A Resource for Counsellors and

Psychotherapists Working with Clients

Suffering from Eating Disorders

C L A S S N A M E

S T U D E N T N A M E

R O O M N U M B E R

Christine Knauss

Margot J. Schofield

School of Public Health, La Trobe University, Melbourne, Australia

February 2009

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© La Trobe University, February 2009 Distributed by PACFA under licence from La Trobe University This publication is copyright. No part may be reproduced by any process except in accordance with the provisions of the Copyright Act 1968. Suggested citation:

Knauss, C. & Schofield, M.J. (2009). A resource for counsellors and psychotherapists working with clients suffering from eating disorders. Melbourne: PACFA. Acknowledgments:

The review was generously funded by an anonymous philanthropic body.

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Foreword This document is a literature review of research prior to 2009 into the effectiveness of therapeutic approaches for treating eating disorders, intended as a resource for counsellors and psychotherapists. It was written on behalf of the PACFA Research Committee. However, this does not imply that PACFA or its Member Associations endorses any of the particular treatment approaches described.

The PACFA Research Committee recognises that it is important to counsellors and psychotherapists that they have access to recent research evidence that demonstrates the effectiveness of different therapeutic approaches, to assist them in their practice. This document is one of a series of reviews that was commissioned by the PACFA Research Committee to support its Member Associations in their work.

The PACFA Research Committee endorses the American Psychological Association’s definition of evidence-based practice as ‘the integration of the best available research evidence with clinical expertise in the context of patient characteristics, culture and preferences’, although we would prefer to use the word client or consumer rather than ‘patient'

The PACFA Research Committee recognises that there is overwhelming research evidence to indicate that, in general, counselling and psychotherapy are effective and that, furthermore, different methods and approaches show broadly equivalent effectiveness. The strength of evidence for effectiveness of any specific counselling and psychotherapy intervention or approach is a function of the number, independence and quality of available effectiveness studies, and the quality of these studies is a function of study design, measurements used and the ecological validity (i.e. its approximation to real life conditions) of the research.

The PACFA Research Committee acknowledges that an absence of evidence for a particular counselling or psychotherapy intervention does not mean that it is ineffective or inappropriate. Rather, the scientific evidence showing equivalence of effect for different counselling and psychotherapy interventions justifies a starting point assumption of effectiveness.

We recognise the need to improve the evidence-base for the effectiveness of various therapeutic approaches. The PACFA Research Committee is committed to supporting our Member Associations and Registrants to develop research protocols that will help the profession to build the evidence-base to support the known effectiveness of counselling and psychotherapy.

We hope that you will find this document useful and would welcome your feedback.

Dr Sally Hunter Chair of the PACFA Research Committee, 2011

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Contents

1. Introduction ...................................................................................................................................... 1

2. Types of eating disorders ............................................................................................................. 1

2.1 Diagnostic criteria for Anorexia Nervosa ....................................................................... 2

Table 1: Summary Anorexia Nervosa ............................................................................... 2

2.2 Diagnostic criteria for Bulimia Nervosa .......................................................................... 2

Table 2: Summary Bulimia Nervosa .................................................................................. 3

2.3 Diagnostic Criteria for Eating Disorder Not Otherwise Specified ......................... 3

Table 3: Summary Binge Eating Disorder ....................................................................... 3

3. Prevalence .......................................................................................................................................... 4

4. Causes and risk factors ................................................................................................................. 4

Table 4: Risk Factors for Eating Disorders ..................................................................... 5

5. Therapeutic interventions ........................................................................................................... 5

5.1 Therapeutic alliance ............................................................................................................... 6

5.2 Therapy for anorexia nervosa............................................................................................. 7

Table 5: Summary therapy for anorexia nervosa ..................................................... 12

5.3 Therapy for bulimia nervosa ............................................................................................ 12

Table 6: Summary therapy for bulimia nervosa ........................................................ 15

5.4 Therapy for eating disorder not otherwise specified ............................................. 15

6. Summary and conclusion .......................................................................................................... 16

Table 7: Internet Resources............................................................................................... 16

References ........................................................................................................................................... 18

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1. Introduction

This literature review is based on available empirical evidence and has been

developed to provide a resource for counsellors and psychotherapists working

with clients who have eating disorders. It is not based on a systematic literature

review but summarizes current evidence base for therapeutic approaches to

working with eating disorders. It has been reviewed by the Research Committee of

PACFA, the PACFA Board, and by international eating disorder experts:

• Professor Phillippa Hay, Professor and Foundation Chair of Mental Health,

School of Medicine, University of Western Sydney, Sydney;

• Professor Susan Paxton, Head of the School of Psychological Sciences, La

Trobe University, Melbourne;

This resource gives an overview of types of eating disorders, prevalence, causes,

risk factors and evidence for effective therapy. The review is consistent with

current scholarship on the definition of evidence base in psychological practice

and mental health areas (e.g., APA Presidential Taskforce on Evidence-Based

Practice, 2006). It also provides information about internet links for other

therapeutic resources and guidelines.

2. Types of eating disorders

Individuals who suffer from an eating disorder have problems with their eating,

weight management practices and body image. These problems often lead to

severe, sometimes life-threatening, physiological and psychological consequences.

Severe restriction of food intake can result in depression, social withdrawal,

preoccupation with food, changes in hormone secretion, amenorrhea (i.e. the

absence of at least three consecutive menstrual cycles), decreases in the metabolic

rate and binge eating. Eating disorders, particularly anorexia nervosa, have one of

the highest mortality rates of any mental disorder, with a death rate of 15.6%

(Zipfel, Lowe, Deter, & Herzog, 2000) due to suicide or medical complications

(often cardiac arrest secondary to arrhythmias). Therefore it is particularly

important, as described in the section about therapeutic interventions, to integrate

risk monitoring and management into therapy.

There are three different disorders listed in the Diagnostic and Statistical Manual

of Mental Disorders, Fourth Edition, Text Revision (DSM-IV) which can be captured

under the phrase of “eating, weight, and shape-related” disorders: Anorexia

nervosa, Bulimia nervosa and Eating Disorder Not Otherwise Specified. Below are

the diagnostic criteria for the three eating disorders according to the DSM-IV-TR

(American Psychiatric Association, 2000a).

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2.1 Diagnostic criteria for Anorexia Nervosa

A. Refusal to maintain body weight at or above a minimally normal weight for age

and height (e.g., weight loss leading to maintenance of body weight less than 85%

of that expected; or failure to make expected weight gain during period of growth,

leading to body weight less than 85% of that expected).

B. Intense fear of gaining weight or becoming fat, even though underweight.

C. 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.

D. In post-menarcheal females, amenorrhea (i.e., the absence of the least three

consecutive menstrual cycles). A woman is considered to have amenorrhea if her

periods occur only following hormone administration.

Table 1: Summary Anorexia Nervosa

Anorexia is characterised by:

A severe restriction of food intake

A loss of body weight to an unhealthy level

A loss of menstrual periods (female)

An intense fear of getting “fat”, and/or losing control of eating

Body image disturbance: regarding the body as fat despite being

underweight.

2.2 Diagnostic criteria for Bulimia Nervosa

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by:

1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount

of food that is larger than most people would eat during a similar period of

time and under similar circumstances;

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).

B. Recurrent, inappropriate compensatory behaviour in order to prevent weight

gain such as: self-induced vomiting; misuse of laxatives, diuretics, enemas, or other

medications; fasting; or excessive exercise.

