Treatment Of Eating Disorders
Eating disorders are characterized by patterns of disturbances in eating behavior often accompanied by feelings of distress and/or concern about body weight or shape. Anorexia Nervosa (AN), Bulimia Nervosa (BN), Eating Disorders-Not Otherwise Specified (ED-NOS) are three categories by which eating disorders identified. The American Psychiatric Association (APA) (1994) first identified Binge Eating Disorder (BED) as a provisional eating disorder diagnosis in the DSM-IV. BED is often classified under the “catch all” of the ED-NOS diagnosis. The DSM-IV-TR (APA, 2000) criteria for AN, BN, and BED are listed in Table 1.
Eating disorders have often been noted as one of the most difficult psychiatric conditions to treat and have been associated with increased mortality and suicide rates (Crow et al., 2009). Other physical and psychosocial health consequences include but are not limited to limb and joint pain, headache, gastrointestinal problems, menstrual problems, shortness of breath, chest pain, anxiety, depressive symptoms, and substance abuse (Johnson, Spitzer, Williams, 2001). Despite numerous co-morbid conditions, effective behavioral and pharmacological treatments for eating disorders have been established. For example, family-based therapy (i.e., Maudsley Approach) is gaining recognition as an evidenced-based treatment for adolescents with AN (Wilson, Grilo, & Vitousek, 2007) in both joint family sessions (Lock, Agras, Bryson, & Kraemer, 2005) and in “separated” format where individual with AN and her family attend separate sessions (Eisler et al., 2000). Additionally, cognitive-behavior therapy (CBT; Hay, Bacaltchuk, & Stefano, 2009), dialectical-behavior therapy (DBT; Chen et al., 2008), and interpersonal therapy (IPT; Fairburn, 1997) have been successful in the treatment of BN. Research tends to support CBT as the treatment of choice for both BN and BED (Hay, Bacaltchuk, Stefano, 2004).
Table 1. DSM-IV-TR diagnostic criteria for AN, BN, BED.
- Refusal to maintain body weight at or above what is normal weight for age and height (i.e., > 85% of what is expected).
- Intense fear of gaining weight or becoming fat, even though underweight.
- Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.
- In postmenarcheal female, amenorrhea (i.e., absence of 3 consecutive menstrual cycles).
Specify Type: Restricting Type – During current episode of AN, individual does not regularly engage
in binge-eating or purging behavior.
Binge-Eating/Purging Type – During current episode of AN, the person has regularly engaged in binge-eating or purging behavior.
- Recurrent binge eating episodes. Characterized by: 1) eating, in a discrete period of time (e.g., within a 2-hour period), an amount of food that is larger than most would eat in a similar period of time under similar circumstances and 2) a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
- Recurrent purging/compensatory weight loss measures in order to prevent weight gain.
- Binge eating and purging/compensatory behaviors present at least 2 times a week for 3 months.
- Self-image unjustifiably influenced by body weight and shape.
- Absence of Anorexia Nervosa.
Specify Type: Purging Type – During current episode of BN, the individual has engaged in
self-induced vomiting or the misuse of laxatives, diuretics, or enemas.
Nonpurging Type – During the current episode of BN, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.
Binge Eating Disorder
- Recurring binge eating episodes. Characterized by: 1) eating, in a discrete period of time (e.g., within a 2-hour period), an amount of food that is larger than most would eat in a similar period of time under similar circumstances and 2) a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
- The binge-eating episodes are associated with 3 or more of the following: 1) eating more rapidly than normal, 2) eating until feeling uncomfortably full, 3) eating large amounts of food when not physically hungry, 4) eating alone because of being embarrassed by how much one is eating, 5) feeling disgusted with oneself, depressed, or very guilty after overeating.
- Marked distress surrounding binge eating.
- The binge eating occurs, on average, at least 2 days a week for 6 months.
- The binge eating is not associated with the regular use of inappropriate compensatory behaviors (e.g., purging, fasting, excessive exercise) and does not occur exclusively during the course of ANor BN.
Pharmacological treatments have been used in conjunction with behavioral treatment or alone (Zhu & Walsh, 2002) in the . Research supports pharmacological treatment for individuals with BN and BED (Bacaltchuck, 2000). Specifically, antidepressants have been found to have short-term benefit in the reduction of binging and purging behaviors (Walsh et al, 2000; McElroy et al, 2003). Unfortunately, pharmacological treatment tends to have high noncompliance rates and relapse is often frequent (Becker, 2003). Currently, there is no empirical support for the use of antidepressants among individuals with AN (Wilson, Grilo, Vitousek, 2007). Behavioral and pharmacological treatments are most often used in combination with another in treating eating disorders due to numerous co-morbid conditions.
