Guideline Watch (August 2012): Practice Guideline for the Treatment of Patients With Eating Disorders, 3rd Edition

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Back to table of contents Previous article Next article Clinical SynthesisFull AccessGuideline Watch (August 2012): Practice Guideline for the Treatment of Patients With Eating Disorders, 3rd EditionJoel Yager, M.D. Michael J. Devlin, M.D. Katherine A. Halmi, M.D. David B. Herzog, M.D. James E. Mitchell III, M.D. Pauline Powers, M.D. Kathryn J. Zerbe, M.D.Joel YagerSearch for more papers by this author, M.D. Michael J. DevlinSearch for more papers by this author, M.D. Katherine A. HalmiSearch for more papers by this author, M.D. David B. HerzogSearch for more papers by this author, M.D. James E. Mitchell IIISearch for more papers by this author, M.D. Pauline PowersSearch for more papers by this author, M.D. Kathryn J. ZerbeSearch for more papers by this author, M.D.Published Online:1 Jan 2014https://doi.org/10.1176/appi.focus.120404AboutSectionsView articleView PDFView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail View articleThis guideline watch reviews new evidence and highlights salient developments since the 2006 publication of APA’s Practice Guideline for the Treatment of Patients With Eating Disorders, 3rd Edition. The authors of this watch constituted the work group that developed the 2006 guideline. We find the guideline to remain substantially correct and current in its recommendations. The sole exception is a recommendation (with moderate-level confidence) for sibutramine for binge-eating disorder. In 2010, the U.S. Food and Drug Administration (FDA) withdrew approval for sibutramine because clinical trials showed increased risk of heart attack and stroke, and the manufacturer, Abbott Laboratories, subsequently withdrew this medication from the U.S. market.Noteworthy recent publications about the treatment of eating disorders include systematic reviews by the Agency for Healthcare Research and Quality (Berkman et al. 2006; Bulik et al. 2007); practice guidelines from international groups, including the Catalan Agency for Health Information, Assessment and Quality (Working Group of the Clinical Practice Guideline for Eating Disorders 2009), the World Federation of Societies of Biological Psychiatry (Aigner et al. 2011), and the German Society of Psychosomatic Medicine and Psychotherapy and the German College for Psychosomatic Medicine (Herpertz et al. 2011); and a 2011 guidance statement by the Academy for Eating Disorders, which was written by some of the authors of this watch. In our opinion, the findings, conclusions, and recommendations of these recent reviews and guidelines are consistent with the 2006 APA guideline.Recent textbooks provide useful practical information for clinicians who wish to learn how to deliver treatments recommended in the practice guideline. The authors of a textbook edited by Grilo and Mitchell (2010) describe therapeutic approaches and reviews supporting evidence on all aspects of eating disorders treatment, from assessment through nutritional rehabilitation to managing the chronically ill. The authors state that there is no single treatment for patients with eating disorders. Rather, a diversity of approaches is recommended. In another recent textbook, Cloak and Powers (2010) review and synthesize the small but growing evidence base for psychodynamic treatment approaches in eating disorders. As do Grilo and Mitchell, the authors recommend integration of treatment modalities. An edited manual by Yager and Powers (2007) and a textbook by Zerbe (2008) also provide practical strategies for providing integrated treatment. These texts highlight that given the long-term nature of eating disorders, it is important to address countertransference issues, medical and psychiatric comorbidities, and quality of life.These and other textbooks also provide practical information about psychodynamic psychotherapy. For example, Zerbe (2008) synthesizes research that demonstrates that clinicians of differing theoretical orientations have been shown to have similar countertransference reactions. Thompson-Brenner and colleagues (2010) review the growing evidence base for psychodynamic psychotherapy in patients with anorexia nervosa, bulimia nervosa, and binge-eating disorder. The studies included in their review suggest that attending to the transference, symptom symbolism, key conflicts, narcissistic vulnerabilities, and relational dynamics are important for reducing core personality and symptom difficulties.MethodsThe literature review for the 2006 guideline ended in 2003. For this watch, we searched MEDLINE, using PubMed, for randomized, controlled trials and meta-analyses published from 2003 through December 13, 2011, using the following terms: “bulimia,” “bulimia nervosa,” “bulimic,” “anorexia nervosa,” “binge eating,” “binge eating disorder,” “binge eating episode,” “eating disorder,” “eating disordered,” and “eating