To what extent are psychological interventions for eating disorders effective?

Eating disorders, which are defined as pathological disturbance of behaviours and attitudes related to food, continue to be a significant problem affecting a significant proportion of children and adolescents. The prevalence of these disorders is on the rise and has led to crucial problems, especially because of the associated comorbidities (Gorla and Mathews, 2005) For instance, it has been estimated that more than 3.3 million lives are lost yearly to an eating disorder-related disability (Hoeken and Hoek, 2020). In consideration of these issues, eating disorders have been the focus of the attention of clinicians and researchers (Rikani, et al., 2013). Firstly, I will briefly underline the characteristics and prevalence of Bulimia Nervosa (BN) and Anorexia Nervosa (AN), then consider their impact and the treatment strategies that can be used to deal with these disorders. AN and BN are specifically chosen because they are the most prevalent eating disorders and have the highest mortality rate (Hoeken and Hoek, 2020). The essay will end with a brief summary, pointing to areas of further research.

Bulimia nervosa and anorexia nervosa make up to be the most prevalent type of disorders (DSM-IV). BN is characterised by reoccurring episodes of eating a vast amount of food, accompanied by a loss of control and inappropriate compensatory behaviours and an over-evaluation of shape and weight (American psychological association, 2013). On the other hand, AN is characterised by weight loss, distorted body image and a fear of weight gain (American psychiatric association, 2013). More than 4% of women and 0.3% of men are afflicted with anorexia nervosa, and in the case of Bulimia nervosa, up to 3%of the females and 1% of the males (Eeden et al., 2021). The rates of both disorders are higher in females when compared to males (Hudson et al., 2007); however, men’s reluctance to participate in the studies or to be diagnosed with an eating disorder are a significant challenge when estimating the prevalence of eating disorder; consequently, there is a possibility of the rate of eating disorder being higher in men then is reported.

In consideration of this significant prevalence, it is important to consider the impact of these disorders. It has been suggested that Anorexia Nervosa has the highest mortality rate when compared with other eating disorders. It has been estimated that the weighted annual mortality rate for anorexia nervosa was 5.10 deaths per 1000 person-years (Arcleus, et al., 2011). Furthermore, it has been found that Bulimia nervosa has a crude mortality rate of 2.0% (Birmingham et al., 2005). This mortality rate is explained in light of the psychiatric and medical co-morbidity that accompanies these eating disorders. A wide range of medical complications like anaemia, cardiovascular diseases, and endocrine system dysfunction accompany these disorders (Dalle-Grave et al., 2007. Along with these medical complications various psychological comorbidities such as anxiety disorders, substance abuse, obsessive-compulsive disorders, depression and personality disorders are found in people suffering from eating disorders. A meta-analysis of 42 studies found these co-morbidities to make the second most common cause of death in eating disorders (Sullivan, 2002). In consideration of these impacts, it is important to consider what psychological treatments can help in treating these disorders.

Firstly, the essay will consider the treatment strategies for AN. Enhanced Cognitive behavioural therapy has shown to be an effective and promising treatment option for adults with AN (Grave et al., 2016). Its efficacy has been further shown in randomised control trials (Byrne, 2017) and cohort studies (Fairburn, 2013). Frostad et al., (2018), also demonstrated that patients who completed CBT-E (enhanced cognitive behavioural therapy) showed a significant increase in BMI after 1 year of the start of the therapy; however, it should be noted that half the participants who started the treatment ended it prematurely and did not show recovery at the same level as those who completed it. This problem of a high number of non-completers has shown itself across various studies (Byrne et al., 2011; Fairburn et al., 2013) (Frostad et al., 2018).

