Highlights of the 2012 APA Guideline Watch for Eating Disorders

Updating significant practice
changes since 2006

An American Psychiatric Association (APA) expert work group recently released a Guideline Watch for treatment of patients with anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). This “Guideline Watch” is not the equivalent of a new practice guideline, since it did not go through the rigorous methodological processes necessary to create a formal guideline. Instead, the Guideline Watch (July 2012): Practice Guideline for the Treatment of Patients with Eating Disorders, 3rd edition, summarizes and updates significant developments in practice since publication of the 2006 guideline and assesses the extent to which the 2006 guideline’s recommendations still hold up.

The work group also addressed eating disorders that emerge later in life. The six-member work group, which included Dr. Joel Yager and four members of EDR’s Editorial Advisory Board (Drs. Jim Mitchell, Mike Devlin, Pauline Powers, and Kathryn Zerbe) rigorously reviewed the available evidence, which then was peer-reviewed before being formally approved by the APA Assembly and Board of Trustees. (The entire guideline watch can be accessed here.

Changes to the DSM-5

The new Diagnostic and Statistical Manual of Mental Disorders, 5th edition, or DSM-5, to be released in May, will contain revised diagnostic criteria for AN, BN, and eating disorders not otherwise specified (EDNOS). The expert work group noted that the diagnostic changes for eating disorders to appear in the DSM-5 are not likely to affect the 2006 practice guideline’s recommendations. The guideline recommends, for example, that patients with subsyndromal AN or BN should receive treatment similar to that of patients who fulfill all criteria for these diagnoses.

ANOREXIA NERVOSA

Treatment

The quality of evidence for treatments for AN remains limited, according to recent systematic reviews and meta-analyses (e.g., Fitzpatrick and Lock 2011; Hartmann et al. 2011). Few randomized, controlled trials exist, and available studies suffer from small sample sizes, short durations, and methodological problems. Another difficulty is that study recruitment is generally poor and dropout rates are high. For example, in a study of two clinical trials for AN, Halmi and colleagues (2005) reported a 46% dropout rate. The only predictor of treatment acceptance was high self-esteem. Also, the available studies are primarily about symptom relief rather than recovery (Strober and Johnson, 2012).

Predictors of recovery remain poorly defined. Using a literature search that evaluated 12 randomized controlled trials, Crane and colleagues (2007) found that obsessive-compulsive personality was linked to poorer outcome.

Choice of treatment setting. The guideline states that it is important to consider a patient’s overall physical condition, psychological status, behaviors, and social circumstances when choosing a treatment setting. Although investigators have attempted to study the advantages of specific settings, conclusions from available research are limited because there are many local variations in the essential features of treatment settings.

In a large multicenter, randomized, controlled trial conducted in the United Kingdom, the Trial of Outcomes for Child and Adolescent Anorexia Nervosa (TOuCAN) study, Gowers and colleagues (2007) randomly assigned 167 adolescent patients with AN to specialist inpatient, specialist outpatient treatment, or routine general outpatient treatment. Improvement on outcome measures was good across all treatment groups, but full recovery rates were poor, only 33% after 2 years. Adherence was lowest in the inpatient treatment group (50%), compared with 71% for the routine outpatient group and 77% for the specialist outpatient group. Inpatient treatment predicted poor outcome (either when patients were initially randomly assigned or after they were transferred from outpatient care). Patients who did not respond to outpatient treatment did very poorly. The authors concluded that first-line inpatient treatment does not necessarily provide advantages over outpatient management, and that patients who do not respond to outpatient treatment do poorly when transferred to inpatient facilities. This may, of course, reflect the level of severity of patients transferred to inpatient care in the United Kingdom.

