patients with eating disorders.

Anorexia nervosa

NICE guidelines1

  • ‘Most people with anorexia nervosa should be managed on an outpatient basis, with psychological treatment (with physical monitoring) provided by a healthcare professional competent to give it and to assess the physical risk of people with eating disorders.’

  • ‘People with anorexia nervosa requiring inpatient treatment should be admitted to a setting that can provide the skilled implementation of refeeding with careful physical monitoring in combination with psychosocial interventions.’

  • ‘Family interventions that directly address the eating disorder should be offered to children and adolescents with anorexia nervosa.’

Psychological therapies for anorexia nervosa

The National Institute for Health and Clinical Excellence (NICE) guidelines1 recommend specialised outpatient psychological therapies that should last at least 6 months. They specify that dietary counselling on its own is not appropriate. They are also mindful of the essential need for monitoring of associated physical risks of anorexia nervosa. The aims of treatment should be to ‘reduce risk, encourage weight gain and healthy eating, reduce other symptoms related to an eating disorder, and facilitate psychological and physical recovery’.

The psychological therapies suggested by NICE1 are cognitive behavioural therapy (CBT), interpersonal psychotherapy (IPT), cognitive analytic therapy (CAT) and focal psychodynamic therapy. The evidence base for the psychological treatment of anorexia nervosa is poor, apart from family therapy that directly addresses the eating disorder for children and adolescents.1 The nature of this illness makes engaging patients in treatment difficult and attrition rates are therefore high. This makes recruitment and retaining patients for research trials challenging. A focus on motivational enhancement work2 can help increase engagement and completion rates in psychological therapies for anorexia nervosa. This in turn may improve the outcomes and quality of research conducted.

A recent systematic review3 of randomised controlled trials looking at psychological therapies for anorexia nervosa found 11 studies, three of which included trials with CBT and where the results were mixed. One of the studies4 found CBT to have an advantage over nutritional counselling in terms of dropout rates, good outcome at the end of treatment and longer time to relapse. It was unclear whether CBT was better in the acutely underweight state. In a study conducted in New Zealand,5 non-specific supportive clinical management was more effective than CBT and IPT in the acute phase.

A study of CAT6 compared with educational behavioural therapy showed an association with higher self-rating of improvement. In a randomised controlled trial comparing CAT, focal family therapy, family therapy and routine treatment, focal family therapy was found to be equivalent to CAT in increasing body weight, restoring the menstrual cycle and reducing bulimic symptoms.7

In the most recent systematic review,3 the studies that focused on family therapy exclusively in adolescents found a strong association between the recency of onset and the likelihood of positive response. NICE1 specify that family interventions should be considered in addition to the person having individual psychological support. Within this younger age group the need for inpatient treatment for urgent weight restoration should be balanced alongside the educational and social needs of the young person.

Outpatient individual and family therapy has been found to be superior to a referral to a family physician in terms of weight gain at follow-up.8 Although most patients should be treated in an outpatient setting, day patient or inpatient treatment may become necessary, particularly when physical health is at significant risk. Treatment in this group should focus on weight gain, eating disordered behaviours and attitudes, and psychosocial problems. There should be a step down to outpatient follow-up over at least 12 months.1

Pharmacological interventions for anorexia nervosa

The NICE guidelines1 suggest that ‘medication should not be used as the sole or primary treatment for anorexia nervosa’. Particular attention should be given to thinking about dosage and physical monitoring when using medication to treat comorbid conditions in people with a very low body weight. Side effects of psychotropic medications may exacerbate the physical complications of eating disorders, such as QTc prolongation, predisposing a patient to fatal arrhythmias.

According to a recent systematic review,3 no psychopharmacological intervention for anorexia nervosa has a significant impact on weight gain or the psychological features of anorexia nervosa. Olanzapine may reduce the intensity of the overvalued ideas about weight and shape, characteristic of anorexia nervosa. This theoretically may in turn help weight gain, and in a recent literature review9 they found that the evidence, although limited, suggests that olanzapine may be helpful at doses of 2.5–15 mg daily. Low mood is common as a result of starvation but antidepressants may only be useful if there is a clear comorbid depressive illness.

Vitamins/supplements and other medications may be necessary in terms of maintaining physical health during the refeeding process.