disorders.” Terms for limiting the search (using Boolean “or” logic) included the following: “systematic review,” “random allocation,” “randomly allocated,” “randomly assigned,” “randomization,” “randomize,” “randomized,” “randomized controlled trial,” “placebo,” “active comparator,” “double blind,” “double blinded,” “controlled clinical trial,” “meta analysis,” “meta-analytic,” and not “editorial,” “letter,” “case report,” or “comment.” We limited the search to English-language articles.We also searched the Cochrane database, using the terms “anorexia nervosa,” “bulimia,” and “binge eating” as well as corresponding Medical Subject Headings (MeSH) for reviews published from 2003 through December 13, 2011.These search strategies yielded 1,346 articles. Of these articles, 693 were rejected as not relating to treatment of eating disorders. We retained and reviewed 91 articles pertaining to anorexia nervosa, 84 to bulimia nervosa, 95 to binge eating, 12 to osteoporosis treatment in eating disorders, and 60 to miscellaneous topics, most of which covered more than one eating disorder.The following discussion focuses on randomized, controlled trials identified by our search but also includes some recent open trials of which we are aware. For some topics, instead of discussing all studies, in this watch we summarize the conclusions of an available systematic review. This watch is not intended to be a comprehensive review of all possible treatments for eating disorders. Rather, we review recent research that relates to key recommendations of the 2006 APA practice guideline.Clinical AssessmentDSM-5, to be published in 2013, is expected to contain some revisions of the diagnostic criteria for anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified (EDNOS). For example, amenorrhea may be dropped as a necessary criterion for anorexia nervosa, binge-eating disorder may become a distinct diagnosis apart from EDNOS, and the frequency criteria for both bulimia nervosa and binge-eating disorder may drop from twice per week to once per week. These changes are unlikely to affect utility of the 2006 practice guideline, which recommends that patients with subsyndromal anorexia nervosa or bulimia nervosa, such as patients with EDNOS who meet all criteria for anorexia nervosa except for being amenorrheic for 3 months, should receive treatment similar to that of patients who fulfill all criteria for these diagnoses. Proposed revisions to the criteria are available on the DSM-5 development website, www.dsm5.org, under “Feeding and Eating Disorders.”Anorexia NervosaThe quality of evidence for treatments for anorexia nervosa remains limited, according to recent systematic reviews and meta-analyses (e.g., Fitzpatrick and Lock 2011; Hartmann et al. 2011). There are few randomized, controlled trials, and available studies suffer from small sample sizes, short duration, and methodological problems. A contributing factor is that study recruitment is generally poor and dropout rates are high. For example, in a study of two clinical trials for anorexia nervosa, Halmi and colleagues (2005) reported that 46% of patients who had entered into the study dropped out. The only predictor of treatment acceptance Halmi et al. identified was high self-esteem, not a particularly common characteristic of patients with eating disorders. Furthermore, available studies are primarily about symptom relief rather than recovery (Strober and Johnson 2012).Predictors of recovery from anorexia nervosa remain poorly defined. In a systematic review of studies published from 1990 to 2005 on anorexia nervosa treatments, Espindola and Blay (2009) identified 3,415 studies, of which 16 addressed recovery. The authors concluded that a complexity of factors, extending well beyond conventional treatment factors and including self-acceptance, determination, and spirituality, accounts for recovery. In another systematic review of 12 randomized, controlled trials, Crane and colleagues (2007) found that obsessive-compulsive personality disorder traits were associated with poorer outcome in patients with anorexia nervosa and opined that treatment might moderate these traits. In a study by Schebendach and colleagues (2011), 41 weight-restored patients with anorexia nervosa who had been hospitalized were followed for up to 1 year. Differences were observed in the total number of different foods selected by patients with “success” outcomes (n = 29) versus patients with “failure” outcomes (n = 12). The authors stated that the results suggest that a diet limited in variety may be associated with relapse.Choice of SettingThe guideline states that it is important to consider a patient’s overall physical condition, psychology, behaviors, and social circumstances when choosing a treatment setting. Although investigators have attempted to study the advantages of specific settings, conclusions from available research are limited because there are many local variations in the essential features of settings.In