C. The binge eating and inappropriate compensatory behaviours both occur, on

average, at least twice a week for 3 months.

D. Self-evaluation is unduly influenced by body shape and weight.

E. The disturbance does not occur exclusively during episodes of anorexia nervosa.

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Table 2: Summary Bulimia Nervosa

Bulimia nervosa is characterised by a cycle of binge eating followed by

compensatory behaviour such as purging, laxative abuse or over-exercising to

get rid of the food.

2.3 Diagnostic Criteria for Eating Disorder Not Otherwise Specified

The Eating Disorder Not Otherwise Specified (EDNOS) category is for disorders of

eating that do not meet the criteria for any specific eating disorder. One form of

EDNOS can be binge eating disorder.

Diagnostic Criteria for Binge-Eating Disorder

A. Recurrent episodes of binge eating. An episode of binge eating is characterized

by:

1. Eating, in a discrete period of time (e.g., within any 2-hour period), an

amount of food that is larger than most people would eat during a similar

period of time and under similar circumstances

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).

B. The binge-eating episodes are associated with three (or more) of the following:

1. Eating much more rapidly than normal

2. Eating until feeling uncomfortably full

3. Eating large amounts of food when not feeling 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.

C. Marked distress regarding binge-eating is present.

D. The binge eating occurs, on average, at least 2 days a week for 6 months.

E. The binge eating is not associated with the regular use of inappropriate

compensatory behaviours (e.g., purging, fasting, excessive exercise) and does not

occur exclusively during the course of anorexia nervosa or bulimia nervosa.

Table 3: Summary Binge Eating Disorder

Binge eating disorder is characterised by periods of binge eating (uncontrolled,

impulsive or continuous eating) without compensatory behaviours such as

vomiting or excessive exercise.

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3. Prevalence

Eating disorders have been reported to be one of the ten leading causes of

disability and distress among young women in Australia (Mathers, Vos, Stevenson,

& Begg, 2000). The prevalence of specific eating disorders such as anorexia

nervosa or bulimia nervosa has been considered relatively low in comparison to

other mental disorders such as affective disorders or anxiety disorders (Piran,

Levine, & Steiner-Addir, 1999). However, when the prevalence rates of various

eating disorders are summed and the higher prevalence rates of sub-clinical eating

disorders or eating disorders not otherwise specified are included, it can be stated

that many individuals, particularly women, suffer from an eating disorder

(Thompson, 2004; Wade, Bergin, Tiggemann, Bulik, & Fairburn, 2006).

The accurate prevalence of eating disorders is difficult to assess due to the

sometimes secretive nature of the disorder. The prevalence rates given by the

American Psychiatric Association (2000a) are approximately 0.5% for anorexia

nervosa and between 1% and 3% for bulimia nervosa. Wade and colleagues

(2006) reported in an Australian study a lifetime prevalence of 1.9% for anorexia

nervosa and an additional 2.4% of women who partially met the criteria for

anorexia nervosa (they did not show amenorrhea). Bulimia nervosa was shown by

2.9% of the women and binge eating disorder also by 2.9%; while 5.3% showed an

eating disorder not otherwise specified. It is also notable that there has been an

increase in disordered eating behaviours in Australia between 1995 and 2005

(Hay, Mond, Buttner, & Darby, 2008).

Eating disorders are much less prevalent in men (Hay, Loukas, & Philpott, 2005;

Hoek, 2006; Hoek & Hoeken, 2003) with a ratio of about 10 women to 1 man

(Thompson, 2004). In an Australian study (Hay et al., 2005) the prevalence of

eating disorders in men was 1.2%. Men showed similar symptoms to women.

However, they were less weight concerned or less likely to use self-induced

vomiting as compensatory behaviour.

The onset of eating disorders occurs mostly during adolescence or young

adulthood. Anorexia nervosa typically begins during adolescence and bulimia

nervosa in young adulthood. An eating disorder can, however, also develop in later

years and, if untreated, persist into a person’s adult life.

4. Causes and risk factors

Knowledge about causes of, and risk factors for, eating disorders is still limited

(Field, 2004; Striegel-Moore & Bulik, 2007) due to the lack of longitudinal studies

with large sample sizes. It has been suggested that a complex set of biological,

cultural and psychological factors contribute to the risk of developing an eating

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disorder. Therefore, the etiology of eating disorders has been described as

complex and multifactorial (Jacobi, Hayward, de Zwaan, Kraemer, & Agras, 2004;

Striegel-Moore & Bulik, 2007). Risk factor research has focused on biological

processes and factors involved in appetite and weight regulation, and cultural

factors that lead to attitudes and behaviours associated with body image and

eating. Higher body mass index has not been found to be a risk factor for eating

disorders (Jacobi et al., 2004). Table 4 shows a list of risk factors for eating

disorders (Pike et al., 2008; RANZCP, 2004; Striegel-Moore & Bulik, 2007). Pike et

al. (2008) have shown that negative affectivity, perfectionism, family discord, and

high parental demands were risk factors for anorexia nervosa.

Socio-cultural models have focused on the influence of the media and beauty ideals

on body image and eating behaviour. The thin body ideal is mostly equated with

beauty or success and has been shown to be a strong influencing factor on body

dissatisfaction and disordered eating. Body dissatisfaction has been found to be a

significant predictor of eating pathology (Stice & Agras, 1998), particularly for

bulimic symptoms (Stice, 2002). The research on genetic risk factors in eating

disorders is still in its early stages. Results of twin studies suggest that there is a

substantial genetic component that contributes to the development of eating

disorders (Striegel-Moore & Bulik, 2007). More sophisticated models need to be

developed and further investigated. These need to incorporate longitudinal study

designs and include the interplay of genes/biological factors and environment.

Table 4: Risk Factors for Eating Disorders

• Being female

• Having a parent with an eating disorder

• Body dissatisfaction, focus on appearance and internalization of the thin

ideal

• Low self-esteem

• Dieting

5. Therapeutic interventions

Many individuals with an eating disorder do not seek or receive appropriate

therapy for their eating problems (Mond, Hay, Rodgers & Owen, 2007). Results of

an Australian study (Hay, Marley, & Lemar, 1998) indicated that only a minority of

individuals with a bulimic disorder sought appropriate therapy. Some key reasons

that people do not seek help include fear of stigma, shame, fear of change and costs

(Hepworth & Paxton, 2007; Hepworth, Paxton, & Williams, 2007). However, the

sooner the disorder is treated, the more likely it is that the disorder can be

overcome. Therefore, it is important to make appropriate therapy available and

more easily accessible for people with an eating disorder. It is also important to

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focus on active engagement of clients in therapy. The following section

summarizes recommendations and research results from existing literature and

aims to give information about appropriate therapy for anorexia and bulimia. In

this literature review, the focus was exclusively on counselling and

psychotherapeutic approaches, not on drug treatments.

5.1 Therapeutic alliance

A strong and positive therapeutic alliance, in the form of a collaborative, empathic

and accepting bond between client and therapist, is an established predictor of

outcome in psychotherapy (Martin, Garske, & Davis, 2000). This is true for

psychotherapy in general, and specifically for working with clients suffering from

an eating disorder (Constantino, Arnow, Blasey, & Agras, 2005; Brisman, 1994;

Geller, 2006; Toman, 2002; Loeb et al., 2005). This is related to the salience of

issues of trust and control which are important features of eating disorder

conditions (Pyle, 1999). The therapeutic relationship is considered to be the

central factor contributing to therapy outcome (APA, 2005).

