Hunna J. Watson, Ph.D.

Evidence-Based Cynthia M. Bulik, Ph.D.

Psychotherapy for
Eating Disorders

SYNTHESIS
CLINICAL
Abstract: Recommended psychotherapies for treating bulimia nervosa and binge eating disorder have been clearly established,
with cognitive-behavioral therapy representing the leading choice. Second line psychotherapies for bulimia nervosa and binge
eating disorder are interpersonal psychotherapy, as well as dialectical behavior therapy for bulimia nervosa and behavioral
weight loss for binge eating disorder. An urgent need remains for effective and acceptable treatments for anorexia nervosa
among adults with the choice of treatment currently informed by an array of psychotherapies with weak efficacy; trends toward
high treatment drop out and poor adherence are important issues to resolve. Among children and adolescents with anorexia
nervosa, and to some extent bulimia nervosa, family-based treatments that directly target eating are favored. Pharmacotherapy
may also be recommended for some individuals with eating disorders, which would be administered by a primary care
practitioner or psychiatrist for more severe, chronic cases or cases in which considerable psychiatric comorbidity is present.
Treatment for eating disorders commonly involves a collaborative health care team that includes a psychotherapist and
psychiatrist along with a primary care practitioner for regular monitoring of physical state.

EVIDENCE-BASED PSYCHOTHERAPY FOR a restriction of intake below energy needs, omitting

EATING DISORDERS
CLINICAL CONTEXT
According to the Diagnostic and Statistical Manual,
Fourth Edition (DSM-IV) (1), lifetime prevalence
estimates for eating disorders in the United States are:
0.9% for anorexia nervosa, 1.5% for bulimia nervosa,
and 3.5% for binge eating disorder among women;
and 0.3% for anorexia nervosa, 0.5% for bulimia
nervosa, and 2.0% for binge eating disorder among
men (2). The onset of eating disorders is typically in
adolescence, with puberty a critical risk period, but
the disorders may occur in patients as young as 7 and
as old as 70 years or more (3). Eating disorders can
have substantial and sustained physical consequences,
comorbidity, mortality, chronicity, and functional
impairment (4, 5).
The Diagnostic and Statistical Manual (DSM-5)
(6) groups together eating and feeding disorders;
here we cover the eating disorder diagnoses anorexia
nervosa, bulimia nervosa, binge eating disorder, and
other specified feeding and eating disorders. The
diagnostic criteria are outlined in Table 1. Eating
disorders involve dysregulated eating habits such as
entire food groups (e.g., fats or carbohydrates),
calorie counting, skipping meals, and fasting. For
some there is a cyclic pattern of restricting, which
brings on the body’s starvation response, triggers
binge eating, and then leads to further restricting
and compensatory behaviors to neutralize the calo-
ries consumed. Binge eating is similar to overeating
in that both involve consuming an unusually large
amount of food in a discrete period of time, but
Author Information and Disclosure
Hunna J. Watson, Ph.D., Department of Psychiatry, University of North Carolina at Chapel Hill, North
Carolina, United States; Eating Disorders Program, Specialized Child and Adolescent Mental Health
Service, Department of Health in Western Australia, Perth, Western Australia, Australia; School of
Psychology and Speech Pathology, Curtin University, Perth, Western Australia, Australia; and School of
Paediatrics and Child Health, The University of Western Australia, Perth, Western Australia, Australia
Cynthia M. Bulik, Ph.D., Department of Psychiatry, University of North Carolina at Chapel Hill;
Department of Nutrition, University of North Carolina at Chapel Hill, North Carolina, United States; and
Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
Dr. Watson reports no competing interests.
Dr. Bulik reports the following disclosure: Consultant: Shire Biopharmaceuticals.
Address correspondence to Dr. Cynthia Bulik, Department of Psychiatry, University of North Carolina at
Chapel Hill, CB#7160, 101 Manning Drive, Chapel Hill, NC, 27599; e-mail: cbulik@med.unc.edu