a large multicenter, randomized, controlled trial conducted in the United Kingdom (the Trial of Outcomes for Child and Adolescent Anorexia Nervosa, or TOuCAN study), Gowers and colleagues (2007) randomly assigned 167 adolescent patients with anorexia nervosa to specialist inpatient, specialist outpatient, or routine general outpatient treatment. Improvement on outcome measures was good across all treatment groups, but full recovery rates were poor, at only 33 % after 2 years (of the 96% of the sample available for follow-up). Adherence was lowest in the inpatient treatment group, at 50%, as compared with 71% for the routine outpatient and 77% for the specialist outpatient groups. Inpatient treatment predicted poor outcome (either when patients were initially randomly assigned or after they were transferred from outpatient care). Patients who did not respond to outpatient treatment did very poorly (Gowers et al. 2010). The authors concluded that first-line inpatient treatment does not provide advantages over outpatient management, and that patients who do not respond to outpatient treatment do poorly on transfer to inpatient facilities (however, it is possible that patients in these difficult cases would do poorly in any setting) (Gowers et al. 2007). This same study found no statistical differences in outcomes after 2 years, but specialist outpatient treatment was shown to be most cost-effective (Byford et al. 2007). On the whole, these investigators concluded that under the British National Health Service there is little support for long-term inpatient care, either for clinical or for health economic reasons (Gowers et al. 2010). These investigators also interviewed 215 patients and their parents to compare satisfaction with specialist versus generalist care. Levels of satisfaction were high across all types of treatment, but higher for specialist care. Parents reported higher levels of satisfaction than did adolescents (Roots et al. 2009).In the meta-analysis by Hartmann and colleagues (2011), 57 studies, covering 84 treatment areas and involving 2,273 patients, were analyzed. With respect to choice of setting, the authors concluded that there is little high-quality evidence on which to base specific guidance, finding only that perhaps patients gain more rapidly on inpatient than on outpatient treatment settings.Nutritional RehabilitationFor underweight individuals with anorexia nervosa, the guideline recommends that hospital-based programs for nutritional rehabilitation should be considered. A study by Garber and colleagues (2012) lends additional support to the utility of inpatient care for underweight patients to reduce complications of nutritional rehabilitation, particularly the refeeding syndrome. In that study, 35 adolescent patients were followed during a hospital-based refeeding protocol in which calorie intake was increased every other day, from an average of 1,205 to 2,668, over an average length of stay of 16 days. No patients had refeeding syndrome, but 20% had low serum phosphorus levels. Percent mean body mass index (BMI) increased from 80.1 (11.5) to 84.5 (9.6), and overall gain was 2.10 (1.98) kg. Most of the patients (83%) initially lost weight, an important finding for clinicians who must justify the value of hospital-based nutritional rehabilitation programs to insurance companies. Mean percent BMI did not increase significantly until day 8. Higher calories prescribed at baseline were significantly associated with faster weight gain and a shorter hospital stay.For patients who refuse to eat and require life-preserving nutrition, the guideline recommends nasogastric feeding. The utility of nasogastric feedings has been studied in open trials by Rigaud and colleagues (2007, 2011). In the first trial (2007), malnourished patients with anorexia nervosa were randomly assigned to a tube-feeding group (n = 41) or a control group (n = 40) groups. After 2 months, weight gain was 39% higher in the tube-feeding group, binge-eating episodes were decreased, and most patients thought the intervention improved their eating disorder. After discharge, the tube-feeding group had a longer relapse-free period (34.3 ± 8.2 weeks vs. 26.8 ± 7.5 weeks). In the second trial (2011), adult outpatients with anorexia nervosa or bulimia nervosa were randomly assigned to 2 months of cognitive-behavioral therapy (CBT) alone (n = 51) or CBT plus tube feeding (n = 52). By the end of treatment those receiving CBT plus tube feeding were more rapidly and frequently abstinent from binge eating and purging, had more improvement on symptoms of depression and anxiety, and had a better quality of life. These superior results were also seen 1 year later. It should be noted that the average BMI for patients entered into the tube feeding plus CBT arm in the 2011 study was 18.2 ± 3.3, thin but not severely underweight, and the analysis did not separate normal-weight patients with bulimia nervosa from patients with anorexia nervosa, binge-eating