Both clients and therapists have reported that the therapeutic alliance is an

important factor in the quality of the therapy for eating disorders (de la Rie,

Noordenbos, Donker, & van Furth, 2008). From the client’s perspective, trust in the

therapist has been found to be the most important criterion for the quality of the

therapy for eating disorders (de al Rie et al., 2008). Gallop, Kennedy and Stern

(1994) found that clients in an inpatient unit for eating disorders, who stayed in

treatment, reported a stronger therapeutic alliance than clients who left treatment

before completion.

However, therapeutic relationships with clients suffering from an eating disorder

have been described as challenging (Ardovini, 2002), due to the client’s self-

harming thoughts and behaviours, the risk of suicide, the influences of cognitions,

emotions and activity level caused by starvation or malnutrition, and the client’s

ambivalence towards recovery and the therapeutic process (Manley & Leichner,

2003). Clients’ characteristics which have been shown to be related to the quality

of the therapeutic relationship in clients suffering from bulimia nervosa included

the severity of symptoms, expected improvement in therapy, and interpersonal

problems at the beginning of therapy (Constantino et al., 2005). A further client

characteristic that may be related to the quality of the therapeutic relationship is

the body mass index of the client (Toman, 2002). Manley and Leichner (2003)

describe the challenges counsellors or psychotherapists have to face in the work

with clients who suffer from an eating disorder and emphasized the importance of

a sound therapeutic relationship. They recommended understanding, empathy and

careful listening as key elements to ensure good therapeutic process.

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5.2 Therapy for anorexia nervosa

What evidence about the efficacy of therapy of anorexia nervosa do we have?

The evidence base for the efficacy of psychotherapeutic interventions for anorexia

nervosa is weak (Bulik, Berkman, Brownley, Sedway, & Lohr, 2007; Fairburn, 2005;

Keel & Haedt, 2008; Steinhausen, 2002; Wilson, Griol, & Vitousek, 2007) and the

quality of the studies has been judged to be mostly poor (Keel & Haedt, 2008; Royal

Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines

Team for Anorexia Nervosa, 2004; Wilson et al., 2007). This lack of empirical

evidence is mostly due to the low prevalence rate and the high morbidity.

Does therapy work?

A review article by Steinhausen (2002), in which 119 studies and 5590 clients

have been included, has shown that nearly 50% of people who suffered from

anorexia and who completed the treatment recovered, one-third improved and

20% remained chronically ill after treatment. A study about effective treatment of

eating disorders in Europe has reported that treatment was successful in 37% of

702 clients with anorexia at 1 year follow-up (Richard, 2005). Vomiting, bulimia,

chronicity of the disorder, onset of the disorder in adulthood and coexisting mental

disorders were factors which influenced the prognosis negatively. Zipfel et al.

(2000) have reported a recovery rate of 50.6% with an additional 20.8% of the

clients having intermediate outcome at 21-years follow-up after inpatient

treatment. One reason for the low success rates in anorexia is the egosyntonic

nature (sufferers do not feel that they have a problem) of this disorder and the fact

that individuals with anorexia often do not have a high motivation to overcome it

(Pike, Devlin, & Loeb, 2004). Positive influences on the prognosis are prompt

therapy after onset of the disorder, a strong motivation to change behaviour and

outpatient treatment in less severely disordered people (RANZCP, 2004;

Steinhausen, 2002). Furthermore, higher initial body weight and a younger age

significantly predicted higher effectiveness of therapy (Richard, 2005). There is

only limited empirical evidence available about the effectiveness of group therapy

for clients with anorexia (American Psychiatric Association, 2006).

Therapy content and aims: What principles guide therapy for anorexia

nervosa?

The following section summarizes recommendations for the therapy of anorexia

nervosa (American Psychiatric Association, 2006; American Psychiatric

Association, 2000b; National Institute for Clinical Excellence, 2004; RANZCP,

2004). Because of the high mortality rate for this disorder and the challenging

nature of treatment, the literature review outlines the broader treatment context

and the need for therapists to work collaboratively with other health professionals

in relation to the wider medical and dietary aspects of treatment.

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Therapy context

• Therapy is provided by a multidisciplinary team including a general

practitioner, a dietitian and a mental health specialist.

• Therapy addresses medical, psychological, nutritional and social

components of the disorder.

• Therapy includes and/or supports family members and friends where

possible.

• Family-based therapy may be offered to children and adolescents suffering

from anorexia.

• Outpatient treatment lasts for at least 6 months.

• If the course of therapy does not lead to significant improvements such as

weight restoration and changes in dysfunctional thinking and behaviours,

more intensive forms of therapy are recommended. Inpatient treatment

and the provision of life-preserving care is indicated if the body mass index

is less than 14 or the weight of the client is less than 75% of the healthy

body weight. Following inpatient treatment, outpatient treatment combined

with physical monitoring lasts for at least 12 months.

Aims and important parts of the therapy for anorexia nervosa

Preventing death by restoring nutrition and regaining weight.

Fostering more positive eating behaviours and attitudes to weight and

shape with encouragement for weight gain and healthy eating.

Supporting clients to reassess and change dysfunctional thoughts, attitudes,

feelings and behaviours.

Integrating an understanding of the client’s disorders of self-esteem, self-

regulation, psychodynamic conflicts, cognitive development, traumas and

family relationships.

Educating and providing information on the nature, course and treatment

of anorexia nervosa to the client and carers (where appropriate).

In most cases, the aims of therapy include helping the client to have an

average weight gain of 0.5 kg in an outpatient setting. Controlled weight

gain could result from a nutritional rehabilitation program.

Medical management including the monitoring of weight (weighing once or

twice per week), vital signs and dietary intake, to monitor the medical risk

and the treatment response but also to avoid the ‘re-feeding syndrome.’

(Re-feeding after recent, rapid weight loss can lead to weakness, peripheral

oedema, seizures, coma, visual and auditory hallucinations or sudden

death). Detailed information about risk assessment and risk monitoring can

be found in Waller et al. (2007) and in a guide to the medical risk

assessment for eating disorders by Treasure (2004) which is available on

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the internet (see Table 8).

Addressing comorbid disorders, such as depression or anxiety following

best practice for those issues.

Facilitating psychological and physical recovery and preventing relapse.

Management of physical risks and complications of anorexia nervosa

• Physical risk in clients with anorexia nervosa needs to be monitored

regularly by a medical specialist throughout treatment. Physical symptoms

associated with starvation need to be treated.

• Clients with anorexia and their carers need to be informed about the

physical risk.

• Health care professionals treating clients with anorexia nervosa need to be

aware of the increased risk of self-harm and suicide, and implement

behavioural contracting with clients.

Monitoring of the process

• It is important to monitor the level of risk to the client’s mental and physical

health during therapy. The physical state of the client needs to be

monitored regularly, including weight gain/loss and other specific

indicators of increased physical risk.

• Responsibility for the monitoring of progress and of risk needs to be

discussed and agreed by all involved health care professionals and the client.

Inpatient or outpatient treatment?