Nutritional Rehabilitation

For underweight patients with AN, clinicians should consider hospital-based programs for nutritional rehabilitation. For patients who refuse to eat and who require lifesaving nutrition, the guideline recommends that nasogastric feeding be considered. In one study (Rigaud et al, 2007), malnourished AN patients were randomly assigned to a tube-feeding group or to a control group. After 2 months, weight gain was 39% higher in the tube-feeding group, binge eating episodes were deceased, and most patients felt the intervention improved their eating disorder. After discharge those treated with tube feeding had a longer relapse-free period than did the control group. In the second study in 2011, again conducted by Riguad and colleagues, adult patients with AN or BN were randomly assigned to 2 months of cognitive-behavioral therapy (CBT) alone or CBT plus tube feeding. By the end of treatment those who received CBT plus tube feeding were more rapidly and frequently abstinent from binge eating and purging, had greater improvement in depression and anxiety, and had a better overall quality of life. The Watch does, however, point out that nasogastric feeding can be harmful and thus does not specifically recommend it for normal-weight patients.

Psychosocial Interventions

Once malnutrition has been corrected and patients begin regaining weight, psychotherapy can be helpful. The work group based their recommendations on a strong consensus but weak evidence because research on psychotherapy of AN remains limited.

The group assessed the following interventions: mindfulness training, CBT, spiritually focused group therapy, eye movement desensitization and reprocessing (EMDR), yoga, and body awareness therapy. Although available data support the value of most of these interventions (Walden-Berghe et al, 2011), many of these studies have significant limitations.

The work group noted that in actual practice clinicians who treat patients with eating disorders use a wide array of psychosocial interventions. When Tobin and colleagues (2007) asked 265 clinicians about the treatments they use for AN patients, 6% reported adhering closely to treatment manuals, and 98% indicated they use both behavioral and dynamically informed interventions.

Family Therapy

The 2012 practice guideline strongly recommends family treatment for children and teens with eating disorders, and suggests that family assessment and involvement may be useful for older patients as well (see later section on eating disorders later in life). Study results continue to provide support for the value of family therapy, but the overall quality of evidence remains poor, according to the task force.

Pharmacotherapy and Somatic Treatment

The new Practice Guideline describes limited evidence for the use of medication to restore weight, to prevent relapse, or to treat chronic AN. The evidence that antipsychotic medications are effective is now backed by results from randomized controlled trials, but studies have shown mixed results, methodological limitations, and often these studies involve small numbers of patients. These medications also come with serious potential side effects.

McKnight and Park (2011) reviewed 4 randomized controlled trials and 5 open-label trials, and found limited evidence that olanzapine, quetiapine and risperidone have positive effects on depression, anxiety, and core eating pathology. In addition, there is not enough evidence of the effects on weight gain. Zinc supplements may be helpful for weight restoration, although no specific hormone or vitamin supplements have been shown to be helpful for weight restoration, according to the Task Force on Eating Disorders of the World Federation of Societies of Biological Psychiatry (Aigner et al., 2011).

Estrogen preparations have shown uncertain benefits for amenorrhea associated with AN, and thus should be avoided in these patients, according to Sim and colleagues (2010). Misra et al. (2011) suggested that physiologic estradiol replacement is useful in 13- to 18-year-old girls with AN and low bone density.

The practice guideline states that the limited available evidence on the use of antidepressants for weight gain suggests they confer no benefit. This was supported by a Cochrane review by Claudino et al. (2006). Also in 2006, Walsh and colleagues found that adding fluoxetine to CBT after weight restoration in patients with AN was no better than placebo and CBT. The best predictors of weight maintenance after discharge were the level of weight restoration at the conclusion of acute treatment and the avoidance of weight loss immediately after intensive treatment (Kaplan et al., 2009).

Osteopenia and Osteoporosis

The current guideline recommends weight gain through nutritional rehabilitation with sufficient intake of dietary protein, carbohydrates, fats, calcium, and vitamin D. It does not recommend using bisphosphonates such as alendronate. Golden and colleagues found that while alendronate increased bone mineral density of the lumbar spine and femoral neck at 1 year, body weight was the most important determinant of bone mineral density (Adolescc Med. 2003; 14:97). Further studies are needed to test the efficacy of and long-term safety of alendronate, risedronate, and other bisphosphonates.

BULIMIA NERVOSA

As in the case of treatment for AN, studies about treatment for BN have been short and have focused on symptom relief rather than recovery, according to the task force. As described by McIntosh and colleagues (2011), a substantial proportion of BN patients remain unwell.