focus.psychiatryonline.org FOCUS Fall 2014, Vol. XII, No. 4 379

 WATSON AND BULIK

Table 1. Summary of DSM–5 Eating Disorder Diagnoses

Diagnosis Key features
Anorexia nervosa Significantly low body weight due to persistent restriction of energy intake, fear of
gaining weight or becoming fat, or enduring behavior that prevents weight gain, and
body image disturbance.
Bulimia nervosa Objective binge eating plus inappropriate compensatory behaviors to prevent weight
gain (e.g., self-induced vomiting, fasting, excessive exercise) that recur on average
more than or at least once per week for 3 months.
Binge eating disorder Binge eating associated with feeling embarrassed, depressed, or guilty afterward,
and marked distress regarding the binge episode that recurs more than or at
least once per week for 3 months with no recurrent use of inappropriate compensatory
behaviors.
Other specified feeding or Atypical anorexia nervosa: individual’s weight is within or above the normal range
eating disorders (although significant weight loss has occurred);
Bulimia nervosa (of low frequency and/or limited duration);
Binge eating disorder (of low frequency and/or limited duration);
Purging disorder: purging behavior to influence weight or shape while no binge eating is present;
Night eating syndrome: episodes of eating after awakening from sleep, or by consumption of high
amounts of food after the evening meal.
Unspecified feeding or Eating-related behaviors causing clinically significant distress while full criteria for any
eating disorder of the feeding or eating disorders are not met.

binge eating is distinguished by the accompanying
sense of loss of control (i.e., feeling unable to stop
eating). Compensatory behaviors include purging
(self-induced vomiting, laxatives, and diuretics), fast-
ing, and compulsive exercise.
Long-term medical complications of eating dis-
orders are significant. Starvation and purging symp-
toms have the potential to deteriorate every major
organ system in the body, leading to kidney damage,
anemia, cardiovascular problems, dental problems,
and changes in brain structure. Osteoporosis and
osteopenia are irreversible consequences of malnu-
trition. Obesity is commonly associated with BED,
but BED also occurs in normal weight individuals
(7). Mortality and morbidity are elevated across all
eating disorders (4, 8).
Psychotherapy for eating disorders may occur in
a number of contexts. Some patients may do well
with empirically supported self-help or outpatient
psychotherapy. Others may require more intensive
treatment in the form of day or partial hospitaliza-
tion or intensive outpatient treatment, which may
include structured meal support, family interven-
tions, group psychotherapy, cooking and nutrition
groups, and social skills interventions (9). Psy-
chotherapy for anorexia nervosa may occur along
with medical admissions for those patients who are
acutely medically unwell and/or severely malnour-
ished. Attempts to conduct formal psychotherapy
when the patient is severely malnourished can be
ineffective, because of mild cognitive impairment
(10). Supportive psychotherapeutic interventions
more intensive psychotherapies until renourishment is
well underway (10).
TREATMENT STRATEGIES AND EVIDENCE
The “gold standard” method for evaluating the
efficacy of psychotherapies is the randomized con-
trolled trial (RCT). Yet, controlled trial research in
anorexia nervosa and among children with eating
disorders in general is hampered by methodological
challenges. The acute prospect of mortality from
anorexia nervosa and the long-term risks to growth
and physical development in children preclude the
use of a no-treatment or delayed treatment control
group, complicating the evaluation of specific treat-
ment effects (11). For anorexia nervosa, high treatment
drop out (∼50%) can compromise randomization,
and the egosyntonicity of the illness can lead to low
treatment adherence. In some RCTs, uncontrolled
background treatments (i.e., inpatient care) are present
(12). To understand the current state of the evidence
for psychotherapies in eating disorders, a multipronged
approach that considers RCTs or other systematic re-
search studies, clinical practice guidelines, and emerg-
ing interventions is worthwhile. This approach informs
this review.
ADULTS
ANOREXIA NERVOSA

that provide empathy, support, and positive behav- There is no strong evidence for the efficacy of any
ioral reinforcement may be more appropriate than psychotherapy or pharmacotherapy in the treatment