The National Institute for Clinical Excellence (NICE, 2004) recommends that the

majority of people suffering from anorexia nervosa should be treated in an

outpatient setting with psychological treatment provided by a service that is

competent in giving specific treatment for this disorder and in assessing the

physical risks. Inpatient treatment is necessary if the medical risks for outpatient

treatment are too high and rapid weight loss or physical deterioration occurs

(Beumont, Hay, & Beumont, 2003). Clients with a weight below 75% of healthy

body weight or with rapid and severe weight loss can be too severely compromised

to be treated in a weekly outpatient psychotherapy setting and it may be necessary

to treat in an intensive outpatient or inpatient setting (American Psychiatric

Association, 2000b), where malnutrition can be corrected and regular monitoring

of the medical risk can be assured. However, not only weight, but also the client’s

overall physical condition, rate of weight loss, cardiac function, psychological

condition and the social circumstances should be considered in determining the

appropriate level of care (American Psychiatric Association, 2006).

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What kind of therapeutic approach?

At this point, no specific psychotherapeutic approach can be considered to be

superior to other approaches for the treatment of anorexia nervosa (Hay,

Bacaltchuk, Byrnes, Claudino, Ekmejian, & Yong, 2003; PYNICE, 2004; RANZCP,

2004). It has been recommended that dietary advice should be part of the

treatment when combined with individual or family psychotherapy (RANZCP,

2004). Psychotherapies used for the treatment of anorexia nervosa include CBT,

family therapy, psychodynamic therapy, art therapy and interpersonal therapy.

Other therapeutic approaches increasingly used in the treatment of anorexia

nervosa are motivational enhancement therapy, dialectical behavioural therapy

(Kotler, Boudreau, & Devlin, 2003) and mindfulness and acceptance-based

approaches (Baer, Fischer, & Huss, 2005). Yager (2003) has suggested the use of e-

mail as an adjunct to outpatient treatment of anorexia nervosa.

Cognitive behavioural therapy

CBT for anorexia nervosa is the individual therapy most often evaluated in

research studies. However, CBT has not been shown to be significantly more

effective than other psychotherapies (Channon, De Silva, Hemsley & Perkins, 1989;

Wilson et al., 2007). Pike, Walsh, Vitousek, Wilson and Bauer (2003) have reported

in their randomized controlled trial in which they compared CBT to nutritional

counselling that clients who received CBT showed significantly better outcome and

were less likely to relapse than clients who received nutritional counselling. Of the

clients who had received CBT, 44% had good outcome compared to 7% of the

nutritional counselling group. Details about CBT for eating disorders can be found

in a comprehensive treatment guide by Waller and colleagues (2007).

Family therapy

Review articles indicate that most research about the efficacy of treatment for

anorexia in adolescents has been undertaken on family therapy (Wilson et al.,

2007). The evidence base for the Maudsley model of family-based therapy for the

treatment of anorexia nervosa in adolescents is strongest (Keel & Haedt, 2008;

Wilson et al., 2007). Details about the Maudsley model and the treatment process

can be found in the published manual (Lock, le Grange, Agras, & Dare, 2001).

Family-based therapy involves 10-20 sessions over 6-12 months with all family

members. In the first phase of therapy, the role of the parents is to take complete

control over their child’s eating and weight. In later stages of therapy, the client

regains autonomy and engages in age-appropriate individuation from the parents

which is related to recovery.

Eisler (2005) has given an overview of empirical evidence for family therapy and

its effectiveness for the treatment of anorexia nervosa in adolescents and a

description of a treatment model. Recovery rates for adolescents have been shown

to be slightly higher after family therapy than for individual therapy (Wilson et al.,

11

2007). Eisler et al. (2000) have shown that after receiving family therapy 38% had

a good and 25% had an intermediate outcome. It has also been shown that

although outcomes of family therapy were comparable to outcomes after

individual therapy (Robin et al., 1999; Robin, Siegel, & Moye, 1995), adolescents

who received family therapy recovered faster (Robin et al., 1999).

In a randomized controlled trial by Schmidt et al. (2007) in which family therapy

was compared to CBT guided self-care, the two treatment outcomes did not

significantly differ from each other after 12 months. Furthermore, there is no

supportive evidence for the effectiveness of family therapy in adults and

individuals who have suffered from the disorder for a longer period of time.

Therefore, family therapy has been shown to be more effective for adolescent

clients than for adult individuals (Bulik et al., 2007). It has been suggested that for

clients with a late onset of anorexia nervosa, individual therapy could be a better

therapeutic intervention than family therapy (Beumont et al., 2003). It can be

concluded that children and adolescents with anorexia nervosa should be offered

family interventions, as also recommended by the NICE guideline (NICE, 2004).

Psychodynamic therapy

Kächele and colleagues (2001) found in their study of the outcome of

psychodynamic inpatient treatment of eating disorders in Germany that 33% of

the clients who had suffered from anorexia nervosa were free of symptoms at the

two and a half year follow-up. In a study about the effectiveness of focal

psychoanalytic psychotherapy, cognitive-analytic therapy and family therapy, one

third of the clients no longer showed symptoms at the end of therapy (Dare, Eisler,

Russell, Treasure, & Dodge, 2001). However, the sample sizes in this study were

small. Therefore, reduced power due to small sample sizes made it impossible to

differentiate between the three psychotherapy approaches. The effectiveness of

psychodynamic therapy for the treatment of anorexia nervosa has only been

investigated to a limited extent.

Interpersonal therapy

Interpersonal therapy has mostly been investigated with individuals who suffer

from bulimia nervosa. Little empirical evidence exists about the efficacy of this

therapy for anorexia nervosa. In a study by McIntosh and colleagues (2005), CBT,

interpersonal therapy and a treatment combining specialist supportive clinical

management (psycho-education and supportive psychotherapy) were compared in

clients with anorexia nervosa. The specialist supportive clinical management and

CBT were more effective than interpersonal therapy. However, sample sizes were

small and overall outcome was low (9% of the clients had a very good outcome and

21% showed improvements).

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Art therapy

To our knowledge, there is no empirically based study that has investigated the

efficacy of art therapy as a therapeutic intervention for eating disorder. However,

narrative reports on the use of this approach for the treatment of eating disorders

imply positive outcomes (Frisch, Franko, & Herzog, 2006). This therapeutic

approach combines non-verbal and verbal elements and is frequently used in

combination with other psychotherapeutic approaches (Matto, 1997). Art therapy

can help clients to work on cognitive distortions related to their body or their

eating patterns, facilitate the expression of emotions or the exploration of conflicts

and problems, and can help to develop new coping strategies. Levens (1995)

describes treatment of eating disorders through art therapy and how the art

therapist can facilitate the client’s treatment process.

Table 5: Summary therapy for anorexia nervosa

Based on the currently available research results it can be concluded that

psychotherapeutic treatment is significantly more effective than no treatment

(Dare et al., 2001) or dietary advice on its own (Pike et al., 2003). Family

therapy is the most widely tested and efficient method for adolescents.

Furthermore, a multidimensional and multidisciplinary treatment approach

including thorough assessment, ongoing risk management, and integration of

multiple treatment modalities is recommended.

5.3 Therapy for bulimia nervosa

What evidence about the efficacy of therapy of bulimia nervosa do we have?

The empirical evidence for psychological treatment of bulimia nervosa is strong

(NICE, 2004; Shapiro et al., 2007), particularly for CBT and interpersonal therapy

(Wilson et al., 2007). Studies about the efficacy of alternative treatment

approaches are rare.

Does therapy work?