The aforementioned studies indicate that patients do improve with treatments; however, in these treatments, there is a significant dropout and therefore a subset of participants remain symptomatic. This suggests a need for a treatment that addresses this dropout and leads to an increase in treatment remission. Cognitive Remediation therapy (CRT) is a treatment that addresses the impaired cognition that may contribute to the persistence of AN; This could play a significant role in reducing the dropout from treatment and improving engagement in the treatment leading to a better outcome (Tchanturia, et al., 2013). CRT has been found to lead to significant changes in cognitive styles related to set-shifting and central coherence, however, the long-term duration of the effect remains doubtful for patients suffering from AN (Lock et al., 2013). It should be noted, however, that the treatment literature has focused mostly on a small case series (Tchanturia, et al., 2013; Abbate-Daga, et al., 2010) and further studies of CRT with adequate power are required to establish its effectiveness (Lock et al., 2013).

In addition to CRT, another therapy that deals with the crucial problem of dropouts in anorexia nervosa is the Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA). MANTRA’s efficacy has been shown in various studies, which show a stable and significant BMI and ED psychopathology of the patients, furthermore, it also shows low drop-out and high acceptability rates (Schmidt et al., 2015; Schmidt et al., 2016). However, there is a lack of clarity on whether the low dropout rates and high acceptability seen in adult patients can be transferred to adolescents with AN. Wittek et al., (2021), suggested the effectiveness of MANTRA for adolescents suffering from AN; While the findings are important, there is an absence of randomisation in the study. Further research is pertinent to extend the effectiveness of MANTRA to adolescents.

The crucial need for psychological therapy is also pointed out by the inefficacy of medicines. Overall, none of the medicines available has proven to be effective on their own in the treatment of AN (Gorla and Mathews, 2005). The inefficacy of pharmaceuticals in dealing primarily with AN is reflected in APA guidelines that state psychotropic medications should not be used as the primary treatment for Anorexia Nervosa (APA, 1993) (Gorla and Mathews, 2005).

Generally, psychological treatments have proven to be effective in treating AN. In the next part of the essay, we will consider the treatment strategies for Bulimia Nervosa. First, we will consider psychological treatments that have proved effective in treating Bulimia Nervosa. Substantial support for CBT as the leading approach treatment for BN has been demonstrated in various studies (Agras, et al., 2000; National Institute of Clinical Excellence, 2004). Furthermore, the National Institute of Clinical Excellence, (2004), recommends CBT-BN be offered for 16-10 sessions over a period of four to five months, and recommends Interpersonal psychotherapy (IPT) as an alternate treatment, but suggests that IPT takes eight to 12 months to achieve a result comparable with CBT. Schmidt et al., (2007) demonstrated CBT-guided self-care to be more effective in achieving abstinence from binge eating than Maudsley model of treatment for AN; however, at a follow up this advantage was not maintained. Furthermore, the impact of purging did not vary by treatment (Schmidt et al., 2007).

Overall, studies show CBT to be an effective therapy for Bulimia nervosa. Another therapy that studies have supported is psychodynamic therapy (Poulsen et al., 2014; Garnet et al., 1993). Poulsen et al., (2014), found a substantial effect on general psychopathology and global eating disorder psychopathology; however, when compared to CBT these improvements were slower in the psychoanalytical treatment, and overall CBT emerged as more efficacious than psychoanalytical therapy (Poulsen et al., 2014). The effectiveness of Psychodynamic theory was also found by Stefini et al., (2017), however, the study reported no significant difference between the effect of CBT and psychodynamic therapy.

Overall CBT appears to be effective for both AN and BN. In addition to AN and BN .CBT has shown promising results for binge eating disorders also. CBT has been shown to be effective at 1 and 2-year follow-ups. Hibert et al., (2012), further extended these findings by evaluating 5-year outcomes, and still finding CBT effective. Similar results were shown for Interpersonal psychotherapy (IPT), also (Kass et al., 2014).

In summary, the research literature indicates that there are effective treatments for eating disorders. In the case of Anorexia nervosa psychological therapies like CBT, CRT, and MANTRA show a significant effect. However, It remains unclear as to which approach is superior. Furthermore, there is still no clear evidence for the effects of pharmaceuticals in dealing with anorexia. In the case of Bulimia nervosa, there is substantial support for CBT an psychodynamic therapy in dealing with the disorder. Despite these positive effects, there is a further need to hone these psychological treatments, especially in consideration of long-term outcomes and the identification of treatments for patients who remain symptomatic.