Denise E. Wilfley, PhD

Disseminating Evidence-Based Psychological Treatment

Eating disorders (EDs) affect individuals from every socioeconomic status, race, ethnicity, and gender, with approximately 10% of the population affected by an ED at some point in their lifetime.

 EDs are associated with high medical and psychiatric comorbidity, poor quality of life, and high mortality, and mortality from anorexia nervosa (AN) is the highest of all mental disorders.

 Fortunately, there are a number of evidence-based psychological treatment approaches for EDs. Three well-established treatments have emerged for patients who are medically and psychiatrically stable enough for outpatient care.

The basic tenets of family-based treatment-often referred to as the Maudsley method-for adolescents with anorexia nervosa include

The family is not blamed as the cause of the illness.

The adolescent’s acceptance of family and parent involvement in therapy is crucially important; thus, parents are tasked with taking charge of weight gain in their malnourished child.

The entire family is an important part of treatment success.

Normal adolescent development is seen as having been interrupted by the illness.

The treatment typically consists of 10 to 20 sessions over the course of 6 to 12 months. Full nutrition is viewed as a critical first step toward recovery, and the early part of treatment is focused on the therapist coaching the parents to provide this nutrition by actively feeding their child.

Cognitive behavioral therapy (CBT) is a treatment for bulimia nervosa and binge eating disorder. According to the cognitive-behavioral theory of EDs, the over-evaluation and control of shape and weight is central to ED maintenance, with most of the other clinical features understood as directly resulting from this psychopathology, including extreme weight-control behavior and preoccupation with thoughts about eating, shape, and weight.

The core components of CBT are designed to be delivered in 20 sessions over 5 months. Key strategies include establishing control over eating with behavioral techniques, such as self-monitoring and establishing a regular pattern of eating and addressing maintaining factors (eg, control and over-evaluation of shape and weight, dietary restraint). In the enhanced version of CBT for EDs (CBT-E), modules can be added to address one or more external processes that may be maintaining the ED, including perfectionism, low self-esteem, and interpersonal problems.

Research findings suggest that guided self-help based on CBT can be effective in treating bulimia nervosa and binge eating disorder as well.

 Guided self-help can be defined as a psychological treatment where the patient takes home a standardized treatment, which is often written down in book form or available through some other media, and primarily works through it independently but also has the guidance of a therapist or coach. This guidance is primarily supportive or facilitative in nature and is meant to support the patient in working through the standardized treatment themselves.

The amount of contact in guided self-help is minimized relative to standard treatment approaches. It is acceptable to patients, highly cost-effective, and can be implemented successfully by a wide variety of individuals (eg, nurses, non-specialists with no formal clinical qualifications). For these reasons, as of 2017, the United Kingdom National Institute for Health and Care Excellence (NICE) guidelines for EDs recommend guided self-help CBT as the first-line treatment for adults with bulimia nervosa and binge eating disorder.

Interpersonal psychotherapy is another treatment for bulimia nervosa and binge eating disorder. It assumes that ED symptoms develop and are maintained in an interpersonal context. Specifically, interpersonal problems may contribute to negative affect and low self-esteem, which can in turn lead to the use of ED behaviors as a coping strategy.

 Engaging in ED behaviors can further intensify social difficulties, perpetuating the cycle. Interpersonal psychotherapy works to break this cycle by helping patients improve relationships and communication and resolve interpersonal issues.

Interpersonal psychotherapy typically includes 15 to 20 sessions over 4 to 5 months. During the early part of treatment, the onset and maintenance of the ED are linked to at least one of four identified problem areas (ie, interpersonal deficits, interpersonal role disputes, role transitions, grief) and interpersonal goals are developed. The focus of treatment then transitions to working towards these goals. During this process, the therapist helps the patient recognize the connections between improvement in ED symptoms and positive changes in interpersonal functioning.

Many international, evidence-based clinical treatment guidelines recommend use of these evidence- based psychological treatments for EDs. Despite the recommendations, when individuals with EDs receive care, it is frequently not evidence- based treatment. Referred to as the research-practice gap, this is the discrepancy between what is known about effective treatment and what is actually provided to patients who receive care. Indeed, the number of ED specialist clinicians who report adhering to evidence-based protocols is between 6% and 35%. Far more clinicians report using an eclectic mix of techniques derived from both evidence-based treatments and techniques with no evidence for efficacy.