Review studies about the efficacy of treatment for bulimia nervosa have concluded

that a high percentage of clients still suffer from the disorder after treatment

(Mitchell, Hoberman, Peterson, Mussell, & Pyle, 1996). Results of a European

collaborative study in which treatment outcomes from several European countries

have been combined indicated that 40% of the 981 clients with bulimia showed

positive outcome at a one year follow-up (Richard, 2005). This success rate was

relatively low compared to other studies.

A study of the long term course of bulimia nervosa (Fichter & Quadflieg, 1997)

showed that six years after treatment, 60% achieved a good outcome, and 29% an

13

intermediate outcome. Thompson-Brenner, Glass, and Westen (2003) conducted a

meta-analysis of psychotherapy for bulimia nervosa, in which they included 26

clinical trials (N = 1427) of different therapeutic approaches. They found that of the

clients who completed therapy, 40.1% were classified as recovered post-treatment

(recovery rate for intention-to-treat sample was 32.6%). The recovery rate after

treatment for individual CBT was on average 48% for completers. Follow-up data

has been available for seven studies. After the average follow-up time of 12.75

months, 43.7% of clients were recovered (across different treatments).

The recovery rate for individual therapies was significantly higher than for group

therapies. Frequency of binge eating, age, psychological distress and family

relationships were factors that were related to the effectiveness of therapy

(Richard, 2005).

Therapy content and aims: What principles guide therapy for bulimia nervosa?

In the following section, standards of treatment for bulimia nervosa are

summarised (American Psychiatric Association, 2006; American Psychiatric

Association, 2000b; NICE, 2004; RANZCP, 2004):

Therapy context

• Inpatient treatment should be considered for clients with risk of suicide or

risk of severe self-harm only. The majority of clients can be treated in an

outpatient setting.

• Therapy addresses the reduction of binge eating and purging behaviour.

• Fluid and electrolyte balance should be monitored throughout treatment,

particularly in clients who are vomiting frequently or using large quantities

of laxatives.

• Dietary advice in combination with other treatment approaches can be

useful to establish healthy eating patterns and reduce eating disorder

behaviour such as vomiting.

• Eating disorder symptoms and the client’s medical condition should be

assessed and monitored throughout the treatment.

• Family therapy could be considered for adolescents.

Cognitive-behavioural therapy for bulimia nervosa

The NICE guideline (NICE, 2004) recommends that adults suffering from bulimia

nervosa should be offered CBT for 16 to 20 sessions over 4 to 5 months. Hay,

Bacaltchuk and Stefano (2004 found CBT to be an efficacious treatment in their

Cochrane review. This therapeutic approach is the most investigated evidence-

based treatment with the most evidence of efficacy and has been recommended as

the therapy of choice for bulimia nervosa (Pike et al., 2004; Wilson et al., 2007).

About 30% to 50% of the clients typically overcome binge eating and purging after

14

they receive CBT (Anderson & Maloney, 2001; Wilson et al., 2007). Ghaderi (2006)

found that a more individualized CBT treatment, instead of a strictly manual-based

treatment, was slightly more beneficial particularly in terms of drop-outs. At post-

treatment, 62% (n = 32) of the clients did not show binge episodes or compensatory

behaviour. The treatment of bulimia nervosa with CBT has been described in

Fairburn (2002).

Interpersonal psychotherapy for bulimia nervosa

Interpersonal therapy (IPT) is an alternative therapeutic approach recommended

by the NICE guideline (2004) for the treatment of bulimia nervosa. However, it

usually takes 8-12 months to reach results comparable with CBT. Reviews about

IPT (Tantleff-Dunn, Gkee-LaRose, & Peterson, 2004) have provided evidence for

the efficacy of interpersonal therapy in the treatment of bulimia. Some studies

found CBT was more effective than IPT - in some studies CBT was as effective as

IPT and in others CBT was more effective at the end of therapy. However both

therapeutic interventions showed comparable outcomes at follow-up (Tantleff-

Dunn et al., 2004).

Psychodynamic therapy for bulimia nervosa

There is little empirical evidence for the effectiveness of psychodynamic

treatments for bulimia nervosa. Murphy, Russell and Waller (2005) have shown in

their study that after psychodynamic treatment 50% of the sample (N = 14) was

symptom-free at three and six month follow-ups.

Guided self-help and self-help for the treatment of bulimia nervosa

Guided self-help (GSH) has been recommended as a valuable and effective first step

in the treatment process of bulimia (NICE, 2004). In guided self-help, a self-help

manual based on CBT is introduced to the client by the therapist. The client works

through the manual independently, learns about the disorder, how to change

behaviour and cognitions and about new skills and problem solving techniques. In

the sessions with the therapist, the client gets support, encouragement and

assistance in working through the manual. GSH has been found to be an effective

treatment approach for the treatment of bulimia nervosa. It has been evaluated in

comparison with waiting list controls, CBT, family therapy and pure self-help

treatment (Grilo, 2000; Mitchell, Agras, & Wonderlich, 2007; Shapiro et al., 2007;

Stefano, Bacaltchuk, Blay, & Hay, 2006). An Australian study (Banasiak, Paxton, &

Hay, 2005) found that 28% of the GSH group compared to 11% of the delayed

treatment group showed absolute remission from binge eating and all

compensatory behaviours. An overview of guided self-help manuals has been given

in Paxton, Knauss and Shelton (in press).

A CD-ROM-based CBT self-help intervention has also been described as a valuable

first step in treatment for clients who have no access to face-to-face treatment

(Bara-Carril et al., 2004).

15

Table 6: Summary therapy for bulimia nervosa

Based on current available research, CBT can be considered as the treatment of

choice for the treatment of bulimia nervosa, with interpersonal therapy as an

alternative approach for clients who do not respond to CBT. CBT currently has

stronger and more consistent empirical support than interpersonal therapy and

results in more rapid alleviation of symptoms. To increase global outcome it may

be helpful to use CBT in combination with other psychotherapies. Family therapy

should be considered for adolescents. Guided self-help is an effective approach

as a first step in the treatment process and may be an effective treatment in

some cases.

There is a lack of clinical trials which include therapeutic approaches other than

CBT or interpersonal therapy (Thompson-Brenner et al., 2003). Cognitive-

behavioural therapy is currently the treatment of choice for bulimia nervosa, but

further studies that include different therapeutic approaches are necessary to be

able to draw a more precise conclusion about the efficacy of other treatment

approaches.

5.4 Therapy for eating disorder not otherwise specified

A high percentage of clients with eating disorders do not fully meet the diagnostic

criteria for anorexia nervosa or bulimia nervosa but clearly suffer from disordered

eating. This group of clients fall under the DSM-IV-TR category eating disorders

not otherwise specified (EDNOS). The required therapeutic intervention depends

on symptoms and severity of impairment (APA, 2000b). Treatment strategies for

the reported problems such as binge eating, unhealthy dieting behaviour and body

dissatisfaction can be nutritional counselling and dietary management combined

with cognitive-behavioural, interpersonal or psychodynamic psychotherapy (APA,

2000b). The APA (2006) also recommends dialectical behavioural therapy for the

treatment of binge eating disorders.

