Eating Disorders in Adults: Assessment & Treatment Options

Eating disorders, broadly defined by disturbances in eating behaviour and distress centred on food, eating, and body image, affect nearly one million Australians[1].  The more common eating disorders include anorexia nervosa, bulimia nervosa, and binge-eating disorder, and each of these illnesses are associated with profound physical, psychological, and social complications.

Although many people with an eating disorder do not receive or seek help, research shows that those who do get professional help are likely to improve. For example, between 40-50% of adults with eating disorders are expected to fully recover from psychological treatments, with many more showing partial recovery [2, 3] .

Assessment

Assessing or screening for eating disorders is a complex process. Many people with an eating disorder present late in the course of the illness and nearly half of those with an eating disorder may never seek help [4].

For those that do, it is usually based on recommendations from a local general practitioner.

It takes a team of health professionals to help motivate the patient to seek help and to engage and remain in empirically-supported psychological treatments.

Someone presenting with a potential eating disorder needs psychological and physical assessment. Health practitioners should ask patients’ about:

• Attitudes toward weight, shape, and eating
• Prior dieting and weight-control behaviours
• Other psychiatric conditions (e.g., depression, anxiety etc.)
• Suicidal ideation and self-harm risk
• Body mass index
• Familial environment

In addition to enquiring about this information, trained mental health professionals should conduct a standardized, well-validated semi-structured interview to confirm a diagnosis of an eating disorder. The Eating Disorder Examination is considered the “gold standard” assessment tool for eating disorders, which takes around 60 minutes to complete [5].

Treatment

Bulimia Nervosa and Binge Eating Disorder

Australian clinical practice guidelines recommend outpatient cognitive-behavioural treatment (CBT) as the first-line treatment for both bulimia nervosa and binge-eating disorder[6].

CBT is concerned with normalizing eating behaviour and modifying dysfunctional attitudes held towards weight and shape. Recent meta-analyses have shown that CBT for bulimia nervosa and binge-eating disorder is more effective than other psychological therapies in reducing binge eating and purging and in improving attitudes towards weight, shape and eating [7]. Improvements in quality of life and symptoms of depression are also noted [8, 9]. CBT can be effectively delivered in individual, group, or guided self-help format.

Second-line psychological treatments for bulimia nervosa and binge-eating disorder are interpersonal psychotherapy (IPT) and dialectical behaviour therapy (DBT). IPT aims to help patients enhance the quality of social relationships, as it is assumed that interpersonal conflict are a major trigger for binge eating and purging behaviour. Although IPT takes a lot longer to work than CBT, it has shown to be effective in reducing binge eating and purging [10].

 Conversely, DBT assumes that emotion dysregulation is the primary cause of binge eating and purging. Thus, DBT teaches a broad range of adaptive coping skills. Randomized trials have demonstrated DBT to be more effective than wait-list controls [11]. 

Anorexia Nervosa

In adults with anorexia nervosa, no particular specialised treatment stands out as the treatment of choice for this population.

Individual CBT, the Maudsley Model Anorexia Nervosa Treatment for Adults (MANTRA), and Specialist Supportive Clinical Management (SSCM) have all been shown in randomized controlled trials to be effective in people with anorexia nervosa, with no clear differences between the three approaches [12]. Outpatient treatments like these involve a collaborative approach among health professionals.

In addition to individual psychotherapy, all patients need to be re-fed and monitored for any potential medical complications. Re-feeding involves a slow increase in food to promote weight gain and normalize eating behaviour.

In more severe cases (e.g., when weight loss is rapid and severe and medical and psychiatric complications exist), intensive residential day or inpatient care may be required. However, the evidence base for inpatient and day patient treatment for severe anorexia nervosa is small.

References

1. Deloitte Access Economics, Paying the price: The economic and social impact of eating disorders in Australia. 2012, The Butterfly Foundation.: New South Wales.
2. Linardon, J., Rates of abstinence following psychological or behavioral treatments for binge-eating disorder: Meta-analysis. International Journal of Eating Disorders, 2018: p. 1-13.
3. Linardon, J. and T. Wade, How many individuals achieve symptom abstinence following psychological treatments for bulimia nervosa? A meta-analytic review. International Journal of Eating Disorders, 2018. 51: p. 287-294.
4. Hart, L.M., et al., Unmet need for treatment in the eating disorders: a systematic review of eating disorder specific treatment seeking among community cases. Clinical Psychology Review, 2011. 31: p. 727-735.
5. Fairburn, C.G. and S. Beglin, Assessment of eating disorders: Interview or self‐report questionnaire? International Journal of Eating Disorders, 1994. 16: p. 363-370.
6. Hay, P.J., et al., Royal Australian and New Zealand college of psychiatrists clinical practice guidelines for the treatment of eating disorders. Australian and New Zealand Journal of Psychiatry, 2014. 48: p. 977-1008.
7. Linardon, J., et al., The efficacy of cognitive-behavioral therapy for eating disorders: A systematic review and meta-analysis Journal of Consulting and Clinical Psychology, 2017. 85: p. 1080–1094.
8. Linardon, J. and L. Brennan, The effects of cognitive‐behavioral therapy for eating disorders on quality of life: A meta‐analysis. International Journal of Eating Disorders, 2017. 50: p. 715–730.
9. Linardon, J., et al., Psychotherapy for bulimia nervosa on symptoms of depression: A meta-analysis of randomized controlled trials International Journal of Eating Disorders, 2017. 50: p. 1124–1136.
10. Fairburn, C.G., et al., A transdiagnostic comparison of enhanced cognitive behaviour therapy (CBT-E) and interpersonal psychotherapy in the treatment of eating disorders. Behaviour Research and Therapy, 2015. 70: p. 64-71.
11. Safer, D.L., C.F. Telch, and W.S. Agras, Dialectical behavior therapy for bulimia nervosa. The American Journal of Psychiatry, 2001. 158: p. 632-634.
12. Byrne, S., et al., A randomised controlled trial of three psychological treatments for anorexia nervosa. Psychological Medicine, 2017: p. 1-11.