 Furthermore, even when clinicians say they are using an evidence-based treatment for EDs, key elements may be omitted.

Thomas Insel, MD, the past director of the National Institute of Mental Health has said, “We have powerful, evidence-based psychosocial interventions, but they are not widely available . . . A serious deficit exists in training for evidence-based psychosocial interventions.”

 The following models can be used to increase the dissemination of evidence-based treatments for EDs (

Train-the-trainer. Current approaches to training therapists to conduct new treatments typically consist of a 1- or 2-day workshop delivered by an expert; attendees are provided with a therapy manual. While workshops increase therapists’ knowledge, without further consultation their effect may be short-lived. Alternatively, there is a strong theoretical case for the “train-the-trainer” approach, which centers around an individual (the trainer) from a given setting (eg, community mental health center, college counseling center) who will be trained and will then train his or her colleagues. In addition, the trainer provides consultation as needed to anyone implementing the new treatment. In this way, the trainer becomes an internal coach and champion for the treatment.

This approach has been recommended as the most effective means of changing therapist behavior.

 The train-the-trainer approach also has the benefit of being more sustainable and cost-effective over time, as the trainer can continue to train new cohorts of therapists at relatively low cost. There is preliminary support for the usefulness of this method for guided self-help CBT.

 This approach is currently being tested as a method for training college counselors in interpersonal psychotherapy for EDs and depression.

Web-centered training. Another method is web-centered training, which is scalable and low cost.

Training can be offered to geographically dispersed trainees using minimal person-based resources.

The website can be accessed anytime, anywhere to effectively accommodate busy schedules.

It enables trainees to repeatedly review material, reinforcing learning.

The process can be customized to the trainee with quizzes, feedback, and refresher courses.

The website can be updated regularly, facilitating incorporation of new information.

Data collection on website usage can provide valuable information on the most accessed program features, informing refinement.

A comprehensive platform for training in CBT for EDs has been developed; findings indicate that the use of the platform may increase competence scores.

 Likewise, a comprehensive online training program in interpersonal psychotherapy has also been developed, including telephone-based simulation assessment for measurement of adherence and competence in the treatment, with testing currently underway.

Best-buy interventions. When selecting an evidence-based treatment to disseminate, selection criteria should be based on best-buy interventions and include: efficacy, cost-effectiveness, clinical range, ease of training and learning, and mode of treatment delivery.

Transdiagnostic treatments may be considered best buys because they have the advantage of offering greater clinical range and thus more practicality, which may enhance adoption of the method by therapists. In that sense, interpersonal psychotherapy might be considered a best-buy intervention given its ability to not only address EDs but also a variety of other problems, including depression, anxiety, and PTSD.

Cost-effectiveness is also a key consideration in defining a best buy. Family-based treatment might be considered a best buy given that it is cost effective compared with weight restoration via inpatient hospitalization. Likewise, guided self-help CBT has the advantage of being very easy to learn and deliver, even by inexperienced practitioners, making it very cost-effective.

Electronic support tools. Electronic support tools for therapists have the potential to enhance quality of care. First, checklists can help therapists ensure important points are covered in session and can also aid in decision-making. For instance, an electronic measurement-feedback system for routine outcome monitoring can be used. Meta-analytic work suggests that routine outcome feedback improves patient outcomes, at least in the short-term.

 Such monitoring can provide therapists with alerts that clients are “off track” indicating the current course of treatment may be ineffective. Furthermore, the detection of symptom improvements can reassure clients they are making progress and enhance the therapeutic alliance.

Electronic support tools can also be used to enhance adherence to therapy and facilitate transmission of information to the therapist. Recovery Record is a mobile app that can be used by patients with EDs to self-monitor meals, thoughts, emotions, and behaviors and share this information with the therapist.

Higher-level support and policy. For evidence-based care to dramatically increase, higher-level support is required. Improving Access to Psychological Therapies (IAPT) is a systematic way of organizing the delivery of evidence-based psychological treatment, according to the NICE guidelines, within England’s National Health Service. IAPT services are characterized by use of evidence-based treatments, routine outcome monitoring, and regular and outcomes-focused supervision.