Best Treatment Setting

The practice guideline recommends outpatient treatment for most patients with BN, except in the case of serious medical problems, or when patients are suicidal, or psychotic, or when they have severe disabling symptoms that do not respond to outpatient treatment.

In a Korean Study (Kong, 2004), patients assigned to a day treatment group showed improvements in body mass index (BMI) and binge eating and purging as well as improved scores on the Eating Disorder Inventory-2, the Beck Depression Inventory, and the Rosenberg Self-Esteem Scale.

Nutritional Rehabilitation

Similar to the guideline recommendations for AN patients, the 2012 Watch notes that normalization of nutrition and eating habits is a central goal in the treatment of patients with BN. A study by Burton and Stice (2006) suggests that healthy dieting and modest weight loss may not be incompatible with this goal. In this study, 85 women with full and subthreshold BN were randomly assigned to a 6-session healthy dieting intervention or to a wait-list control condition. At 3-month follow-up, the intervention group had modest weight losses and significant and persistent improvement in bulimic symptoms. These preliminary findings suggest that, contrary to popular belief, controlled dieting behaviors do not necessarily maintain BN.

Psychosocial Rehabilitation

The guideline recommends CBT as the most effective and best-studied intervention for patients with BN, and interpersonal therapy (IPT) is recommended for those who do not respond to CBT. In an evaluation of the results of 48 studies that included 3,054 participants, both CBT and manualized CBT designed specifically for patients with BN were effective (Hay et al., 2009). Other psychotherapies, especially long-term IPT, were also effective, and self-help approaches using highly structured CBT manuals were also promising.

Exposure and response prevention did not enhance the efficacy of CBT and the review found that psychotherapy alone is not likely to reduce or change body weight in people with BN or similar eating disorders.

Studies that examined the use of telemedicine and the Internet as means of administering therapy for BN showed that these are as effective as face-to-face sessions and were well accepted by patients. In a study of Internet-based CBT plus e-mail support, at 3- and 6-month follow-up, patients who received immediate treatment had better outcomes than those assigned to the wait list followed by treatment, suggesting the importance of providing services as soon as possible when problems are identified.

Self-Help Programs

A variety of self-help programs are effective for patients with BN. One such program is “guided self-help,” a CBT-based approach in which patients conduct much of the treatment on their own, using a workbook, while also receiving some counseling and support from a mental health professional. Several randomized controlled trials have shown the value of guided self-help and its superiority to wait-list control conditions. Traviss and colleagues (2011) found that guided self-help was significantly more effective than being on a waiting list in reducing psychopathology of eating disorders, laxative abuse, exercise behaviors, and global distress, and gains were maintained 3 and 6 months after the intervention.

In another study of a CBT-based self-care intervention delivered by CD-ROM, Schmidt and colleagues (2008) randomly assigned 97 patients either to intervention without support, followed by 3 months of a flexible number of therapist sessions, or to a 3-month wait-list condition followed by 15 sessions of therapist-delivered CBT. At 3 and 7 months post-treatment, the authors found no significant differences between the two groups in binge eating or vomiting frequency. However, it is hard to interpret this without knowing how many therapist sessions were used by the intervention group during the 3-month flexible treatment phase.

Family Therapy

Studies continue to demonstrate the value of family therapy for patients with BN, particularly for adolescents, but findings for BN are less strong than for adolescent patients with AN, and fewer studies have been done. Family-based treatment may be most effective in patients who have relatively low levels of binge-purge frequency (Le Grange et al. 2008).

Pharmacotherapy

As in the 2006 APA guideline, which recommended antidepressants for BN, especially selective serotonin reuptake inhibitors, there were few new recommendations. In a systematic review, Aigner and colleagues (2011) identified 36 randomized controlled trials of medications for the treatment of BN. Fluoxetine use is supported by Grade A evidence with a good benefit-risk ratio. Tricyclic antidepressants are supported by Grade A evidence, with a moderate risk-to-benefit ratio. Topiramate use is supported by Grade A evidence, but has a moderate risk-benefit ratio. Other agents, such as oxycarbazepine, baclofen, and aripiprazole, have been reported to be effective for BN patients, but most results have come from small case series or drug-manufacturer-sponsored studies.