In a review article about the effectiveness of the treatment of binge eating

disorders it has been concluded that evidence of the efficacy of treatments for

binge eating disorders is still limited (Brownely, Berkman, Sedway, Lohr, & Bulik,

2007). It can be helpful to use a ‘non-diet’ approach with a focus on self- and body

acceptance, exercise and improvement of nutrition and health. Guided self-help

can be a valuable treatment approach particularly for binge eating disorders

(Paxton, Knauss, & Shelton, in press). For overweight clients with binge eating

disorder, CBT and behaviour weight loss therapy have both been found effective

(Munsch, Biedert, Meyer, Michael, Schlup, Tuch, & Margraf, 2007). A guided self-

help manual for the treatment of disordered eating is accessible on the internet

(Fursland, Byrne, & Nathan, 2007; see Table 8).

16

6. Summary and conclusion

The success rate of treatment of anorexia nervosa is still low. Available and

empirically evaluated therapeutic approaches have not shown to be as effective as

one would wish. Risk monitoring and management is an important part of the

therapeutic process. Important aims of therapy are weight gain, change of eating

behaviour, of attitudes to weight and shape and of dysfunctional thoughts and

feelings.

There is a strong evidence-base for the treatment of bulimia nervosa showing that

CBT is the most effective treatment approach and that interpersonal therapy can

be considered as an alternative approach. Guided self-help which is based on CBT

can be recommended as a first step in the treatment process for bulimia nervosa

and can also be considered as helpful in the treatment of binge eating disorders.

For the treatment of EDNOS and binge eating disorders nutritional counselling,

exercise and dietary management combined with psychotherapy can be

recommended. Guided self-help can also be a valuable treatment approach for

binge eating disorders.

Table 7: Internet Resources

American Psychiatric Association Practice Guidelines. (2006). Treatment of

patients with eating disorders, 3rd edn. Retrieved on 12th February 2009 from:

http://www.psychiatryonline.com/content.aspx?aID=138866

Eating Disorder Interstate Contact List 2008. Retrieved on 12th February 2009

from:

http://www.eatingdisorders.org.au/documents/interstate%20list%200808.p

df

Fursland, A.., Byrne, S., & Nathan, P. (2007). Overcoming disordered eating.

Perth, WA: Centre for Clinical Interventions. Guided self-help manual

retrieved on 12th February from:

http://www.cci.health.wa.gov.au/resources/infopax.cfm?Info_ID=48 and

http://www.cci.health.wa.gov.au/resources/infopax.cfm?Info_ID=49

National Institute for Health and Clinical Excellence (NICE). (2004). Eating

disorders: Core interventions in the treatment and management of anorexia

nervosa, bulimia nervosa and related eating disorders. Clinical guideline 9.

Retrieved on 12th February 2009 from:

http://www.nice.org.uk/CG009NICEguideline

17

Royal Australian and New Zealand College of Psychiatrists Clinical Practice

Guidelines Team for Anorexia Nervosa. (2004). Australian and New Zealand

clinical practice guideline for the treatment of anorexia nervosa. Australian and

New Zealand Journal of Psychiatry, 38, 569-670. Retrieved on 12th February

2009 from http://www.ranzcp.org/images/stories/ranzcp-

attachments/Resources/Publications/CPG/Clinician/CPG_Clinician_Full_Anor

exia.pdf

Royal Australian and New Zealand College of Psychiatrists. (2005). Anorexia

Nervosa: Australian treatment guide for consumers and carers. Melbourne:

Author. Retrieved on 12th February 2009 from:

http://www.ranzcp.org/images/stories/ranzcp-

attachments/Resources/Publications/CPG/Australian_Versions/AUS_Anorexi

a_nervosa.pdf

Treasure, J. (2004). A guide to the medical risk assessment for eating disorders.

London: King’s College London, Eating Disorders Unit. Retrieved on 12th

February 2009 from: http://www.iop.kcl.ac.uk/sites/edu/?id=73#item03

18

References

American Psychiatric Association (2006). Practice guideline for the treatment of patients with eating disorders (3rd ed). [WWW document]. URL http://www.psychiatryonline.com/content.aspx?aID=138866.

American Psychiatric Association (2000a). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington DC: Author.

American Psychiatric Association (2000b). Practice guideline for the treatment of patients with eating disorders (revision). The American Journal of Psychiatry, 157, 1-39, Supplement.

American Psychological Association Task Force on Evidence-Based Practice (2006). Evidence-based practice in psychology. American Psychologist, 61, 271-285.

Anderson, D. A., & Maloney, K. C. (2001). The efficacy of cognitive-behavioral therapy on the core symptoms of bulimia nervosa. Clinical Psychology Review, 21, 971-988.

Ardovini, C. (2003). Attachment theory, metacognitive functions and the therapeutic relationship in eating disorders. Eating and Weight Disorders, 7, 328-331.

Baer, R. A., Fischer, S., & Huss, D. B. (2005). Mindfulness and acceptance in the treatment of disordered eating. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 23, 281-300.

Banasiak, S. J., Paxton, S. J. & Hay, P. J. (2005). Guided Self-Help for bulimia nervosa in primary care: A randomized controlled trial. Psychological Medicine, 35, 1283-1294.

Bara-Carril, N., Williams, C. J., Pombo-Carril, M. G., Reid, Y., Murray, K., Aubin, S., Harkin, P. J. R., Treasure, J., & Schmidt, U. (2004). A preliminary investigation into the feasibility and efficacy of a CD-ROM-Based cognitive-behavioral self-help intervention for bulimia nervosa. International Journal of Eating Disorders, 35, 538-548.

Beumont, P., Hay, P., & Beumont, R. (2003). Summary Australian and New Zealand clinical practice guideline for the management of anorexia nervosa. RANZCP clinical practice guidelines. Australasian Psychiatry, 11, 129-133.

Brisman, J. (1994). Learning to listen: Therapeutic encounters and negotiations in the early stages of treatment. Eating Disorders: The Journal of Treatment & Prevention, 2, 68-73.

Brownley, K. A., Berkman, N. D., Sedway, J. A., Lohr, K. N., & Bulik, C. M. (2007). Binge eating disorder treatment: A systematic review of randomized controlled trials. International Journal of Eating Disorders, 40, 337-348.

19

Bulik, C. M., Berkman, N. D., Brownley, K. A., Sedway, J. A., & Lohr, K. N. (2007). Anorexia nervosa treatment: A systematic review of randomized controlled trials. International Journal of Eating Disorders, 40, 310-320.

Channon, S., De Silva, P., Hemsley, D., & Perkins, R. (1989). A controlled trial of cognitive-behavioural and behavioural treatment of anorexia nervosa. Behaviour Research and Therapy, 27, 529-535.

Cluzeau, F., Littlejohns, P., Grimshaw, J., & Feder, G. (1997). Appraisal instrument for clinical guidelines. Version 1. London, Health Care Evaluation Unit, St George’s Hoppital Medical School.

Constantino, M. J., Arnow, B. A., Blasey, C., & Agras, W. S. (2005). The Association between patient characteristics and the therapeutic alliance in cognitive-behavioral and interpersonal therapy for bulimia nervosa. Journal of Consulting and Clinical Psychology, 73, 203-211.

Dare, C., Eisler, I., Russell, G., Treasure, J., & Dodge, L. (2001). Psychological therapies for adults with anorexia nervosa. British Journal of Psychiatry, 178, 216-221.

De la Rie, S., Noordenbos, G., Donker, M., & van Furth, E. (2008). The quality of treatment of eating disorders: A comparison of the therapists’ and the patients’ perspective. International Journal of Eating Disorders, 41, 307-317.