 Routine outcome monitoring not only provides the patient and therapist with valuable information on symptom improvement, but it also provides information on whether this is a cost-effective approach. In the US, the Veterans Health Administration (VHA) is actively implementing a national initiative to disseminate and implement evidence-based treatments.

IAPT and the VHA models involve centralized control of money from the top and their implementation is mandated. Such initiatives have a much greater likelihood of success in changing therapist behavior relative to relying on individual therapists to voluntarily receive training and modify their behavior.

The establishment of several evidence-based psychological treatments for EDs, including family-based treatment, CBT, and interpersonal psychotherapy, represent an enormous advance. However, only a minority of patients with EDs who access care receive one of these treatments. To address the research-practice gap and ensure that more people obtain high-quality, evidence-based care, the use of novel approaches are required.

What will be most effective in terms of meaningfully addressing the research-practice gap is higher-level support and policy, which has the greatest likelihood of generating widespread change. It is important to work with policy makers to develop research questions that will answer important policy-related questions. Such an approach may dramatically increase access to evidence-based care for patients with EDs.

There is an enormous treatment gap in the field of EDs, whereby the vast majority of patients with EDs (≥ 80%) receive no clinical care whatsoever.

 Moving forward, in addition to continuing to improve the quality of treatment for the minority of individuals with EDs who receive services, increased attention needs to be devoted to finding novel approaches to delivering treatment that can reach the vast number of individuals in need of care who currently receive no services at all.

Dr Fitzsimmons-Craft is Assistant Professor of Psychiatry, and Dr Wilfley is the Scott Rudolph University Professor of Psychiatry, Medicine, Pediatrics, and Psychological and Brain Sciences, Washington University School of Medicine, St. Louis, MO. The authors report no conflicts of interest concerning the subject matter of this article.

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Articles

Eating disorders (EDs) are associated with high medical and psychiatric comorbidity, poor quality of life, and high mortality, and mortality from anorexia nervosa (AN) is the highest of all mental disorders. Fortunately, there are a number of evidence-based psychological treatment approaches for EDs.

Closing the Research-Practice Gap in Eating Disorders

It is essential to detect the presence of an eating disorder because of high associated mortality. Clinicians are faced with the difficulty of determining the presenting problem and identifying the appropriate diagnostic code needed for insurance billing. Although efforts have been made to improve the diagnostic criteria, not all presentations fit perfectly into the established criteria. Moreover, diagnosis is further complicated by the differences in criteria outlined in DSM-5 and ICD-10 (

). Many applaud the recognition of binge eating disorder in DSM-5 as a major improvement in the field, but it does not have its own code in ICD-10.

Anorexia nervosa was first included in DSM-III and ICD-9. The key clinical criterion in anorexia nervosa is a significantly low body weight. However, the level at which body weight is considered “significantly low” has evolved. DSM-5 criteria for low weight consider what is “normal” for one’s age, sex, physical health, and developmental trajectory. Severity level may be assigned based on specified BMI. Previously, the weight criteria were criticized for being arbitrary because the criterion of 15% below ideal body weight was not empirically derived. ICD-10 (F50.0) quantifies low weight as at least 15% below what is expected or a BMI of 17.5 or lower.

Criteria from DSM-5 and ICD-10 recognize a fear of gaining weight and significant body image disturbance as essential features. One major change in DSM-5 is the removal of the amenorrhea criterion, which was criticized for not being applicable to males or prepubescent females. Moreover, the presence of amenorrhea does not differentiate severity of psychopathology.

 ICD-10, however, still acknowledges that amenorrhea may be present in females with anorexia nervosa. Anorexia nervosa is divided into 2 subtypes:

• Restricting type (F50.01): the patient has refrained from binge eating and/or purging in the past 3 months

• Binge-eating/purging type (F50.02): characterized by recurrent episodes of bingeing and/or purging over the past 3 months

Bulimia nervosa first appeared in DSM-III-R and ICD-9 and is characterized by recurrent episodes of binge eating followed by compensatory behaviors. Binge eating is defined as eating what would be considered an objectively large amount of food in a relatively short period. DSM specifies the presence of a feeling of “loss of control” of one’s eating in addition to the large amount consumed. Both criteria include the presence of compensatory behaviors (eg, self-induced vomiting, laxatives, diuretics, excessive exercise, or fasting) and recognize similar concern about shape and weight as found in anorexia nervosa. DSM-5 specifies a frequency threshold of binge eating and compensatory behaviors as an average of once per week, over the past 3 months.