Unfortunately, the aforementioned behavioral treatments have a number of limitations when delivered outside a specialty setting (e.g., outpatient mental health clinic, inpatient eating disorder center). For example, the delivery of family-based therapy for AN requires 10-20 hour- long family sessions over a 6-12 month period (Lock, le Grange, Agras, & Dare, 2001), and manualized CBT for BN requires 15-20 sessions over five months (Fairburn, 1989; 1993). Treatments for AN and BN are not only lengthy and costly, but eating disorder specialty providers are limited, and individuals with eating disorders are often resistant to specialty care (Fairburn & Carter, 1996). Additionally, only a small portion of individuals with eating disorders are treated in mental healthcare (Hoek & van Hoeken, 2003), and are more likely to present with eating disordered symptoms in a primary care setting (Hoek, 2006). While primary care physicians often recommend specialty treatment on claim forms, there is little follow- through with referrals (Hach et al., 2005; 2003). Thus, the primary care setting is often the main treatment facility for those with a lifetime eating disorder diagnosis (Hudson, Hiripi, Pope, & Kessler, 2007). Due to the fast-paced nature of a primary care setting, treatments need to be brief, cost-effective, and feasible in application for existing staff. Therefore, development and identification of brief, effective interventions for eating disorders are necessary.
A number of studies have tested the efficacy of specific brief interventions for AN, BN, and BED outside of primary care environment. Fichter, Cebulla, Quadflieg, & Naab (2008) implemented a self-help component (i.e., self-help CBT manual) to the pretreatment phase of specialty care for individuals with AN yielding significantly shorter inpatient care. For treatment of individuals with BN and BED, a stepped-care approach has gained support (Laessle, 1991; Treasure, 1996; Carter, 1998). This approach may fit well with the structure of primary care, since individuals with BN are offered brief interventions and then reevaluated. Brief interventions for BN are frequently in the form of abridged CBT often accompanied by a self-help component (Treasure, 1996; Cooper, Coker, & Fleming, 1994). A number of self-help CBT books have been published aimed at helping individuals with binging and purging (e.g., Cooper, 1995; Fairburn, 1995). Brief implementation of CBT (Leonard et al., 1997), self-help CBT (Sysko & Walsh, 2008), telephone guidance (Palmer, Birchall, McGrain, & Sullivan, 2002), internet delivery (Pretorius et al, 2009), and motivational enhancement (Schmidt, 1997; Vitousek, 1998) are all examples of promising brief interventions explored for the treatment of binging and purging symptoms. While primary care has been identified as an ideal setting for treating BN and BED, few effectiveness studies employing brief interventions for eating disordered symptoms have been conducted in the primary care setting.
A number of eating disorder treatment guidelines for primary care providers have been published (e.g., Carter & Fairburn, 1995; Gurney & Halmi, 2001; Pritts & Susman, 2003; Williams, Goodie, Motsinger, 2008). However, there is limited information about the effectiveness or implications of behavioral interventions for eating disorders delivered in the primary care setting. Thus, the aims of the current study are to 1) identify all studies delivering a behavioral component for AN, BN or BED in a primary care setting, 2) examine the characteristics and treatment outcomes of studies identified, and 3) provide treatment implications as well as directions for future research.
The review of the literature involved multiple computer searches and review of previous review papers as well as studies cited within these papers. Search databases included CINAHL, EMBASE, PsycARTICLES, PsychInfo, and PubMed using the search terms “bulimia nervosa” OR “binge eating disorder” OR “anorexia nervosa” AND “primary care.” Figure 1 outlines the literature search and shows 314 abstracts of articles reviewed for inclusion as well as references cited in five eating disorder treatment review papers (i.e., Berkman et al., 2006; Hay, Bacaltchuk, Stefano, & Kashyap, 2009; Kondo & Sokol, 2006; Williams, Goodie, & Motsinger, 2008; Wilson, Grilo, & Vitousek, 2007). If insufficient information was provided in an abstract the first author obtained the full article for review.
Inclusion and Exclusion Criteria
Primary care-based intervention studies targeting AN, BN, and BED, were identified based on the following inclusion and exclusion criteria. Inclusion criteria included: 1) the study incorporated a behavioral component to the intervention for individuals with AN, BN, or BED; 2) the intervention was conducted in a primary care setting (or the intervention was implemented in a setting explicitly intended to emulate primary care, as stated in the study’s “methods section”); 3) the study was a) published in 2009 or earlier, b) in English, c) and included empirical data; thus, qualitative and case studies were excluded. Exclusion criteria included: 1) interventions in settings other than primary care setting (or not explicitly stating an intent to simulate a primary care setting); 2) non-intervention studies (e.g., studies conducted in primary care with goals of obtaining epidemiological data); 3) intervention studies focusing on weight loss or including an obesity-oriented approach; 4) non-behavioral interventions (i.e., solely medicinal interventions). International and domestic studies were included in this review. Given the limited literature, studies were not excluded on the basis of whether or not participants were randomized to treatment, type of behavioral intervention, sample size, duration of treatment, or participant characteristics (e.g., gender). A total of five studies met criteria for the current review. All studies included were on the treatment of BN and BED. No studies were found on AN.