Eisler, I. (2005). The empirical and theoretical base of family therapy and multiple family day therapy for adolescent anorexia nervosa. Journal of Family Therapy, 27, 104-131.

Eisler, I., Dare, C., Hodes, M., Russell, G., Dodge, E., & Le Grange, D. (2000). Family therapy for adolescent anorexia nervosa: The results of a controlled comparison of two family interventions. Journal of Child Psychology and Psychiatry, 41, 727-736.

Fairburn, C. G. (2005). Evidence-based treatment of anorexia nervosa. International Journal of Eating Disorders, 37, S26-S30.

Fairburn, C. G. (2002). Cognitive-behavioral therapy for bulimia nervosa. In C. G. Fairburn & K. D. Brownell (Eds.), Eating disorders and obesity: A comprehensive handbook (2nd edition, pp. 302–307). New York: Guilford.

Fichter, M. M., & Quadflieg, N. (1997). Six-year course of bulimia nervosa. International Journal of Eating Disorders, 22, 361-384.

Field, A. E. (2004). Risk factors for eating disorders: An evaluation of the evidence. In J. K. Thompson (Ed.), Handbook of eating disorders and obesity (pp.17-32). Hoboken, NJ: John Wiley & Sons Inc.

Frisch, M. J., Franko, D. L., & Herzog, D. B. (2006). Arts-based therapies in the treatment of eating disorders. Eating Disorders: The Journal of Treatment & Prevention, 14, 131-142.

20

Fursland, A., Byrne, S., & Nathan, P. (2007). Overcoming disordered eating. Perth, Western Australia: Centre for Clinical Interventions: [WWW document]. URL http://www.cci.health.wa.gov.au/about/objectives.cfm.

Gallop, R., Kennedy, S. H., & Stern, D. (1994). Therapeutic alliance on an inpatient unit for eating disorders. International Journal of Eating Disorders, 16, 405-410.

Geller, J. (2006). Mechanisms of action in the process of change: Helping eating disorder clients make meaningful shifts in their lives. Clinical Child Psychology Psychiatry, 11, 225-237.

Ghaderi, A. (2006). Does individualization matter? A randomized trial of standardized (focused) versus individualized (broad) cognitive behaviour therapy for bulimia nervosa. Behaviour Research Therapy, 44, 273-288.

Grilo, C. M. (2000). Self-help and guided self-help treatments for bulimia nervosa and binge eating disorders. Journal of Psychiatric Practice, 6, 18-26.

Hay, P. P. J., Bacaltchuk, J., Byrnes, R. T., Claudino, A. M., Ekmejian, A. A., Yong, P. Y. (2003). Individual psychotherapy in the outpatient treatment of adults with anorexia nervosa (Review). Cochrane Database of Systematic Reviews, 4. Art. No.: CD003909. DOI:10.1002/14651858.CD003909.

Hay, P. J., Bacaltchuk, J., Stefano, S. (2004). Psychotherapy for bulimia nervosa and binging. Cochrane Database of Systematic Reviews, 3. Art. No.: CD000562. DOI: 10.1002/14651858.CD000562.pub2.

Hay, P. J., Loukas, A., Philpott, H. (2005). Prevalence and characteristics of men with eating disorders in primary care: How do they compare to women and what features may aid in identification? Primary Care & Community Psychiatry, 10, 1-6.

Hay, P.J., Marley, J., & Lemar, S. (1998). Covert eating disorders: the prevalence, characteristics and help-seeking of those with bulimic eating disorders in general practice. Primary Care Psychiatry, 4, 95-99.

Hay, P.J., Mond, J., Buttner, P., Darby, A. (2008). Eating disorder behaviours are increasing: Findings from two sequential community surveys in South Australia. PLoS ONE 3(2):e1541. Doi:101371/journal.pone0001541. Retrieved on 12 February 2009 from: http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0001541.

Hepworth, N. S., & Paxton, S. J. (2007). Pathways to help-seeking in bulimia nervosa and binge eating problems: a concept mapping approach. International Journal of Eating Disorders, 40, 493-504.

Hepworth, N. S., Paxton, S. J. & Williams, B. (2007). Predictors of attitudes towards treatments for bulimia nervosa. Australian and New Zealand Journal of Psychiatry. 41, 247-256.

Hoek, H. W. (2006). Incidence, prevalence and mortality of anorexia nervosa and other eating disorders. Current Opinion in Psychiatry, 19, 389-394.

21

Hoek, H. W., & Hoeken, D. van. (2003). Review of the prevalence and incidence of eating disorders. International Journal of Eating Disorders, 34, 383-396.

Jacobi, C., Hayward, C., de Zwaan, M., Kraemer, H. C., & Agras, W. S. (2004). Coming to terms with risk factors for eating disorders: Application of risk terminology and suggestions for a general taxonomy. Psychological Bulletin, 130, 19-65.

Kächele, H., Kordy, H., Richard, M., & Research Group TR-EAT (2001). Therapy amount and outcome of inpatient psychodynamic treatment of eating disorders in Germany: Data from a multicenter study. Psychotherapy Research, 11, 239-257.

Keel, P. K., & Haedt, A. (2008). Evidence-based psychosocial treatments for eating problems and eating disorders. Journal of Clinical Child and Adolescent Psychology, 37, 39-61.

Kotler, L. A., Bodreau, G. S., & Devlin, M. J. (2003). Emerging psychotherapies for eating disorders. Journal of Psychiatric Practice, 9, 431-441.

Levens, M. (1995). Eating disorders and magical control of the body. Treatment through art therapy. London: Routledge.

Lock, J., le Grange, D., Agras, W. S., & Dare, C. (2001). Treatment manual for anorexia nervosa: A family-based approach. New York: Guilford Press.

Loeb, K. L., Wilson, G. T., Labouvie, E., Pratt, E. M., Hayaki, J., Walsh, B. T., Agras, W. S., & Fairburn, C. G. (2005). Therapeutic alliance and treatment adherence in two interventions for bulimia nervosa: A study of process and outcome. Journal of Consulting and Clinical Psychology, 73, 1097-1106.

Manley, R. S., & Leichner, P. (2003). Anguish and Despair in Adolescents with Eating Disorders: Helping to Manage Suicidal Ideation and Impulses. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 24, 32-36.

Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology, 68, 438-450.

Mathers, C. D., Vos, E. T., Stevenson, C. E., & Begg, S. J. (2000). The Australian burden of disease study: measuring the loss of health from diseases, injuries and risk factors. Medical Journal of Australia, 172, 12, 592-596.

Matto, H. C. (1997). An integrative approach to the treatment of women with eating disorders. The Arts in Psychotherapy, 24, 347-354.

McIntosh, V. V. W., Jordan, J., Carter, F. A., Luty, S. E., McKenzie, J. M., Bulik, C. M., Frampton, C. M. A., & Joyce, P. R. (2005). Three psychotherapies for anorexia nervosa: A randomized, controlled trial. American Journal of Psychiatry, 162, 741-747.

Mitchell, J. E., Agras, S. & Wonderlich, S. (2007). Treatment of bulimia nervosa: Where are we and where are we going? International Journal of Eating Disorders, 40, 95-101.

22

Mitchell, J. E., Hoberman, H. N., Peterson, C. B., Mussell, M., & Pyle, R. L. (1996). Research on the psychotherapy of bulimia nervosa: Half empty or half full. International Journal of Eating Disorders, 20, 219-229.