Binge eating disorder was identified as worthy of further study in DSM-IV-TR and is officially recognized in DSM-5. However, although widely accepted as a diagnosis, binge eating disorder is not recognized in ICD-10, and individuals would receive a diagnosis of F50.8 under other eating disorders. Binge eating disorder criteria include recurrent binge eating at the frequency threshold of at least an average of once per week, over the past 3 months, and the presence of at least 3 of the following 5 criteria:

• Eating a lot when not physically hungry

• Eating alone because of embarrassment

• Feeling very bad or guilty after eating

In DSM-5, individuals who meet significant criteria for an eating disorder but do not meet criteria for 1 of the 3 disorders described above may receive a diagnosis of other specified feeding and eating disorder, or OSFED. This includes individuals who may not meet the weight threshold for anorexia nervosa, or the frequency and duration of bulimia nervosa or binge eating disorder. In addition, purging disorder (ie, recurrent purging in the absence of bingeing) and night eating syndrome (ie, recurrent episodes of consciously eating at night) may be specified under an OSFED diagnosis. In ICD-10, diagnoses of atypical anorexia nervosa (F50.1) and atypical bulimia nervosa (F50.3) are specified as unique disorders, but any other eating disorder may receive the code of F50.8 for other eating disorders.

The differences across eating disorder diagnoses in DSM-5 and ICD-10 complicate the work of clinicians. One obvious criticism of ICD-10 is the absence of a unique code for and recognition of binge eating disorder as a distinct eating disorder-given that it is the most common eating disorder and is associated with significant comorbidities and impairment.

Some additional guidance for determining low weight has been added to the criteria for anorexia nervosa in DSM-5. However, it still may be somewhat subjective and may be difficult to assess without obtaining a patient’s growth charts.

The frequency threshold of binges and compensatory behavior for bulimia nervosa and binge eating disorder was reduced from DSM-IV-TR, because DSM-IV criteria were criticized for being arbitrary.

 Findings suggest that reducing the criteria to once per week over 3 months would not significantly increase the prevalence but should still identify the majority of individuals who have clinically significant eating disorder pathology.

There is some criticism regarding the definition of a binge. As written, there are no well-defined guidelines as to what constitutes “objectively large.” Similarly, criticism surrounds whether the amount of food consumed is necessary or whether the feeling of loss of control is sufficiently indicative of pathology. Perhaps the most salient critique of the diagnostic criteria in DSM-5 is the absence of any shape and weight concerns in the diagnosis of binge eating disorder.

Clinically significant shape and weight concerns are related to greater psychopathology among those with binge eating disorder. However, a considerable number of individuals with clinically significant binge eating do not exhibit shape and weight concerns, so many feel that these concerns should be a specifier because they may indicate severity of pathology.

The severity specifiers in DSM-5 for binge eating disorder are based on number of binge episodes per week and are not empirically derived. Subsequent research has demonstrated that these severity criteria are not related to pathology. A shape and weight specifier would provide more clinical utility.

Knowing how to conduct a differential diagnosis is important; however, it necessitates first asking questions to assess eating behaviors. Because many of the behaviors associated with eating disorders can occur in secret, these disorders may go unnoticed for years. Thus, all physicians should routinely ask their patients about eating behaviors.

Because of the high levels of comorbidity of other psychiatric conditions with eating disorders, psychiatrists need to ask eating behavior questions even if eating is not the primary reason a client presents for treatment. Furthermore, although weight may be associated with certain eating disorders, clinically significant disordered eating behaviors may be present across the weight spectrum. For example, a person who is of normal weight may endorse bingeing and purging behaviors, or someone who is overweight may significantly restrict food intake-resulting in substantial weight loss-and thus meet the criteria for atypical anorexia nervosa.