purging type. As described in the practice guideline, there are potential harms to nasogastric feeding, and the guideline does not specifically recommend it for normal-weight patients.Psychosocial InterventionsThe practice guideline recommends psychotherapeutic management during acute refeeding and weight gain and states that psychotherapy can be helpful once malnutrition has been corrected and weight gain has begun. These recommendations were based on strong consensus but weak evidence. Research on psychotherapy for anorexia nervosa remains limited. It is difficult to carry out rigorously designed trials of psychotherapies, and as with trials of pharmacotherapy, long-term follow-up is uncommon. In addition, available studies have used a variety of psychosocial interventions, often in mixed populations (i.e., with patients with different kinds of eating disorders). As a result, the following studies do not significantly change the overall quality of evidence supporting psychosocial interventions for anorexia nervosa.In an open trial that used a “transdiagnostic” approach and broad inclusion criteria, Byrne and colleagues (2011) administered 20–40 individual sessions of “enhanced” CBT, which included aspects of interpersonal therapy (IPT), to 125 patients at a public outpatient clinic. The investigators reported that two-thirds of those completing treatment (and 40% of the total) achieved partial remission. However, only 53% of those who entered the trial completed treatment.Since motivation for treatment is a problem for many patients with anorexia nervosa or bulimia nervosa, several groups have examined ways to enhance motivation at the start of treatment. In general, results have not been dramatic, but some are promising. Wade and colleagues (2009) randomly assigned 47 young adult inpatients with anorexia nervosa to four sessions of motivational interviewing with a “novice” therapist (n = 22) or treatment as usual (n = 25). Not surprisingly, those who had started out with higher motivation did better overall. Patients receiving motivational interviewing were more likely to move from low to high readiness to change at 2- and 6-week follow-up. In a similar study by Dean and colleagues (2008), 42 inpatients were randomly assigned to receive four initial motivational interviewing sessions or treatment as usual. In this study, although no significant differences were seen between the groups, motivational enhancement treatment appeared to foster longer-term motivation and engagement and thus promote treatment continuation.Carter and colleagues (2011) investigated long-term outcomes of specialized psychotherapies in women with broadly defined anorexia nervosa who had participated (an average of 6.7 years prior to Carter et al.’s analysis) in a randomized, controlled trial comparing conventional CBT and a modified form of IPT in which therapists were constrained from discussing nutrition, weight, and shape issues, as well as a control condition (specialist supportive clinical management). No differences were seen in outcomes among the three groups. Only 43 of the original sample of 56 patients participated in this follow-up study, leaving the study underpowered.Several studies have examined the impact of exercise or strength training on patients with eating disorders. In a nonrandomized study, Calogero and Pedrotty (2004) compared 127 women in a residential treatment center who participated in an exercise program plus treatment as usual with 127 nonparticipants who received treatment as usual only. Women in the exercise group who had anorexia nervosa gained more than a third as much weight and demonstrated significantly reduced obligatory attitudes toward exercise compared with those in the comparison group. The authors acknowledged that these differences may reflect initial selection biases.In a small study, Chantler and colleagues (2006) randomly assigned 14 hospitalized adolescent females to an 8-week program of light resistance training or treatment as usual, with all participants receiving the same caloric intake. The training group showed increased knee and elbow strength. However, another small (n = 22) study by del Valle and colleagues (2010) found few benefits for a low- to moderate-intensity strength training program (two sessions/week for 3 months) when combined with treatment as usual (conventional psychotherapy and refeeding) compared with treatment as usual alone, even though the intervention was well tolerated and did not cause significant weight loss and no deleterious effects were seen.Results of small randomized trials involving treatment approaches that include mindfulness training along with CBT and other therapeutic approaches have been reported. Courbasson and colleagues (2011) randomly assigned 25 outpatients with comorbid mixed eating disorders and substance abuse disorders to a 1-year program of either dialectical behavior therapy (DBT) or treatment as usual. Those patients receiving DBT showed so much