Do we know how to treat eating disorders (EDs)?
Although eating disorders have been documented and studied for centuries, treatment has been guided by the experience and beliefs of the individual clinician. Over time, countless ideas have circulated about both the causes and best treatments for anorexia and bulimia. Unfortunately, very few psychotherapy approaches have been rigorously studied for use with eating disorders. We suggest parents do careful reading about both evidence based and other untested ways to approach the illness.
Researching Best Practices:
There are no treatments that can be expected to work for everyone, but identifying evidence-based treatment as a first option is important since eating disorder recovery rates decrease the longer a patient is ill. While lack of research does not mean that a given approach will be dangerous or unhelpful, delaying effective care by experimenting with other treatments can worsen the illness and increase the patient's suffering and resistance to treatment.
Psychotherapy is generally considered to be an important component of treatment and patients and carers will find a veritable "alphabet soup" of treatment approaches and combinations of approaches practiced by ED professionals. Although most treatments have not been well researched, as of now, the evidence-base from controlled trials supports the following recommendations:
- For patients with anorexia younger than 18: The Family-Based Maudsley Treatment, also called FBT, or the "Maudsley Approach"
- For bulimia and for adults: Cognitive Behavioral Therapy (CBT)
Just as not all approaches have been tested, the above evidence-based approaches are often used with patients from groups where high quality research has not been done. For example, FBT is often used with patients with bulimia and with older patients. CBT is often used with anorexia and younger patients. There is no indication that these approaches are only helpful in the populations that have been studied so far.
Caregivers need to know:
- Within the professional ED community, there are currently no agreed upon standards of care for treating eating disorders, or for training eating disorder "specialists."
- Each patient and each family is unique, and treatment recommendations are best made by experienced experts in the eating disorder field, after multidisciplinary evaluation, and in close collaboration with medical and psychiatric clinical teams.
- There is very little evidence that pharmaceutical treatments for eating disorders are effective, though some psychiatric medicines can be helpful for co-morbid conditions.
- Malnutrition and purging behaviors damage the body and medical treatment should take prority over psychological treatments.
- Nutritional stability and normalization of body composition are the initial goals in modern eating disorder treatment as the psychological symptoms are understood to be exacerbated and held in place by brain changes from inadequate or erratic nutrition, and weight loss.
Evidence-Based Treatment approaches for Eating Disorders
Family-Based Treatment (FBT), also known as the "Maudsley" approach:
F.E.A.S.T. Resource Link: FBT/Maudsley Treatment for eating disorders
This approach is based on the idea that "food is medicine" and parents are responsible for decisions regarding food choices and amounts. The patient is seen as being under the strong influence of malnutrition and unable to make choices about food and activity until nutrition has been stabilized and the brain is able to think rationally again. In a 3-stage process, the parents and siblings and ill person engage in family therapy sessions focused on:
- restoring lost weight and stopping purging behaviors,
- giving back control of these functions to the patient,
- getting back to normal relationships and age-appropriate development.
Research suggests that the Maudsley approach offers best outcomes for anorexic adolescents living at home who have been ill less than three years, but the approach is also used for bulimia and older patients when appropriate.
Cognitive Behavioral Therapy (CBT)
Article: "What is CBT ?" from the US National Association of Cognitive-Behavioral Therapists
Cognitive behavioral therapy focuses on changing the thoughts and behaviors surrounding the eating disorder. Through the use of specific techniques, therapists work individually with the patient to explore maladaptive thoughts and beliefs as well as the eating disorder behaviors that are driven by the thoughts. Sessions are meant to be focused on results rather than insight, deal with the present and not the past, and to be short-term (6-12 months). CBT is a well-established treatment approach for other illnesses, like depression, anxiety disorders and obsessive compulsive disorders.
The Treatment Team
F.E.A.S.T. Resource Link: Licenses and Certifications
Depending on the treatment approach, a patient may see only one clinician or a multi-disciplinary team of clinicians. While it is ideal to work with a clinic with teams in place, the parent often is responsible for compiling a treatment team. When more than one clinician is involved, all team members should be given legal permission to communicate. One clinician, or the parent, will coordinate information and communication for the team.
It is important that:
- all patients should be monitored by a medical doctor during the recovery process,
- the team include specialists in the physiology and psychology of eating disorders as generalist clinicians receive little to no training in eating disorders and can not be expected to have updated training in this fast-changing specialty,
- due to the nature of the illness, many families and clinicians avoid having the patient be in charge of communication between team members or with the family.
Some of the possible roles on your loved one's treatment team:
- Primary care physician: to monitor medical issues and recovery goals set by a specialist in ED care
- Physician specialized in eating disorder recovery: to oversee and set recovery goals with special attention to medical issues of malnutrition, refeeding, activity, and purging
- Eating disorder therapist: a psychologist, psychotherapist, social worker, or psychiatrist specifically trained in the treatment of eating disorders who will see the patient or whole family in therapy sessions
- Nutritionist: an eating disorder specialist who monitors and educates patient and/or family in nutrition and meal planning specifically for eating disorder recovery
- Psychiatrist: board certified child and adolescent psychiatrist specializing in eating disorder recovery
F.E.A.S.T. Print Resource: "Port in a Storm: How to Choose a Treatment Team for a Loved One with an Eating Disorder in the U.S."
F.E.A.S.T. Resource Link: Other Treatment Approaches