380 Fall 2014, Vol. XII, No. 4 FOCUS THE JOURNAL OF LIFELONG LEARNING IN PSYCHIATRY

of anorexia nervosa in adults. Clinical practice guide-
lines (13, 14) recommend considering cognitive-
behavioral therapy (CBT), interpersonal psychotherapy
(IPT), cognitive analytic therapy, and focal psycho-
dynamic therapy, and regular physical monitoring by
a primary care practitioner. These psychotherapies
are the most well-evaluated and theoretically sup-
ported approaches. The RCT base is limited (11),
and marred by small sample sizes, high drop out, short
duration, lack of long-term follow-up, and other
methodological issues.
Since the publication of clinical guidelines new
data have been reported. A large, multicenter RCT
compared 10 months of focal psychodynamic
therapy, CBT enhanced (CBT-E), and optimized
treatment-as-usual (15). At endpoint, intent-to-treat
analysis showed significantly increased body mass
index (BMI) in all groups and no treatment differ-
ences. At 12 month follow-up, BMI continued to
improve but again, there were no differences by
treatment. Thirty percent of the patients dropped out
during treatment.
In addition, seven year follow-up data were
reported from an RCT that compared CBT, IPT,
and specialist supportive clinical management
(16, 17). At treatment completion, a significantly
greater number of patients who completed spe-
cialist supportive clinical management (36%) no
longer met diagnostic criteria for anorexia ner-
vosa, compared with 8% who completed CBT and
0% who completed IPT. In the intent-to-treat
sample, 25% assigned to specialist supportive clin-
ical management, 5% assigned to CBT, and 0%
assigned to IPT no longer met diagnostic criteria
at posttreatment (16). However, at 7-year follow-
up there were no statistically significant differ-
ences between the treatments, with 64% in IPT,
42% in specialist supportive clinical management,
and 41% in CBT no longer meeting diagnostic
criteria (17).
Several large RCTs involving a range of psy-
chotherapies are currently underway (see 11).
Modalities under evaluation include CBT, couple-
based CBT, exposure and response prevention,
specialist supportive clinical management, focal
psychodynamic therapy, and two relatively new
interventions: cognitive remediation therapy and
a social-cognitive interpersonal psychotherapy
(MANTRA). Cognitive remediation therapy ad-
dresses neuropsychological mechanisms impli-
cated in anorexia nervosa including rigidity and
weak central coherence, and MANTRA targets
intrapersonal and interpersonal processes that
maintain anorexia nervosa by helping individ-
uals to express and process emotions and social
relationships.
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WATSON AND BULIK
BULIMIA NERVOSA AND BINGE EATING
DISORDER
FIRST LINE PSYCHOTHERAPY
The first line treatment for adults with bulimia
nervosa (or bulimia-like illnesses) is CBT designed
specifically for bulimia nervosa (13, 14). CBT for
bulimia was developed soon after bulimia nervosa
entered the medical literature (18) and is time-
limited with a duration of approximately 20 weekly
SYNTHESIS
CLINICAL
sessions. CBT is also a first line approach for binge
eating disorder (13, 14).
One CBT model for bulimia (18) proposes that
the disorder is maintained by problems with self-
esteem and extreme concerns about shape and
weight. These interact to produce strict dieting,
binge eating, and compensatory behaviors, which
become part of a self-perpetuating vicious cycle. In
some individuals, binge eating emerges in rebound
from restrictive eating; in others, binge eating arises
in the absence of dieting or dietary restraint. CBT
addresses cognitive, emotional, and behavioral fac-
tors that maintain the disorder. A key first step is the
normalization of meals and snacks, which offsets
the likelihood of a binge episode, in turn reducing
the use of compensatory behaviors. The model has
been extended to binge eating disorder (19) with the
normalization of eating patterns aimed at countering
both restriction and binge eating.
The research supporting a CBT treatment ap-
proach is robust (20, 21), hence it is recommended
in clinical practice guidelines around the world as
the leading treatment for bulimia nervosa (10, 13).
On average, approximately 50% of patients with
bulimia who undergo a course of CBT attain binge-
purge abstinence (22). Treatment normally lasts 12
to 20 sessions held over 3 to 5 months. Antide-
pressant medication may be an alternative or addi-
tional first step (13). Fluoxetine for bulimia nervosa
is the only Food and Drug Administration-approved
medication for any eating disorder, and although it is
effective at reducing binge eating in the short run, it is
of unknown long-term efficacy as a sole treatment
(23). Guided self-help and pure self-help CBT for
bulimia nervosa are also effective in reducing the
frequency of binge eating and purging but may be less
effective in achieving abstinence from these behav-
iors than face-to-face psychotherapy (24). Empiri-
cally supported self-help is recommended for use in
