Module 16 – Eating Disorders

3rd edition as of August 2022

Module Overview

In Module 16, we will discuss matters related to eating disorders to include their clinical presentation, epidemiology, comorbidity, etiology, assessment, and treatment options. Our discussion will include anorexia nervosa, bulimia nervosa, and binge eating disorder. Be sure you refer Modules 1-3 for explanations of key terms (Module 1), an overview of the various models to explain psychopathology (Module 2), and descriptions of the therapies (Module 3). As a reminder, feeding disorders, also part of the chapter in the DSM-5-TR, were covered separately in Module 5.

Module Outline

• 16.1. Clinical Presentation
• 16.2. Prevalence and Comorbidity
• 16.3. Etiology
• 16.4. Assessment
• 16.5. Treatment

Module Learning Outcomes

• Describe how eating disorders present.
• Describe the prevalence and comorbidity of eating disorders.
• Describe the etiology of eating disorders.
• Describe how eating disorders are assessed, diagnosed, and treated.

16.1. Clinical Presentation

Section Learning Objectives

• Clarify the concept of mutually exclusive.
• Describe how anorexia nervosa presents.
• Describe how bulimia nervosa presents.
• Describe how binge-eating disorder (BED) presents.

Feeding and eating disorders are “…characterized by a persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning” (APA, 2022, pg. 371). They are very serious, yet relatively common mental health disorders, particularly in Western society, where there is a heavy emphasis on thinness and physical appearance. In fact, 13% of adolescents will be diagnosed with at least one eating disorder by their 20th birthday (Stice, Marti, & Rohde, 2013). Furthermore, a large number of adolescents will engage in significant disordered eating behaviors just below the clinical threshold (Culbert, Burt, McGue, Iacono & Klump, 2009). While there is no exact cause for eating disorders, the combination of biological, psychological, and sociocultural factors has been identified as major contributors in both the development and maintenance of eating disorders.

Within the DSM 5-TR (APA, 2022), six disorders are classified under the Feeding and Eating Disorders chapter: pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, and binge-eating disorder. In this book, we will cover the latter three whose diagnostic criteria are mutually exclusive, meaning that only one of these diagnoses can be assigned at any given time due to substantial differences in their clinical course, outcome, and treatment needs, despite a number of common psychological and behavioral features.

16.1.1. Anorexia Nervosa

Anorexia nervosa involves the restriction of energy intake, which leads to significantly low body weight relative to the individual’s age, sex, and development. This restriction is often secondary to an intense fear of gaining weight or becoming fat, despite the individual’s low body weight. Altered perception of self and an over-evaluation of one’s body weight and shape contribute to this disturbance of body size.

Typical warning signs and symptoms are divided into two different categories: emotional/behavioral and physical. Some emotional and behavioral symptoms include dramatic weight loss; preoccupation with food, weight, calories, etc.; frequent comments about feeling “fat;” eating a restricted range of foods; making excuses to avoid mealtimes; and not eating in public. Physical changes may include dizziness, difficulty concentrating, feeling cold, sleep problems, thinning hair/hair loss, and muscle weakness, to name a few. When the individual loses weight, they view this as an impressive achievement and a sign of extraordinary discipline, while weight gain is seen as an unacceptable failure of self-control (APA, 2022).

The onset of the disorder typically begins with mild dietary restrictions such as eliminating carbs or specific fatty foods. As weight loss is achieved, the dietary restrictions progress to more severe, e.g., under 500 calories/day.  Symptoms present in adolescence or young adulthood and rarely before puberty or after age 40. The onset of the disorder typically is preceded by a stressful life event such as leaving home for college.

Unlike anorexia nervosa where there is solely restriction of food, bulimia nervosa involves a pattern of recurrent binge eating behaviors. Binge eating can be defined as a discrete period of time where the amount of food consumed is significantly more than most people would eat during a similar time period. Individuals with bulimia nervosa often report a sense of lack of control over-eating during these binge-eating episodes. While not always the case, these binge-eating episodes are followed by a feeling of disgust with oneself, which leads to a compensatory behavior to rid the body of the excessive calories. These compensatory behaviors include vomiting, use of laxatives, fasting (or severe restriction), diuretics or other medications, or excessive exercise. This cycle of binge eating and compensatory behaviors occurs on average, at least once a week for three months (National Eating Disorder Association website; APA, 2022).

