The Endowment for the Advancement of Psychotherapy

Eating Disorders Module

What are eating disorders?

There are three eating disorders included within this diagnostic grouping: bulimia nervosa, anorexia nervosa, and binge eating disorder, all characterized by a severe disturbance in weight regulation and eating behavior. People with eating disorders typically become preoccupied by their body appearance and food intake which leads to significant psychological, physical, and/or social consequences. In the United states, approximately 20 million women and 10 million men will suffer from an eating disorder in their lifetime.1 Not only do eating disorders impact a large number of people, the number of those suffering from an eating disorder has been increasing since 1950.2 Also of concern, preoccupation with body image develops at an early age with 40-60% of elementary school girls age 6-12 being concerned about their weight or being obese.3 Those with eating disorders often suffer from other co-occurring mental disorders including depression and alcohol use disorders.5

 

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Not only do eating disorders have a significant impact on one’s psychological health, they also have a large impact on physical health. Health problems associated with eating disorders can include life-threatening heart arrhythmias, osteoporosis, muscle loss, kidney failure, tooth decay, and rupturing of the gastrointestinal tract. These health problems may help to explain why anorexia nervosa has the highest mortality rate of any psychiatric disorder.4

What are the types of eating disorders?

Anorexia Nervosa

Anorexia nervosa is an eating disorder characterized by an intense preoccupation with weight and body image, with a simultaneous distorted sense of body-image or self-esteem. Persons with anorexia typically see themselves as overweight even when they may have an extremely low weight. As a means to lose weight, persons may restrict food intake, exercise excessively, self-induce vomiting, or misuse laxatives and diuretics. Other people may have episodes when they binge on large amounts of food with subsequent efforts to reduce their weight including vomiting or laxative use. As a result of extremely low weights, people may develop osteoporosis (unhealthy loss of bone density), fatal heart rhythms, muscle wasting, multi-organ failure, and loss of menstrual cycle. For some, anorexia nervosa develops at an early age with full remission of symptoms after one episode. For many others, fears of weight gain and distorted body image are lifelong and may require long-term treatment inpatient and outpatient.

Bulimia Nervosa

Bulimia nervosa is characterized by frequent episodes of eating very large amounts of food with a loss of control over food intake. People may feel they are unable to stop eating while they are in a binging episode and may eat thousands of calories at a time. Binge eating is followed by compensatory behavior to avoid gaining weight or having stomach pain such as self-induced vomiting, use of laxatives, or excessive exercise. As opposed to anorexia nervosa, people suffering from bulimia nervosa are typically normal weight, slightly underweight or slightly overweight. Given the lack of severe weight loss, people with bulimia may go unnoticed by those closest to them. Psychological distress includes feelings of self-condemnation and a disturbing feeling of loss of control. Physical symptoms are largely related to self-induced vomiting or diuretic use. Symptoms may include increased tooth decay, gastric reflux disorder, severe dehydration, and heart rhythm abnormalities that may lead to heart attack.

Binge-eating disorder

Similar to bulimia nervosa, binge-eating disorder is characterized by recurrent episodes of eating unusually large amounts of food with a lack of control over the amount of intake. However, after episodes of binging, people do not have compensatory behaviors to avoid weight gain or stomach pain. As a result, people suffering from binge-eating disorder may be overweight or obese. Physical problems related to binging are largely related to obesity and may include high blood pressure, high cholesterol, diabetes mellitus, or cardiac disease.

What does psychodynamic psychotherapy look like in the treatment of eating disorders?

The person with an eating disorder will meet with a psychotherapist at least once a week for at least several months because the need for enduring change requires sustained involvement and intensity with the process. During the development of the psychotherapy relationship, the person seeking help will be encouraged to speak openly about their eating disorder, past history of symptoms and past and current relationships. As opposed to other types of psychotherapy, psychodynamic psychotherapy focuses on the psychological origins amd meaning of maladaptive behaviors such as self-denial, restrictive eating, and binging. Often, behaviors characteristic of eating disorders represent an expression of how people cope with stresses of which they may be unaware. By understanding these types of behaviors, a person can develop new strategies to have more control over the behaviors in the future leading to an improvement in the eating disorder. Furthermore, for many people, eating disorders are chronic in nature and having a supportive therapist in long-term treatment may be especially helpful.

More generally, the treatment of eating disorders involves psychotherapy (individual, group, and/or family), nutritional counseling, psychiatric medications, and often medical care for complications from eating disorders. Adequate nutrition and weight, avoidance of binging or purging behaviors, and maintenance of medical stability are crucial in the treatment. For some people, eating disorders may become so severe they necessitate psychiatric or medical hospitalization. For many other patients, eating disorders can successfully be treated outside of the hospital.

Is psychodynamic psychotherapy effective in treating eating disorders?