Mond, J. M., Hay, P. J., Rodgers, B., & Owen, C. (2007). Health service utilization for eating disorders: findings from a community-based study. International Journal of Eating Disorders, 40, 399-409.

Munsch, S., Biedert, E., Meyer, A., Michael, T., Schlup, B., Tuch, A., & Margraf, J. (2007). A randomised comparison of cognitive behavioral therapy and behavioral weight loss treatment for overweight individuals with binge eating disorder. International Journal of Eating Disorders, 40, 102-113.

Murphy, S., Russell, L., & Waller, G. (2005). Integrated psychodynamic therapy for bulimia nervosa and binge eating disorder: Theory, practice and preliminary findings. European Eating Disorders Review, 13, 383-391.

Nathan, P. E., & Gorman, J. M. (2002). A guide to treatments that work. London: Oxford University Press.

National Institute for Clinical Excellence (NICE) (2004). Eating disorders. Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. Clinical Guideline 9. [WWW document]. URL http://www.nice.org.uk/CG009NICEguideline

Norcross, J. C. (Ed.). (2002). Psychotherapy relationships that work: Therapist contributions and responsiveness to patient needs. New York: Oxford University Press.

Paxton, S. J., Knauss, C. & Shelton, B. (In press). Guided Self-Help in the treatment of bulimia nervosa and binge eating disorders. In S. J. Paxton & P. J Hay (Eds.). Intervention Approaches for Body Dissatisfaction and Eating Disorders: Evidence and Practice. Sydney: IP Communications.

Pike, K. M., Devlin, M. J., & Loeb, K. L. (2004). Cognitive-behavioral therapy in the treatment of anorexia nervosa, bulimia nervosa, and binge eating disorder. In J. K. Thompson (Ed.), Handbook of eating disorders and obesity (pp. 130 – 162). Hoboken, NJ: John Wiley & Sons

Pike, K. M., Hilbert, A., Wilfley, D. E., Fairburn, C. G., Dohm, F.-A., Walsh, B. T., & Striegel-Moore, R. (2008). Toward an understanding of risk factors for anorexia nervosa: a case-control study. Psychological Medicine, 38, 1443-1453.

Pike, K. M., Walsh, B. T., Vitousek, K., Wilson, G. T., & Bauer, J. (2003). Cognitive behaviour therapy in the posthospitalization treatment of anorexia nervosa. The American Journal of Psychiatry, 160, 2046-2049.

Piran, N., Levine, M. P. Steiner-Addir, C. (Eds) (1999). Preventing Eating Disorders: A handbook of intervention & special challenges. Philadelphia: Taylor & Francis.

23

Pyle, R.L. (1999). Dynamic psychotherapy. In M. Hersen & A.S. Bellack (Eds.),

Handbook of comparative interventions for adult disorders (2nd

edn., pp.460-490).New York: Wiley.

Richard, M. for COST Action B6 (2005). Effective treatment of eating disorders in Europe: Treatment outcome and its predictors. European Eating Disorders Review, 13, 169-179.

Robin, A. L., Siegle, P. T., Moye, A. (1995). Family versus individual therapy for anorexia: Impact on family conflict. International Journal of Eating Disorders, 17, 313-322.

Robin, A. L., Siegel, P. T., Moye, A. W., Gildory, M, Dennis, A B, & Sikand, A. (1999). A controlled comparison of family versus individual therapy for adolescents with anorexia nervosa. Journal of the American Academy of Child Psychiatry, 38, 1482-1489.

Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines Team for Anorexia Nervosa (RANZCP) (2004). Australian and New Zealand clinical practice guidelines for the treatment of anorexia nervosa. Australian and New Zealand Journal of Psychiatry, 38, 659-670.

Schmidt, U., Lee, S., Beecham, J., Perkins, S., Treasure, J., Yi, I. et al. (2007). A randomized controlled trial of family therapy and cognitive behaviour therapy guided self-care for adolescents with bulimia nervosa and related disorders. The American Journal of Psychiatry, 164, 591-598.

Shapiro, J. R., Berkman, N. D., Brownely, K. A., Sedway, J. A., Lohr, K. N., & Bulik, C. M. (2007). Bulimia nervosa treatment: A systematic review of randomized controlled trials. International Journal of Eating Disorders, 40, 321-336.

Steinhausen, H.-C. (2002). The outcome of anorexia nervosa in the 20th

century. The American Journal of Psychiatry, 159, 1284-1293.

Stice, E. (2002). Risk and maintenance factors for eating pathology: A meta-analytic review. Psychological Bulletin, 128, 825-848.

Stice, E., & Agras, S. (1998). Predicting onset and cessation bulimic behaviors during adolescence: A longitudinal grouping analysis. Behavior Therapy. 29, 257-276.

Stefano, S. C., Bacaltchuk, J., Blay, S. L. & Hay, P. (2006). Self-help treatments for disorders of recurrent binge eating: A systematic review. Acta Psychiatrica Scandinavica, 113, 452-459.

Striegle-Moore, R. H., & Bulik, C. M. (2007). Risk factors for eating disorders. American Psychologist, 42, 181-198.

Thompson, J. K. (Ed.). (2004). Handbook of eating disorders and obesity. New Jersey: John Wiley.

24

Thompson-Brenner, H., Glass, S., & Westen, D. (2003). A multidimensional meta-analysis of psychotherapy for bulimia nervosa. Clinical Psychology: Science and Practice, 10, 269-287.

Toman, E. (2002). Body mass index and its impact on the therapeutic alliance in the work with eating disorder patients. European Eating Disorders Review, 10, 168-178.

Treasure, J. (2004). A guide to the medical risk assessment for eating disorders. King’s College London, Section of Eating Disorders, Institute of Psychiatry. [WWW document]. URL http://www.iop.kcl.ac.uk/sites/edu/?id=73#item03.

Tuntleff-Dunn, S., Gokee-LaRose, J., & Peterson, R. D. (2004). Interpersonal psychotherapy for the treatment of anorexia nervosa, bulimia nervosa, and binge eating disorder. In J. K. Thompson (Ed.), Handbook of eating disorders and obesity (pp. 163 – 185). Hoboken, NJ: John Wiley & Sons.

UK Department of Health. (2001). Treatment choice in psychological therapies and counselling: Evidence based clinical practice guideline. [WWW document]. URL Http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4007323.

Wade, T. D., Bergin, J. L., Tiggemann, M., Bulik, C. M., & Fairburn, C. G. (2006). Prevalence and long-term course of lifetime eating disorders in an adult Australian twin cohort. Australian and New Zealand Journal of Psychiatry.40, 121-128.

Waller, G., Cordery, H., Corstorphine, E., Hinrichsen, H., Lawson, R., Mountford, V., & Russell, K. (2007). Cognitive behavioral therapy for eating disorders. A comprehensive treatment guide. Cambridge: University Press.

Wilson, G. T., Grilo, C. M., & Vitousek, K. M. (2007). Psychological treatment of eating disorders. American Psychologist, 62, 199-216.

Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Mahwah, NJ: Lawrence Erlbaum.

Yager, J. (2003). E-mail therapy for anorexia nervosa: Prospects and limitations. European Eating Disorders Review, 11, 198-209.

Zipfel, S., Lowe, B., Deter, H. C. & Herzog, W. (2000). Long-term prognosis in anorexia nervosa: Lessons for a 21-year follow-up study. Lancet, 355, 721-722.