It is important to note that while there are periods of severe calorie restriction like anorexia, the two disorders cannot be diagnosed simultaneously. Therefore, it is important to determine if an individual engages in a binge-eating episode—if they do, they do not meet the criteria for anorexia nervosa.

Signs and symptoms of bulimia nervosa are similar to anorexia nervosa. These symptoms include but are not limited to hiding food wrappers or containers after a bingeing episode, feeling uncomfortable eating in public, developing food rituals, limited diet, disappearing to the bathroom after eating a meal, and drinking excessive amounts of water or non-caloric beverages. Additional physical changes include weight fluctuations both up and down, difficulty concentrating, dizziness, sleep disturbance, and possible dental problems due to purging post binge eating episode.

Symptoms of bulimia nervosa typically present later in development – adolescence or early adulthood. Like anorexia nervosa, bulimia nervosa initially presents with mild restrictive dietary behaviors; however, episodes of binge eating interrupt the dietary restriction, causing bodyweight to rise around normal levels. In response to weight gain, patients engage in compensatory behaviors or purging episodes to reduce body weight. This cycle of restriction, binge eating, and calorie reduction often occurs for years before seeking help.

Additionally, those with bulimia are often ashamed of their eating problems and attempt to hide the symptoms. The binge eating occurs in secrecy or as inconspicuously as possible. Common antecedents of binge eating include negative affect; interpersonal stressors; dietary restraint; boredom; and negative feelings linked to body weight, shape, and food.

16.1.3. Binge-Eating Disorder (BED)

Binge-eating disorder is similar to bulimia nervosa in that it involves recurrent binge eating episodes along with feelings of lack of control during the binge-eating episode. The binge-eating episodes are associated with at least three of the following: eating quicker than usual, eating until uncomfortably full, eating large amounts even if not hungry, eating alone, and feeling disgust with oneself or being depressed. Despite the feelings of shame and guilt post-binge, individuals with BED will not engage in vomiting, excessive exercise, or other compensatory behaviors. These binge eating episodes occur on average, at least once a week for 3 months.

Because these binge-eating episodes occur without compensatory behaviors, individuals with BED are at risk for obesity and related health disorders. Individuals with BED report feelings of embarrassment at the quantity of food consumed, and thus will often refuse to eat in public. Due to the restriction of eating around others, individuals with BED often engage in secret binge eating episodes in private, followed by discrete disposal of wrappers and containers.

While much is still being researched about binge-eating disorder, current research indicates that the onset of BED is adolescence to early adulthood but can begin later in life. Those who seek treatment tend to be older than those with either bulimia or anorexia. Binge eating has been found to be common in adolescent and college-age samples and for all, is associated with social role adjustment issues, impaired health-related quality of life and life satisfaction, and increased medical morbidity and mortality (APA, 2022).

16.2. Prevalence and Comorbidity

Section Learning Objectives

• Describe the prevalence of anorexia nervosa.
• Describe the comorbidity of anorexia nervosa.
• Describe the prevalence of bulimia nervosa.
• Describe the comorbidity of bulimia nervosa.
• Describe the prevalence of binge eating disorder.
• Describe the comorbidity of binge eating disorder.

16.2.1. Prevalence of Eating Disorders

      16.2.1.1. Anorexia nervosa. According to the National Eating Disorder Alliance (NEDA) website, at any point in time more women (0.3-0.4%) than men (0.1%) will be diagnosed with anorexia. Anorexia nervosa is most prevalent in postindustrialized, high-income countries such as the United States, Australia, New Zealand, Japan, and many European countries. In the U.S., prevalence is lower among Latinx and non-Latinx Black Americans than non-Latinx Whites (APA, 2022).

      16.2.1.2. Bulimia nervosa. According to the NEDA website, at any point in time, 1.0% of women and 0.1% of men will meet the diagnostic criteria for bulimia nervosa. A study by Stice and Bohon (2012) found that between 1.1% and 4.6% of females and 0.1% to 0.5% of males will develop bulimia and that subthreshold bulimia occurs in 2.0% to 5.4% of adolescent females. The DSM reports that the 12-month prevalence ranges from 0.14% to 0.3% with higher rates in females and high-income countries. Rates are similar across ethnoracial groups across the U.S. (APA, 2022).