Combining pharmacotherapy and psychotherapy. With moderate confidence, the practice guideline recommends a combination of antidepressant medication and CBT for BN. Mitchell and colleagues (2011) randomly assigned 293 patients with BN at four treatment centers to either: (1) 20 sessions of CBT alone over 18 weeks, with the addition of fluoxetine if non-response was predicted after six sessions, or to (2) stepped care that started with therapist-supervised self-help, followed by fluoxetine if no response was predicted after six sessions, which in turn was followed, if necessary, by CBT. At the end of treatment no differences were found between groups in inducing recovery (no binge eating or compensatory behaviors for 28 days) or remission (no longer meeting DSM-IV criteria). However, at the end of the 1-year follow-up, the stepped-care arm was significantly superior to the CBT arm in terms of reducing binge eating.

BINGE EATING DISORDER

Researchers studying treatments for binge eating disorder (BED) are usually limited by the fact that symptoms are highly changeable and placebo response rates can be high. Thus, any conclusions about effective treatment must be cautiously made.

Psychosocial Treatments

In the APA guideline, individual and group CBT were strongly recommended, along with guided self-help programs. The guideline also stated that IPT and dialectic behavior therapy (DBT) may also be considered.

An analysis of 38 randomized controlled trials using psychotherapy and structured self-help showed that both types of interventions had strong effects on reducing binge eating (Vocks et al., 2010). Combination treatments did not lead to enhanced effects compared with single-treatment regimens. Except for weight loss treatments, none of the interventions led to considerable weight loss. Vocks and colleagues concluded that psychotherapy and structured self-help, both based on cognitive-behavioral interventions, should be recommended as the first-line treatment. In a trial of 101 men and women with BED, subjects were randomly assigned to 20 group sessions of DBT specifically designed for BED or to an active comparison group therapy (Safer et al., 2010), the DBT group had a significantly lower dropout rate (4% vs. 33.3%). The differences did not persist after 3 months.

Pharmacotherapy

In 2010, sibutramine was withdrawn from the market because of safety concerns. As for other medications for treating BED, the task force noted that the 2006 guideline remains current. The task force also noted that Grade A evidence supports the use of imipramine (moderate risk-benefit ratio) for BED. Sertraline and citalopram/escitalopram have good risk-benefit ratios and topiramate has a moderate risk-benefit ratio. In contrast, Grade D evidence was found for fluvoxamine and fluoxetine, indicating inconsistent results. Randomized controlled trials have failed to provide support for use of other medications, including acamprosate and lamotrigine.

Combining Psychotherapy and Pharmacotherapy

For most patients, adding an antidepressant to a behavioral weight control and/or CBT regimen does not have a significant effect on binge suppression compared to medication alone.

IMPROVING MOTHERING SKILLS

Women with eating disorders who have babies or young children may need guidance, assistance, and monitoring of their mothering skills to minimize the risk of their children developing eating problems or eating disorders. Researchers continue to study interventions to improve overall mothering skills of these patients. Stein and colleagues (2006) randomly assigned 80 mothers with BN or similar eating disorders to either supportive counseling or to a video-feedback treatment focusing on the mothers’ interactions with their infants. The video-feedback treatment produced improvement in these interactions and in infant autonomy, suggesting the value of attending to mother-infant interactions in these patients.

EATING DISORDERS DURING MIDDLE AGE AND BEYOND

A growing number of reports and case studies describe eating disorders in later life. The Watch points out that research in this area is quite limited. Some cases arise in later years but most come to psychiatric or medical attention only after many years. Both biological and psychosocial factors probably play a role in the etiology of late-life eating disorders. For example, AN and BN may reflect difficulties with body image and self-image as baby boomers age, Individuals may also seek help or take their eating disorder more seriously because they are facing mortality and other existential issues.

Patient education and therapeutic approaches must be modified to particularly address the medical, psychological, and social needs of this age group; these needs are different from those of younger adults and adolescents.