Bulimia nervosa

NICE guidelines1

  • ‘The great majority of patients with bulimia nervosa should be treated in an outpatient setting.’

  • ‘Cognitive behaviour therapy for bulimia nervosa (CBT-BN) should be offered to adults with bulimia nervosa. The course of treatment should be for 16–20 sessions over 4–5 months.’

  • ‘Adolescents with bulimia nervosa may be treated with CBT-BN, adapted as needed to suit their age, circumstances and level of development, and including the family as appropriate.’

  • ‘Patients with bulimia nervosa who are vomiting frequently or take large quantities of laxatives should have their fluid and electrolyte balance assessed.’

  • ‘No drugs, other than antidepressants, are recommended for the treatment of bulimia nervosa.’

Psychological therapies for bulimia nervosa

Self-help

Unguided or guided self-help treatment for bulimia nervosa involves a treatment manual given to the patient at the start of treatment. In guided self-help, the progress is supervised and monitored over a limited number of short outpatient appointments. Recent research suggests some positive outcomes, particularly with face to face guidance but with mixed results concerning attrition rates.10

Cognitive behavioural therapy

CBT adapted for bulimia nervosa is the treatment recommended by NICE for bulimia nervosa.1 The first stage of treatment focuses on motivation and reducing dietary restraint that is unsustainable and counterproductive. Patients are taught that the subsequent bingeing is a direct consequence of the severity of this restriction and it is not possible to reduce the bulimic behaviours and maintain dietary restraint at the same time. In order to break the cycle, structured eating patterns with the help of food diaries, etc, must be adopted. In the second stage of treatment, cognitive restructuring techniques are used to address unhelpful thinking styles associated with maintaining the disordered eating patterns. The final stage looks at relapse prevention issues.11 ,12

Despite the many studies with positive outcomes for CBT, it is well known that no more than 50% of patients recover completely13 and attrition rates continue to be high. The most consistent predictors of poor response are comorbid personality disorder and high baseline frequency of bingeing and purging. Some of the criticisms of the current type of CBT treatment are that it pays little attention to interpersonal issues. Subsequently, a new enhanced form of CBT-BN was developed by Fairburn et al.14 This includes looking at issues such as clinical perfectionism, interpersonal differences, core low selfesteem and mood intolerance (formulated individually for the patient).

Interpersonal psychotherapy

IPT is a brief psychotherapy that was originally developed for people with depression. It was later adapted for bulimia nervosa and for many years has provided a credible alternative treatment that has had similar outcomes to CBT although the behavioural changes take longer.15 This finding has led to suggestions that it takes longer to facilitate behavioural change when focusing on bringing about changes in eating patterns by indirectly looking at ones relational difficulties rather than directly focusing on behaviour change, as with CBT. IPT focuses on supporting patients to identify and modify past and current interpersonal problems which may underlie and maintain the eating disorder. The first phase of the therapy is devoted to developing an understanding of the interpersonal context surrounding the illness which includes historical factors. In the next phase, the focus is on one or more interpersonal problem areas that have been identified in the first phase of extended assessment. Eating disorder symptoms are tracked throughout therapy, particularly looking at their relationship with interpersonal difficulties. Some time is devoted to psychoeducation around the eating disordered behaviours but this is not the main focus of the therapy sessions.16

Dialectical behaviour therapy

Dialectical behaviour therapy (DBT) was developed by Linehan to treat borderline personality disorder.17 It is based on CBT techniques but includes aspects of mindfulness meditation and psychodynamic psychotherapy. Treatment includes weekly individual therapy, group skills training looking at effective ways of managing interpersonal issues and emotional distress. Individual therapists may also provide telephone contact between sessions. DBT is provided by a team of therapists who also meet on a weekly basis.18

People with eating disorders, who display multi-impulsive behaviours, have difficulty with affect regulation and are unresponsive to standard CBT, may respond to an adapted form of DBT which is usually carried out on an outpatient basis. Palmer et al18 carried out a study on a small number of patients with eating disorders and found a reduction in self-harm incidents and inpatient days and also found that no patient had a full syndrome eating disorder after 18 months. Safer et al found significant reductions in binge/purge behaviour with DBT compared with the waiting list group when treating 31 women with bulimia nervosa, randomly assigned to each group.19