In regards to the efficacy of psychodynamic psychotherapy, research largely supports the use of psychodynamic psychotherapy in the treatment of eating disorders. Clinical research for anorexia nervosa has shown that psychodynamic psychotherapy is efficacious. There have been several different high quality studies comparing psychodynamic psychotherapy to routine treatment and also to other different types of therapy including cognitive behavioral therapy. In one such study by Dare et al., psychodynamic psychotherapy was significantly more effective than routine treatment and there was no appreciable difference between cognitive analytic treatment and family therapy.6 In a study by Zipfel et al. from 2015, a similar analysis was conducted examining a 10 month course of psychodynamic psychotherapy compared to both cognitive behavioral therapy and routine treatment. Similar to the other studies, psychodynamic psychotherapy was found to be significantly more effective than treatment as usual and as effective as cognitive behavioral therapy (CBT).7 However, 12 months after the study treatment was completed, 35% of patients receiving psychodynamic psychotherapy were in recovery compared to 19% for CBT and 13% for routine care. Thus, the study found that psychodynamic psychotherapy may have better long-term effects than other treatments.

Research for bulimia nervosa has shown mixed results for the efficacy of psychodynamic psychotherapy compared to other types of treatments. In one relatively small study published by Bachar et al., psychodynamic psychotherapy was found to be more effective than nutritional counseling and cognitive therapy in patients with bulimia nervosa.8 However, these results were not supported by a later study in which CBT was found to be more effective than psychodynamic psychotherapy in binging and purging behaviors.9 It is important to keep in mind that while these studies show conflicting results in terms of which treatment is more effective, both treatments were found to be effective in the treatment of bulimia. Further research will help clarify which type of psychotherapy is more effective for which patients with the disorder. However, current research supports psychodynamic psychotherapy as an effective treatment for bulimia nervosa.

Limited research has been conducted for binge-eating disorder but available findings suggest psychodynamic psychotherapy as potentially efficacious. In one study, psychodynamic psychotherapy was effective in reducing days binged and interpersonal problems.10 The study also compared psychodynamic psychotherapy to cognitive behavioral therapy but results are limited in their interpretation given the small number of subjects. Current research does, however, support the efficacy of interpersonal psychotherapy, a variant of a psychodynamic approach as has been previously reviewed.11 Further research is needed to determine the efficacy of psychodynamic psychotherapy in the treatment of binge-eating disorder.

Citations:

  1. Wade, T, Keski-Rahkonen A, and Hudson J. Epidemiology of eating disorders. Textbook in Psychiatric Epidemiology (3rd ed.). 2011: 343-360.
  2. Hudson J, Hiripi E, Pope H, and Kessler R. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry. 2007; 61: 48-358.
  3. Smolak, L. Body image development in childhood. In T. Cash & L. Smolak (Eds.), Body Image: A Handbook of Science, Practice, and Prevention (2nd ed.). 2001.
  4. Arcelus, J, Mitchell, A, Wales, J, and Nielsen, S. (Mortality rates in patients with Anorexia Nervosa and other eating disorders. Archives of General Psychiatry. 2011; 68(7), 724-731.
  5. Harrop, E and Marlatt, G. The comorbidity of substance use disorders and eating disorders in women: prevalence, etiology, and treatment. Addictive Behaviors. 2010; 35: 392-398.
  6. Dare C, Eisler I, Russell G, et al. Psychological therapies for adults with anorexia nervosa: randomized controlled trial of out-patient treatments. British Journal of Psychiatry. 2001; 178:216-221.
  7. Zipfel S, Wild B, Gross G, et al. Focal psychodynamic therapy, cognitive behavioral therapy, and optimised treatment as usual in outpatients with anorexia nervosa (ANTOP study): randomized controlled trial. Lancet. 2014; 383(9912): 127-137.
  8. Bachar E, Latzer Y, Kreitler S, Berry EM. Empirical comparison of two psychological therapies. Self psychology and cognitive orientation in the treatment of anorexia and bulimia. J Psychother Pract Res. 1999; 8(2): 115-28.
  9. Poulsen S, Lunn S, Daniel SI, et al. A randomized controlled trial of psychoanalytic psychotherapy or cognitive behavioral therapy for bulimia nervosa. Am J Psychiatry. 2014; 171(1):109-116.
  10. Tasca GA, Ritchie K, Conrad G, Balfour L, et al. Attachments scales predict outcomes in a randomized clinical trial of group psychotherapy for binge eating disorder: an aptitude by treatment interaction. Psychother Res. 2006; 16: 106-121.
  11. Iacovino JM, Gredysa DM, Altman M, Wilfley DE. Psychological treatments of binge eating disorder. Current Psychiatry Rep. 2012; 14(4): 432-446.

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