      16.2.1.3. Binge eating disorder. Hudson et al. (2007) reports that BED is three times more common than anorexia and bulimia and is more common than breast cancer, HIV, and schizophrenia. It has also been found that between 0.2% and 3.5% of females and 0.9% and 2.0% of males will develop binge eating disorder with subthreshold binge eating disorder occurring in 1.6% of adolescent females (Stice & Bohon, 2012). The DSM reports a 12-month prevalence of 0.44% to 1.2% with rates 2-3 times higher in women, similar rates across ethnoracial groups in the United States and between most high-income industrialized countries (APA, 2022).

      16.2.1.4. General comments. Not all individuals with an eating disorder end up being diagnosed or in treatment. For example, Austin et al., (2008) indicated that, when screening high-school students for an eating disorder, 25% of girls and 11% of boys reported disordered eating and weight controlling methods severe enough to necessitate clinical evaluation of the symptoms. However, very few of those students indicated that they had received treatment.

16.2.2. Comorbidity of Eating Disorders

     16.2.2.1. Anorexia nervosa. Anorexia is rarely a single diagnosis. High rates of bipolar, depressive, and anxiety disorders are common among individuals with anorexia nervosa. Obsessive-compulsive disorder is more often seen in those with the restricting type of anorexia nervosa, whereas alcohol use disorder and other substance use disorders are more commonly seen in those with anorexia who engage in binge-eating/purging behaviors. Unfortunately, there is also a high rate of suicidality, with rates reported to be 18 times greater than in an age- and gender-matched comparison group. It is also estimated that between 9% and 25% of individuals with anorexia have attempted suicide (APA, 2022).

     16.2.2.2. Bulimia nervosa. The majority of individuals diagnosed with bulimia nervosa also present with at least one other mental disorder. Similar to anorexia nervosa, there is a high frequency of depressive symptoms (i.e., low self-esteem), as well as bipolar and depressive disorders. While some experience mood fluctuations because of their eating pattern (occurring at the same time or following the development of bulimia), some individuals will identify mood symptoms prior to the onset of bulimia nervosa (APA, 2022).

Anxiety, particularly social anxiety, is often present in those with bulimia nervosa. However, most mood and anxiety symptoms resolve once an effective treatment of bulimia is established. Substance use disorder, and in particular alcohol use disorder, is also prevalent in those with bulimia, with about a 30% prevalence among those with bulimia. The substance abuse begins as a compensatory behavior (e.g., stimulant use is used to control appetite and weight) and over time, as the eating disorder progresses, so does the substance abuse. There is also a percentage of individuals with bulimia nervosa who display personality features that meet the criteria for at least one personality disorder, most often borderline personality disorder. Finally, about one-quarter to one-third of individuals with bulimia have had suicidal ideation and a comparable amount have attempted suicide.

     16.2.2.3. Binge eating disorder. Research shows that BED shares similar comorbidities with anorexia nervosa and bulimia nervosa. Common comorbidities include major depressive disorder and alcohol use disorder. About 25% of those with BED have shown suicidal ideation (APA, 2022).

16.3. Etiology

Section Learning Objectives

• Describe the biological causes of eating disorders.
• Describe the cognitive causes of eating disorders.
• Describe the sociocultural causes of eating disorders.
• Describe how personality traits are the cause of eating disorders.

What causes eating disorders? While researchers have yet to identify a specific cause of eating disorders, the most compelling argument to date is that eating disorders are multidimensional disorders. This means many contributing factors lead to the development of an eating disorder. While there is likely a genetic predisposition, there are also environmental, or external factors, such as family dynamics and cultural influences that impact their presentation. Research supporting these influences is well documented for anorexia nervosa and bulimia nervosa; however, seeing as BED has only just recently been established as a formal diagnosis, research on the evolvement of BED is ongoing.

16.3.1. Biological

There is some evidence of a genetic predisposition for eating disorders, with relatives of those diagnosed with an eating disorder being up to six times more likely than other individuals to be diagnosed also. Twin concordance studies also support the gene theory. If an identical twin is diagnosed with anorexia, there is a 70% percent chance the other twin will develop anorexia in their lifetime. The concordance rate for fraternal twins (who share less genes) is 20%. While not as strong for bulimia, identical twins still display a 23% concordance rate, compared to the 9% rate for fraternal twins.