Pharmacological interventions for bulimia nervosa

The NICE guidelines1 state that ‘as an alternative or adjunct to using an evidence based self-help programme as a first step, adults with bulimia nervosa may be offered a trial of an antidepressant drug’. Fluoxetine, a selective serotonin reuptake inhibitor, may help reduce the urge to binge and has been licensed for use in the treatment of bulimia nervosa. According to a recent systematic review,10 there is good evidence that fluoxetine (60 mg daily) reduces core bulimic symptoms of binge eating and purging and associated psychological features of the eating disorder in the short term. Goldstein et al20 found that fluoxetine at 60 mg daily is beneficial in patients with bulimia nervosa, whether or not they have a diagnosis of comorbid depression. This suggests that its positive impact on the symptoms of bulimia nervosa is not simply related to the antidepressant effect.

Eating disorders not otherwise specified

Eating disorders not otherwise specified (EDNOS) represent a large proportion of patients suffering from eating disorders and they may present with just as significant psychological and physical morbidity, despite not meeting all of the criteria (such as body mass index (BMI), amenorrhoea or frequency of bingeing or vomiting) for anorexia nervosa or bulimia nervosa. EDNOS is a category in DSMIV,21 and the main equivalents in ICD-1022 are ‘atypical anorexia nervosa’ and ‘atypical bulimia nervosa’.

Perhaps the most widely researched subtype of EDNOS is binge eating disorder which is discussed in the NICE guidelines.1 This disorder is characterised by recurrent episodes of binge eating without subsequent compensatory behaviours such as purging, restriction or over exercise, and patients usually have a BMI above 25. CBT is the treatment of choice.

Medication may also be helpful as an adjunct. A study23 found that the efficacy of CBT improved with the addition of the anticonvulsant topiramate (at a maximum dose of 200 mg) compared with CBT+placebo. Bingeing reduced significantly and there was improved weight loss. Topiramate was tolerated well in relation to adverse side effects but it is currently unclear whether the benefits of topiramate are maintained long term.

Other subtypes under EDNOS should be treated in a similar fashion to the classical eating disorder that they most closely represent, with psychological therapies and physical examination and monitoring.

Physical management of eating disorders

The management of patients with severe eating disorders is complex as the physical consequences can be catastrophic. Extreme weight loss can lead to many and varied physical complications but there is little in the literature that guides us as to how and where this risk should be managed. In the UK, emphasis is on shared care between the general practitioner and secondary mental health services and/ or specialist eating disorder services.1 All patients should have a general physical examination. Table 1 describes the specific physical complications that need to be assessed and monitored in someone with an eating disorder.1 ,24

Table 1

Specific physical complications in someone with an eating disorder

NICE1 recommend that if the physical risk is high, a physician or paediatrician with expertise in treating physically at risk patients with anorexia nervosa should be involved. High risk patients should be offered inpatient admissions in either a specialist eating disorder unit or an acute medical ward, depending on the availability of services and the severity of the acute physical risk. Emphasis is given on a collaborative approach to the treatment of an eating disorder. As alluded to previously, motivation to enter into treatment is seen as a good predictor of treatment outcome at any stage of the illness.

The Mental Health Act25 may be used in order to treat the life threatening physical complications of eating disorders and to refeed a patient with anorexia nervosa. Medical wards and some specialist eating disorder units are able to provide nasogastric tube feeding if necessary. Initial refeeding should be carried out with input from a dietician due to the risk of refeeding syndrome and the occasional need for nasogastric tube feeding under control and restraint and/or sedation should be done with caution following national and trust guidelines.

Conclusion

Eating disorders are serious mental illnesses with high morbidity and mortality, particularly anorexia nervosa. The mainstay of treatment should be weight gain and/or maintenance at least at a BMI of 20, in conjunction with psychological therapies, and individual and/or family therapy (particularly adolescents). Management should usually occur in an outpatient setting. However, if the physical risk becomes too great, day or inpatient treatment may be necessary, preferably on a voluntary basis but refeeding under the mental health act may be needed as a life saving measure. The physical complications of eating disorders should never be forgotten, and physical examination, investigations and longitudinal monitoring should be an integral part of the care plan for all patients.

References

Footnotes

  • Competing interests None.