Universal assessment is necessary because eating disorders are found across ages, races, ethnicities, sex, and the weight continuum. Depending on how much time you have for assessment, it may be best to begin by learning about a patient’s eating behaviors. Understanding eating patterns is a good start to see whether patients report that they regularly eat meals. Assessment for any appetite changes is also useful. To evaluate shape and weight concerns, ask how patients feel about their current shape and whether they are actively trying to lose weight. At first it may feel awkward to pose these questions; however, asking in a matter-of-fact way and stating that you ask this of all patients may reduce the stigma and increase the odds your patient will be truthful and less defensive.

If you have minimal time, at least assess for several key eating disorder behaviors so that you can provisionally diagnose an eating disorder and follow up with a more thorough evaluation at the next session. Assess all patients for binge eating by asking about eating large amounts of food and feeling a loss of control over eating. Inquire about purging behaviors, including self-induced vomiting, use of diet pills or laxatives, or excessive exercise. For patients with diabetes, it is important to ask whether an individual manipulates insulin intake to affect weight. Lastly, assess for significant restriction (ie, consciously restricting or limiting the amount that one consumes) and fasting, which is typically defined as refraining from eating for 8 hours or more while awake.

Many providers ask whether a quick screener is available. The one most widely used in primary care is the 5-item SCOFF questionnaire. However, it was initially created to assess for anorexia nervosa and bulimia nervosa and was created in “British English”; thus, some language modification is needed for use in the US.

 More detailed eating disorder assessment tools exist, such as the Eating Disorder Examination (EDE) and the questionnaire version.

 There is also a version of the EDE for children (Ch-EDE).

 However, specialty training is needed to administer the EDE and Ch-EDE interviews.

The EDE was updated to version 17.019 to provide DSM-5 diagnoses by adding detailed description of an algorithm to determine diagnosis. The question about amenorrhea was removed as well. To our knowledge, the Ch-EDE has not been formerly modified; however, because of minor adjustments to the diagnostic criteria, the information needed to determine DSM-5 diagnoses is collected.

Currently, patients cannot present with more than one eating disorder, although certain symptoms (eg, bingeing) may occur across diagnoses. DSM specifies that a diagnosis of anorexia nervosa prevails over a diagnosis of bulimia nervosa. Thus, if a patient binges and purges and meets the low weight threshold for anorexia nervosa, he or she would receive only a diagnosis of anorexia nervosa. Furthermore, the presence of regular compensatory behaviors distinguishes bulimia nervosa from binge eating disorder. Also, avoidant and restrictive food intake disorder may result in similar low weight as in anorexia nervosa but without the pervasive concern about one’s shape and weight or fear of gaining weight.

When diagnosing an eating disorder, it is important to ensure that symptoms such as low weight or vomiting are not due to a medical condition (eg, gastrointestinal condition, hyperthyroidism). Typically, patients with medical conditions responsible for low weight and/or vomiting do not present with significant concern for shape and weight. Keep in mind that decreased or increased appetite may be a symptom of MDD.

Fear of or embarrassment about eating in front of others may be present in binge eating disorder or anorexia nervosa; however, if fears around other social situations outside of eating occur, both an eating disorder diagnosis and a social anxiety disorder diagnosis would be appropriate. Obsessions and compulsions, similar to those seen in obsessive-compulsive disorder, may be characteristic of anorexia nervosa. If they are confined to eating and food alone, anorexia nervosa is the appropriate diagnosis; however, if obsessions and/or compulsions are more general, a diagnosis of obsessive-compulsive disorder may also be appropriate.

Lastly, patients with body dysmorphic disorder may exhibit similar misperception of their body. If these thoughts are confined to shape and weight, only an eating disorder diagnosis is warranted. However, if thoughts extend to a specific body part, then an additional diagnosis of body dysmorphic disorder may be justified.

 of this Special Report on Eating Disorders, you can find the articles 

Dr Eichen is a Postdoctoral Fellow at the University of California, San Diego. Dr Wilfley is The Scott Rudolph University Professor of Psychiatry, Medicine, and Psychological and Brain Sciences at the Washington University School of Medicine in St Louis. Dr Eichen reports no conflicts of interest concerning the subject matter of this article; Dr Wilfley reports that she is a consultant for Shire Pharmaceuticals.

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You must assess the presenting problem and identify the appropriate diagnostic code needed for insurance billing. But diagnosis is complicated. Help here. 

Denise E. Wilfley, PhD

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