In addition to hereditary causes, disruption in the neuroendocrine system is common in those with eating disorders (Culbert, Racine, & Klump, 2015). Unfortunately, it’s difficult for researchers to determine if these disruptions caused the disorder or have been caused by the disorder, as manipulation of eating patterns is known to trigger changes in hormone production. With that said, researchers have explored the hypothalamus as a potential contributing factor. The hypothalamus is responsible for regulating body functions, particularly hunger and thirst (Fetissov & Mequid, 2010). Within the hypothalamus, the lateral hypothalamus is responsible for initiating hunger cues that cause the organism to eat, whereas the ventromedial hypothalamus is responsible for sending signals of satiation, telling the organism to stop eating. Clearly, a disruption in either of these structures could explain why an individual may not take in enough calories or experience periods of overeating.

16.3.2. Cognitive

Some argue that eating disorders are, in fact, a variant of obsessive-compulsive disorder  (OCD). The obsession with body shape and weight—the hallmark of an eating disorder—is likely a driving factor in anorexia nervosa. Distorted thought patterns and an over-evaluation of body size likely contribute to this obsession and one’s desire for thinness. Research has identified high levels of impulsivity, particularly in those with binge eating episodes, suggesting a temporary lack of control is responsible for these episodes. Post binge-eating episode, many individuals report feelings of disgust or even thoughts of failure. These strong cognitive factors are indicative as to why cognitive-behavioral therapy is the preferred treatment for eating disorders.

16.3.3. Sociocultural

Eating disorders are overwhelmingly found in Western countries where there is a heavy emphasis on thinness—a core feature of eating disorders. It is also found in countries where food is in abundance, as in places of deprivation, round figures are viewed as more desirable (Polivy & Herman, 2002). While eating disorders were once thought of as disorders of higher SES, recent research suggests that as our country becomes more homogenized, the more universal eating disorders become.

     16.3.3.1. Media. One commonly discussed contributor to eating disorders is the media. The idealization of thin models and actresses sends the message to young women (and adolescents) that to be popular and attractive, you must be thin. These images are not isolated to magazines, but are also seen in television shows, movies, commercials, and large advertisements on billboards and hanging in store windows. With the emergence of social media (e.g., Facebook, Snapchat, Instagram), exposure to media images and celebrities is even easier.  Couple this with the ability to alter images to make individuals even thinner, it is no wonder many young people become dissatisfied with their body (Polivy & Herman, 2004).

     16.3.3.2. Ethnicity. While eating disorders are not solely a “white woman” disorder, there are significant discrepancies when it comes to race, especially for anorexia nervosa. Why is this? Research indicates that black men prefer heavier women than do white men (Greenberg & Laporte, 1996). Given this preference, it should not be surprising that black women and children have larger ideal physiques than their white peers (Polivy & Herman, 2000). Since black women are less driven to thinness, black women would appear to be less likely to develop anorexia; however, findings suggest this is not the case. Caldwell and colleagues (1997) found that high-income black women were equally as dissatisfied as high-income white women with their physique, suggesting body image issues may be more closely related to SES than that of race. The race discrepancies are also less significant in BED, where the prominent feature of the eating disorder is not thinness (Polivy & Herman, 2002).

     16.3.3.3. Gender. Males account for only a small percentage of eating disorders. While it is unclear as to why there is such a discrepancy, it is likely somewhat related to cultural desires of women being “thin” and men being “muscular” or “strong.”

Of men diagnosed with an eating disorder, the overwhelming percentage of them identified a job or sport as the primary reason for their eating behaviors (Strother, Lemberg, Stanford, & Turberville, 2012). Jockeys, distance runners, wrestlers, and bodybuilders are some of the professions identified as most restrictive regarding body weight.

There is some speculation that males are not diagnosed as frequently as women due to the stigma attached to eating disorders. Eating disorders have routinely been characterized as a “white, adolescent female” problem. Due to this bias, young men may not seek help for their eating disorder in efforts to prevent labeling (Raevuoni, Keski-Rahkonen & Hoek, 2014).

     16.3.3.4. Family. Family influences are one of the strongest external contributors to maintaining eating disorders. Often family members are praised for their slenderness. Think about the last time you saw a family member or close friend- how often have you said, “You look great!” or commented on their appearance in some way? The odds are likely high. While the intent of the family member is not to maintain maladaptive eating behaviors by praising the physical appearance of someone struggling with an eating disorder, they are indirectly perpetuating the disorder.