greater retention (80% vs. 20% at posttreatment) that the protocol was terminated early. The authors suggest that DBT may be effective at keeping such patients in treatment. A review of eight studies of variable quality that used mindfulness training for the treatment of patients with eating disorders suggests that available evidence supports the value of such interventions (Wanden-Berghe et al. 2011).Other therapies for anorexia nervosa and related conditions that have been studied include spirituality focused group therapy, eye movement desensitization and reprocessing (EMDR), yoga, and body awareness therapy. Available studies on these therapies, as described below, have design limitations.In one randomized, controlled study conducted at a treatment center that provides Christian therapy, 122 female inpatients with mixed eating disorder diagnoses were randomly assigned to treatment as usual plus either spirituality focused group therapy or cognitive and emotional group therapy. The spirituality group was reported to have a faster therapeutic response (Richards et al. 2006). The authors noted several limitations to the study, including small sample size, small magnitude of effect, and uncertain generalizability beyond the unique study setting (a facility known for promoting spirituality in treatment). As for many psychotherapy research studies, another limitation is possible expectancy bias from both therapists and patients.In another study, 86 women in a residential treatment program were randomly assigned to treatment as usual plus EMDR or treatment as usual only. Those receiving the addition of EMDR reported less distress related to negative body image memories and less body dissatisfaction at 3, 6, and 12 months compared with the treatment-as-usual group, but no other differences in body image measures or other clinical outcomes were seen (Bloomgarden and Calogero 2008). Limitations acknowledged by the authors include contamination effects and lack of blinding. In addition, the control group did not receive an active psychotherapy.In a pilot study by Carei et al. (2010), 54 adolescent outpatients with mixed eating disorders were randomly assigned to treatment as usual with or without eight sessions of yoga. Although both groups maintained BMI levels and reported reduced anxiety and depression scores over time, those in the yoga group demonstrated greater sustained reduction in eating disorder symptoms and decreased food preoccupation. Limitations of this pilot study include small sample size, anticipation effects from the use of repeated measures, and uncertain generalizability to inpatient or community samples.In a pilot study by Catalan-Matamoros and colleagues (2011), 28 outpatients with mixed eating disorders who had been symptomatic for less than 5 years were randomly assigned to treatment as usual with or without five sessions of basic body awareness therapy. Those patients in the body awareness therapy group showed modest but consistent improvements in measures of body dissatisfaction compared with those who received treatment as usual alone. The authors acknowledged that this small study had high dropout rates and was unblinded.In actual practice, clinicians who treat patients with eating disorders, including anorexia nervosa, use a wide array of psychosocial interventions. Tobin and colleagues (2007) surveyed 265 clinicians, who were recruited online and at professional meetings, about the treatment modalities they use. Only 6% of respondents reported they adhered closely to treatment manuals, and 98% indicated they used both behavioral and dynamically informed interventions. Factor analysis suggested theoretically linked dimensions of treatment but also dimensions that are common across models. The authors concluded that overlapping of treatment modalities is a common practice, and more studies are needed to assess what clinicians actually do.Family TherapyThe practice guideline strongly recommends family treatment for children and adolescents with eating disorders and suggests that family assessment and involvement may be useful for older patients as well. Family therapy of various types for anorexia nervosa continues to be a focus of considerable research. Results continue to provide support for the value of family therapy, but the overall quality of the evidence remains poor.In a Cochrane review, Fisher and colleagues (2010) evaluated the efficacy of family therapy compared with standard and other treatments. Thirteen trials were included in the analysis. The authors concluded that there is some evidence to suggest that family therapy may be more effective than treatment as usual in the short run, but they cautioned that the few available studies are small and have potential biases.In a review of family therapy for adolescents with anorexia nervosa, Gardner and Wilkinson (2011) identified six randomized, controlled trials, the large majority with small sample sizes, and concluded that these studies were