Characteristics of the Studies Reviewed
Of the five studies that met inclusion criteria, four of the studies were randomized (i.e., Banasiak, Paxton, Hay, 2005; Carter and Fairburn, 1998; Durand and King, 2003; Walsh et al., 2004). Among randomized studies, none of the studies fulfilled all of the criteria of the Consolidated Standards of Reporting Trials (CONSORT), a standard and minimum set of guidelines for reporting randomized-controlled trials. All studies included were self-described as effectiveness studies. Thus, feasibility of intervention was paramount to the study. Only two of the five studies recruited participants in the primary care setting (Durand & King, 2003; Waller et al., 1996). The number of participants in the five studies ranged from 11 to 109 (M = 70.2, SD = 36.9). Primary care providers (PCPs) were the sole provider of the behavioral intervention in two of the five studies (i.e., Banasiak et al., 2005; Durand & King, 2003), and PCPs delivered behavioral interventions in conjunction with nurses in two other of the five studies (i.e., Waller et al., 1996; Walsh et al., 2004). Minimally trained facilitators (i.e., former ballet dancer, medical secretary, and group leader) delivered the behavioral intervention in the one study (Carter & Fairburn, 1998). Three of the five studies provided at least 2-6 hours of training for physicians and/or nurses carrying out the intervention (i.e., Banasiak, Paxton, Hay, 2005; Waller et al., 1994; Walsh et al., 2004). Two of the studies did not provide separate training for those carrying out the intervention, but rather gave facilitators the same educational materials distributed to the participants (i.e., Carter & Fairburn, 1998; Durand & King, 2003). One study incorporated both behavioral and pharmacological treatment approaches (Walsh et al., 2004). See Table 2 for additional study characteristics.
Overall, this current review identified two principal approaches to treating BN and BED in primary care. The first was for practitioners to provide behavioral counseling themselves, with an augmentation (i.e., self-help manual). The second option used a collaborative approach in which a non-physician (e.g., nurse) served as the primary treatment provider with the physician in a supporting role with or without an augmentation (i.e., self-help manual, psychopharmacological medication). A PCP was the sole provider of the intervention in two studies (Banasiak et al., 2005; Durand & King, 2003) and a non-physician (i.e., nurse) in two studies (Waller et al., 1996; Walsh et al., 2004). A fifth study used facilitators (i.e., ballet dancer, medical secretary, and a group leader) to emulate primary care providers (Carter and Fairburn, 1998).
Guided Self-help versus Pure Self-help
Among all studies examined, four studies implemented cognitive behavioral self-help in the intervention and incorporated the use of a self-help manual (i.e., Banasiak, Paxton, Hay, 2005; Carter and Fairburn, 1998; Durand and King, 2003; Walsh et al., 2004). Overcoming Binge Eating (Fairburn, 1995), Bulimia Nervosa and Binge-Eating: A Guide to Recovery (Cooper, 1995), and Bulimia Nervosa: A Guide to Recovery (Cooper, 1993) were the three manuals used. The addition of the self-help manual came in two forms: 1) guided self-help and 2) pure self-help. Guided self-help practice included a physician or other provider ‘guiding’ and directing the participants through the manual during scheduled visits and assigning specific reading in the manual to the participant. Pure self-help involved the provider supplying a manual to the participant and the instructions to read the manual over the course of the intervention.
Three of the four studies using self-help found self-help methods to be beneficial in alleviating binge eating episodes (Banasiak, Paxton, & Hay, 2005; Carter & Fairburn, 1998; Durand & King, 2003). One study comparing guided self-help and fluoxetine found no benefits of guided self-help used alone or used in conjunction with the medication (Walsh et al., 2004). However, medicinal benefits of decreasing bulimic symptoms were significant. These results should be interpreted with caution, since this study yielded a 69% attrition rate. Another study comparing the benefits of guided self-help, pure self-help, and wait-list control found those who received guided self-help and pure-self help to have significantly fewer binge-eating episodes at post treatment and three month follow-up (Carter & Fairburn, 1998). While no significant differences were obtained between guided self-help and pure self-help treatment groups at the end of treatment, the guided self-help group attained significance over the pure self-help group across post-treatment time points (i.e., 3 months and 6 months) (Carter & Fairburn, 1998). Waller et al. (1996) was the only study not employing a self-help component, but rather an abridged CBT treatment. This treatment yielded a 55% improvement rate in bulimic symptoms. See Table 3 for outcome data on each study.