While family involvement can help maintain the disorder, it can also contribute to the development of an eating disorder. Families that emphasize thinness or place a large emphasis on physical appearance are more likely to have a child diagnosed with an eating disorder (Zerbe, 2008). In fact, mothers with eating disorders are more likely to have children who develop a feeding/eating disorder than mothers without eating disorders (Whelan & Cooper, 2000). Additional family characteristics that are common among patients receiving treatment for eating disorders are enmeshed, intrusive, critical, hostile, or overly concerned with parenting (Polivy & Herman, 2002). While there has been some correlation between these family dynamics and eating disorders, they are not evident in all families of people with eating disorders.

16.3.4. Personality

There are many personality characteristics that are common in individuals with eating disorders. While it is unknown if these characteristics are inherent in the individual’s personality or a product of personal experiences, the thought is eating disorders develop due to the combination of the two.

     16.3.4.1. Perfectionism. It should come as no surprise that perfectionism, or the belief that one must be perfect, is a contributing factor to disorders related to eating, weight, and body shape (particularly anorexia nervosa). While an exact mechanism is unknown, it is believed that perfectionism magnifies normal body imperfections, leading an individual to go to extreme (i.e., restrictive) behaviors to remedy the flaw (Hewitt, Flett & Ediger, 1995).

     16.3.4.2. Self-Esteem. Self-esteem, or one’s belief in their worth or ability, has routinely been identified as a moderator of many psychological disorders, and eating disorders are no exception. Low self-esteem not only contributes to the development of an eating disorder but is also likely involved in the maintenance of the disorder. One theory, the transdiagnostic model of eating disorders, suggests that overall low self-esteem increases the risk for over-evaluation of body, which in turn, leads to negative eating behaviors that could lead to an eating disorder (Fairburn, Cooper & Shafran, 2003).

16.4. Assessment

Section Learning Objectives

• Outline assessment processes for eating disorders.

When assessing for eating disorders, a multidisciplinary team is necessary. This is because many of the symptoms of an eating disorder require an understanding of physical symptoms as well as psychological symptoms and so the team may include a medical doctor, dietician, nurse, psychologist, therapist, etc.

16.4.1. Physical Assessment

A full medical and physical exam should occur. The medical exam should rule out inflammatory bowel disease, hyperthyroidism, chronic infection, diabetes, and other serious medical conditions. A female’s menstruation history should also be obtained to include information about their first menstrual period (if menarche has occurred) and if their menstrual period has become irregular or completely stopped (Lask & Bryant-Waugh, 2013).

The physical exam should be done alone unless the child requests otherwise. The provider will look for physical consequences of the eating disorder and rule out other serious disorders. Physical growth will be assessed, and weight/body measurements will be obtained such as body mass index. Additionally, laboratory tests will be utilized to assess various systems and nutritional information including protein levels, liver functioning, and hormone levels (Lask & Bryant-Waugh, 2013).

16.4.2. Psychological Assessment

A clinical interview is conducted not just with the individual, but also family members. During the interview, a timeline will be established which includes life events and the onset or progression of eating behaviors. Eating behaviors will be thoroughly assessed. Additionally, weight-controlling behaviors such as excessive exercise, induced vomiting, laxatives, etc.; their overall body image; and an assessment of mental health checking for suicidal ideation, will be assessed (Lask & Bryant-Waugh, 2013).

Although interviews can be conducted informally, structured interviews can also be used, and are preferred at times. The gold standard for assessing for eating disorders in children is the Child Eating Disorder Examination (ChEDE). Additionally, standardized objective measures to screen for levels of symptoms such as the Eating Disorder Examination Questionnaire (EDEQ) and Eating Disorder Inventory for Children (EDIC) are used. Helpful screening tools include Children’s Eating Attitudes Test (ChEAT) or the Kids’ Eating Disorder Survey (KEDS; Lask & Bryant-Waugh, 2013).

16.5. Treatment

Section Learning Objectives

• Describe treatment options for anorexia nervosa.
• Describe treatment options for bulimia nervosa.
• Describe treatment options for binge eating disorder.
• Discuss the outcome of treatment for eating disorders.

16.5.1. Anorexia Nervosa

The immediate goal for the treatment of anorexia nervosa is weight gain and recovery from malnourishment. This is often established via an intensive outpatient program, or if needed, through an inpatient hospitalization program where caloric intake can be managed and controlled. Both the inpatient and outpatient programs use a combination of therapies and support to help restore proper eating habits. Of the most common (and successful) treatments are Cognitive-Behavioral Therapy (CBT) and Family-Based Therapy (FBT).