on the whole weak. In one of the stronger studies (Lock et al. 2010), 121 patients with anorexia nervosa ages 12–18 years were randomly assigned to 24 outpatient hours of family-based therapy or to adolescent-focused individual therapy delivered over 12 months. At the end of treatment no group differences in full remission were seen, but there were more patients in partial remission in the family-based therapy group, and at 6- and 12-month follow-up there were greater rates of full remission in this group.In an earlier study of family-based therapy by Lock and colleagues (2005), 86 adolescents were randomly assigned to receive family-based therapy either short term (10 sessions over 6 months) or long term (20 sessions over 12 months). There were no differences in outcome. However, patients with obsessive-compulsive personality disorder and patients from non-intact families received greater benefit from the longer-term protocol. In this study, more dropouts occurred when patients had comorbid psychiatric disorders, were older, were assigned to the longer term protocol, or had problematic family behaviors (Lock et al. 2006).Ball and Mitchell (2004) randomly assigned 25 adolescents and young adults with anorexia nervosa who were living with their families either to a 12-month program involving 21–25 sessions of CBT or to behavioral family therapy. Sixty percent of the intent-to-treat group and 72% of completers were rated as having “good outcomes,” with no differences in outcomes seen between the groups. The majority of patients did not achieve symptomatic recovery.In a 5-year follow-up of 40 adolescent patients with anorexia nervosa who had participated in a randomized study of two forms of family therapy (conjoint or separated), Eisler and colleagues (2007) found no differences in outcomes. Seventy-two percent of the patients had recovered. However, patients from families with elevated levels of maternal criticism gained less weight and generally did less well with conjoint family therapy. The investigators suggested that for these families, conjoint therapy should be avoided, at least early on in treatment when raised levels of parental criticism are evident.Finally, Godart and colleagues (2012) randomly assigned 60 female adolescent patients with anorexia nervosa at time of hospital discharge either to 18 months of ambulatory treatment as usual or to treatment as usual augmented with family therapy (1.5 hours every 3–4 weeks) focusing on family dynamic issues and the “here and now” but not on eating behaviors or weight. Fifty-one of the 60 families were intact. Treatment as usual consisted of individual consultations, regular interviews involving the parents, and individual psychotherapy with another therapist if required. As necessary, psychiatrists prescribed medication, offered parental guidance regarding conflicts with daughters, and secured nutritional/dietetic advice for patients gaining insufficient weight. At 18 months, good outcomes were observed in 40% of the group receiving family therapy versus 17.2% of the group receiving treatment as usual.Parents and other close family members of patients with anorexia nervosa have been found to have high levels of psychological distress, burden, and expressed emotion (EE) (Zabala et al. 2009). Interventions to help these individuals cope with their burdens have been studied. Grover and colleagues (2011) randomly assigned 64 caregivers of individuals with eating disorders, primarily anorexia nervosa, to a Web-based CBT program designed to help caregivers plus limited clinician-supported guidance by e-mail or phone or to treatment as usual, consisting of usual support from caregiver organizations. At 4- and 6-month follow-up posttreatment, those patients who participated in the Web-based program reported reduced anxiety and depression, and a trend was observed in reduced EE. The same investigator group (Rhodes et al. 2009) also randomly assigned and compared 10 caregivers receiving treatment as usual with 10 who received “carer to carer” (i.e., parent-to-parent) consultations to supplement Maudsley model care. Qualitative analysis showed that those receiving parent-to-parent care felt less alone and more empowered. Further, educational workshops and skills training given to two families together was as effective as individual family therapy (Whitney et al. 2012).PharmacotherapyThe practice guideline describes limited evidence for the use of medications to restore weight, prevent relapse, or treat chronic anorexia nervosa.Evidence for antipsychotic medications, consisting of case series at the time the guideline was developed, now includes some randomized, controlled trials, but the studies have shown mixed results and have methodological limitations, including small sample sizes. In addition, as described in the guideline, these medications have serious potential adverse effects.A task force on eating disorders of the World Federation of Societies of Biological Psychiatry (Ai