Individuals with eating disorders have some of the highest mortality rates of all psychiatric conditions (Crow et al, 2008) coupled with high physical and psychological co-morbid conditions. Because of these co-morbid conditions, individuals with eating disorders are likely to present in primary care setting with co-morbid complaints (CITE). PCPs and staff are in a unique position to provide early detection and treatment. Due to time constraints, primary care providers often lack the experience and training to implement interventions for individuals with eating disorders. Thus, brief, evidenced-based interventions with minimal required training are paramount to the adoption and dissemination of eating disorder treatment.
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Results of this review expose the limited amount of research that has been conducted on the treatment of AN, BN, and BED in a primary care setting. The current review identified five studies – four on BN, one on BED, and no studies were found on the treatment of AN in a primary care setting. Of the five studies that met criteria for inclusion, four were randomized-controlled trials (RCTs), which are frequently recognized as the gold standard in efficacy research. Among the RCTs, none of the studies fulfilled all of the suggested CONSORT standards.
Four of the five studies reviewed implemented CBT self-help in the form of a manual with educational components targeting binging and purging behaviors. Three of the four studies using self-help treatment found the treatment to be beneficial (i.e., Banasiak, Paxton, & Hay, 2005; Carter & Fairburn, 1998; Durand & King, 2003). Thus, self-help treatment may be a beneficial treatment for some patients presenting in primary care. Among studies reporting benefits, guided self-help proved to be more beneficial than pure self-help; however, pure self-help was still found to have benefit (Carter & Fairburn, 1998). In a setting comparison study, guided self-help CBT treatment was deemed as effective as specialty clinic treatment (Durand & King, 2003).
Effectiveness and Feasibility
While all studies were conducted in a primary care setting or in a setting that explicitly simulated a primary care setting, only two studies recruited participants from this setting (Durand & King, 2003; Waller et al. 1996). The recruitment context may limit the effectiveness of the treatments examined given reports of individuals presenting in primary care exhibit higher rates of somatization, mental illness, and chronic conditions (Jyvasjarvi et al., 2001; Toft et al., 2005). Also, given this study was an international review, primary care settings differ across national health care systems; therefore, not only may community samples differ from primary care samples, but primary care samples may differ from country to country (Bailer et al., 2004).
Similarly, PCPs in different countries may have varying time constraints with regards to training and treatment delivery. However, minimal training and delivery efficiency are important characteristics for PCPs (CITE). In this review, two studies required less than an hour of training for the primary care providers delivering the intervention (Durand & King, 2003; Carter & Fairburn, 1998). Given PCPs time restraints, training requiring more than an hour may not be feasible for the typical provider. Another limitation to generalizing treatment to the primary care setting is the duration of treatment in the studies examined. Duration of intervention ranged from 5-10 visits at 20-30 minutes per visit. The length of treatment could explain the high rates of attrition (i.e., 12-69%) found in the studies reviewed. However, Waller et al. (1996) noted the indicated treatment may not take as long as the prescribed treatment, since participants dropping out prior to completion of treatment still benefitted. The long-term effects and relapse rates of brief intervention treatments in this setting is unknown, since the none of the studies collected follow-up data six months post treatment.
Implications for Practice
Brief methods interventions may only be effective for a subset of patients with bulimia nervosa and binge eating tendencies. Most studies reviewed excluded participants with co-morbid disorders. Thus, findings may not be generalizable to the typical primary care population. Identifying the subset of individuals in which brief interventions will be most effective remains challenging. While evidenced-based, brief interventions are considered the first line of treatment for individuals presenting in primary care (NICE, 2004), it is unclear how patients failing to respond to these interventions should be treated. Given the absence of data on treatment of anorexia nervosa in primary care, a stepped-care approach is merely speculative.
PCPs electing not to provide behavioral treatment to patients with BN or binge eating must still play a crucial role in assessing and treating the physical symptomatology of eating disorders. With the emergence of integrated care, psychologists and mental health providers are becoming more present in the primary care setting. Thus, individuals with BN and binge eating tendencies may be treated holistically in the primary care setting.
Directions for Future Research
While numerous methods in the delivery of evidenced-based interventions are currently being studied, very few studies have actually implemented BN or binge eating interventions in the primary care setting. A stepped- care approach poses methodological challeng es for clinical research and raises a number of clinical issues. Future research should focus on honing self-help CBT treatment in the primary care setting and including participants with co-morbid characteristics. Expanding delivery of treatment beyond primary care physicians to other providers, such as nurses, nutritionists, social workers, and staff workers, may allow for more tailored treatment for the individual presenting with eating disordered behavior.
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