     16.5.1.1. CBT. Because anorexia nervosa requires changes to both eating behaviors as well as thought patterns, CBT strategies have been very effective in producing lasting changes to those suffering from anorexia nervosa. Some of the behavioral strategies include recording eating behaviors—hunger pains, quality and quantity of food—and emotional behaviors—feelings related to the food. In addition to these behavioral strategies, it is also important to address the maladaptive thought patterns associated with their negative body image and desire to control their physical characteristics. Changing the fear related to gaining weight is essential in recovery.

     16.5.1.2. Family based therapy (FBT). FBT is also an effective treatment approach, often used as a component of individual CBT, especially for children and adolescents with the disorder. FBT has been shown to elicit 50-60% of weight restoration in one year, as well as weight maintenance 2-4 years post-treatment (Campbell & Peebles, 2014; LeGrange, Lock, Accurso, Agras, Darcy, Forsberg, et al, 2014). Additionally, FBT has been shown to improve rapid weight gain, produce fewer hospitalizations, and is more cost-effective than other types of therapies with family involvement (Agras, Lock, Brandt, Bryson, Dodge, Halmi, et al., 2014).

FBT typically involves 16-18 sessions which are divided into 3 phases: (1) Parents take charge of weight restoration, (2) client’s gradual control of overeating, and (3) addressing developmental issues including fostering autonomy from parents (Chen, et al., 2016). While FBT has shown to be effective in treating adolescents with anorexia nervosa, the application for older eating patients (i.e., college-aged students and above) is still undetermined. As with adolescents, the goal for a family-based treatment program should center around helping the patient separate their feelings and needs from that of their family.

     16.5.1.3. Refeeding. Refeeding is a nutritional rehabilitation effort to prevent refeeding syndrome which can lead to serious complications (e.g., serious cardiovascular, neurological, and hematologic events) due to a significant and potentially fatal shift in fluid and electrolyte levels following the individual increasing nutritional intake/calories (Fuentebella & Kerner, 2009). Refeeding therapy is done to ensuring adequate nutrition and hydration yet minimize the risk of refeeding syndrome.  In severe cases, nasogastric (nasal tube) and gastrostomy (tube inserted into stomach) tubes to appropriately achieve hydration and electrolyte balance may be required. More commonly, graded refeeding can occur. Oral refeeding, the preferred refeeding approach, when possible, occurs when a dietician helps outline appropriate nutritional expectations. Then, a plan for gradually increasing food for the child/adolescent as they become more comfortable and less fearful of food, is established and implemented.

16.5.2. Bulimia Nervosa

Just as anorexia nervosa treatment initially focuses on weight gain, the first goal of bulimia nervosa treatment is to eliminate binge eating episodes and compensatory behaviors. The aim is to replace both negative behaviors with positive eating habits. One of the most effective ways to establish this is through Cognitive Behavioral Therapy (CBT).

     16.5.2.1. CBT. Similar to anorexia nervosa, individuals with bulimia nervosa are expected to keep a journal of their eating habits; however, with bulimia nervosa, it is also important that the journal include changes in sensations of hunger and fullness, as well as other feelings surrounding their eating patterns in efforts to identify triggers to their binging episodes (Agras, Fitzsimmons-Craft & Wilfley, 2017). Once these triggers are identified, psychologists will utilize specific behavioral or cognitive techniques to prevent the individual from engaging in binge episodes or compensatory behaviors.

One method for modifying behaviors is through Exposure and Response Prevention. As previously discussed in the OCD chapter, this treatment is very effective in helping individuals stop performing their compulsive behaviors by literally preventing them from engaging in the action, while simultaneously using relaxation strategies to reduce anxiety associated with not engaging in the negative behavior. Therefore, to prevent an individual from purging post-binge episodes, the individual would be encouraged to partake in an activity that directly competes with their ability to purge, e.g., write their thoughts and feelings in a journal at the kitchen table. Research has indicated that this treatment is particularly helpful for individuals suffering from comorbid anxiety disorders (particularly OCD; Agras, Fitzsimmons-Craft & Wilfley, 2017).

In addition to changing behaviors, it is also important to change the maladaptive thoughts toward food, eating, weight, and shape. Negative thoughts such as “I am fat” and “I can’t stop eating when I start” can be modified into more appropriate thoughts such as “My body is healthy” or “I can control my eating habits.”  By replacing these negative thoughts with more appropriate, positive thought patterns, individuals begin to control their feelings, which in return, can help them manage their behaviors.

     16.5.2.2. Interpersonal Psychotherapy (IPT). IPT has also been established as an effective treatment for those with bulimia nervosa, particularly if an individual has not been successful with CBT treatment. The goal of IPT is to improve interpersonal functioning in those with eating disorders. Originally a treatment for depression, IPT-E was adapted to address the social isolation and self-esteem problems that contribute to the maintenance of negative eating behaviors.

IPT-E has 3 phases typically covered in weekly sessions over 4-5 months. Phase One consists of engaging the patient in treatment and providing psychoeducation about their disease and the treatment program. This phase also includes identifying interpersonal problems that are maintaining the disease.

Phase Two is the main treatment component. In this phase, the primary focus is on problem-solving interpersonal issues. The most common types of interpersonal issues are lack of intimacy and interpersonal deficits, interpersonal role disputes, role transitions, grief, and life goals. Once the main interpersonal problem is identified, the clinician supports the patient in their pursuit to identify ways to change. A key component of IPT-E is the supportive role of the clinician, as opposed to the teaching role in other treatments. The idea is that by having the patient make changes, they can better understand their problems, and as a result, make more profound changes (Murphy, Straebler, Basden, Cooper, & Fairburn, 2012).

Phase Three is the final stage. The goals of this phase are to ensure that the changes made in Phase two are maintained. To achieve this, treatment sessions are spaced out, allowing patients more time to engage in their changed behavior. Additionally, relapse prevention (i.e., problem-solving ways not to relapse) is also discussed to ensure long term results. In doing this, the patient reviews the progress they have made throughout treatment, as well as identifying potential interpersonal issues that may arise, and how their treatment can be adapted to address those issues.

Support for IPT-E is limited; however, two extensive studies suggest that IPT-E is effective in treating bulimia nervosa, and possibly BED. While treatment is initially slower than CBT, it is equally effective in long-term follow-up and maintenance of disorder (Fairburn, Marcus, & Wilson, 1993).

16.5.3. Binge Eating Disorder

Given the similar presentations of BED and bulimia nervosa, it should not be surprising that the most effective treatments for BED are similar to that of bulimia nervosa. CBT, along with antidepressant medications, are among the most effective in treating BED. Interpersonal therapy, as well as dialectical behavioral therapy, have also been effective in reducing binge-eating episodes; however, they have not been effective in weight loss (Guerdjikova, Mori, Casuto, & McElroy, 2017). Goals of treatment are, of course, to eliminate binge eating episodes, as well as reduce body weight as most individuals with BED are overweight. Seeing as BED has only recently been established as a separate eating disorder, treatment research specific to this disorder is expected to grow.

     16.5.3.1. Antidepressant medications. Given the high comorbidity between eating disorders and depressive symptoms, antidepressants have been a primary method of treatment for years. While they have been shown to improve depressive symptoms, which may help individuals make gains in their eating disorder treatment, research has not supported antidepressants as an effective treatment strategy for treating the eating disorder itself.

16.5.4. Outcome of Treatment

Now that we have discussed treatments for eating disorders, how effective are they? Research has indicated favorable prognostic features for anorexia nervosa are early age of onset and a short history of the disorder. Conversely, unfavorable features are a long history of symptoms prior to treatment, severe weight loss, and binge eating and vomiting. The mortality rate over the first 10 years from presentation is about 10%. Most of these deaths are from medical complications due to the disorder or suicide.

Unfortunately, research has not identified any consistent predictors of positive outcomes for bulimia nervosa. However, there is some speculation that individuals with childhood obesity, low self-esteem, and those with a personality disorder have worse treatment outcomes. While treatment outcome for BED is still in its infancy, initial findings suggest that remission rates of BED are much higher than that for anorexia nervosa and bulimia nervosa.

Module Recap

Module 16 covered eating disorders in terms of their clinical presentation, prevalence, comorbidity, etiology, and treatment options. The discussion included anorexia nervosa, bulimia nervosa, and binge eating disorder.

Our next and final chapter will cover substance use disorders.

3rd edition