a stepped care approach or when standard CBT is
inaccessible.
CBT for binge eating disorder has been tested in
individual, group, and self-help formats (25) and is
recognized in guidelines as the first line approach
FOCUS Fall 2014, Vol. XII, No. 4 381
 WATSON AND BULIK
(13, 14). Remission rates for binge eating at post-
treatment are around 50% (26). In the United
Kingdom, self-help is recommended as the first line
approach in the treatment of binge eating disor-
der (13). Pharmacotherapy may also play a role
in the treatment of binge eating disorder. Classes
of medications showing some efficacy include
antidepressants, anticonvulsants, and antiobesity
agents (25).
CBT has been recast by Fairburn (27) to apply to
all eating disorders (CBT-E) and to address addi-
tional maintaining factors (perfectionism, mood
intolerance, core low self-esteem, and interpersonal
difficulties).
SECOND LINE PSYCHOTHERAPIES
IPT is recommended as a second line approach in
the National Institutes of Health and Clinical Ex-
cellence and American Psychiatric Association
practice guidelines (13, 14). IPT was originally de-
veloped in the 1960s for the treatment of unipolar
depression, and was adapted for bulimia nervosa in
the late 1980s (28) and for binge eating disorder in
the 1990s (29). For individuals with bulimia ner-
vosa and binge eating disorder who complete treat-
ment, binge (and purge) abstinence rates are around
50% (30). The IPT model posits that difficulties in
interpersonal relationships and functioning contrib-
ute to the development and maintenance of psy-
chiatric symptoms. The treatment is time-limited
(approximately 20 weekly sessions) and involves
three phases: assessment of the interpersonal issues
affecting the patient’s symptoms, therapeutic work
to help the patient make interpersonal changes in
one or more of four IPT areas of role disputes, role
transitions, interpersonal deficits, unresolved grief,
and last, a termination phase. IPT for bulimia nervosa
demonstrates equivalent outcomes to CBT at longer-
term follow-up, but achieves its effects less rapidly
(21, 30). In a large multicenter trial of CBT and IPT
for bulimia nervosa (30), binge eating and purging
abstinence in the intent-to-treat sample was 29%
for CBT and 6% for IPT at posttreatment, and 22%
for CBT and 18% for IPT at 4 month follow-up.
Regarding binge eating disorder, the first line of
treatment is CBT in a self-help form with direct
support from a health professional, followed by
standard CBT if self-help is declined. If the illness
persists, IPT or dialectical behavior therapy (DBT)
modified for binge eating disorder are treatments to
consider.
DBT has been less extensively evaluated for bu-
limia nervosa and binge eating disorder than CBT,
but has demonstrated efficacy. DBT acts on the
patient’s emotion regulation skills, with the goal of
382 Fall 2014, Vol. XII, No. 4 FOCUS THE JOURNAL OF LIFELONG LEARNING IN PSYCHIATRY
improving coping with emotional distress so that
binging and purging are reduced. Treatment is
adapted from Linehan’s DBT protocol for border-
line personality disorder (31, 32) and detailed in
a manual (33), which recommends 20 weekly ses-
sions. DBT has been evaluated among individuals
with binge eating disorder in two RCTs, in a group
format. In the first, DBT was superior to wait-list,
with 89% binge abstinent at posttreatment com-
pared with 12.5% for wait-list, and 56% in the
DBT group abstinent at 6-month follow-up (34).
The second trial found that DBT was superior to
a nonspecific control at posttreatment (64% versus
36%), but there was no difference at 12-month
follow-up (64% versus 56%) (35).
A behavioral weight loss (BWL) intervention
widely used in obesity RCTs and empirically sup-
ported as a self-help intervention for obesity (36) has
been tested for efficacy among overweight and obese
individuals with binge eating disorder. It has been
effective in reducing binge eating and eating pa-
thology, however, CBT and IPT have been shown
to be more effective in addressing core eating pa-
thology (37). The BWL intervention involves life-
style changes in exercise and nutrition with a focus
on increased physical activity and moderate caloric
restriction to produce gradual, modest weight loss.
The intervention lasts for 12 weeks.
OTHER EATING DISORDERS
Expert consensus suggests that to manage other
and unspecified eating disorders, the best approach
is to match the clinical presentation to one for
which a treatment is indicated, and to treat with the
respective first line psychotherapy and/or pharma-
cotherapy, until new evidence emerges (14). Night
eating syndrome is a recently described presenta-
tion. Selective serotonin reuptake inhibitors have
shown promise for night eating syndrome in two
RCTs, but these also indicate a strong placebo
response (38). Night eating syndrome has not been
the subject of any psychotherapy RCTs. CBT
has been suggested as a candidate psychotherapy
approach.
CHILDREN AND ADOLESCENTS
ANOREXIA NERVOSA
For young people with anorexia nervosa, a spe-
cific type of family therapy known as family-based
treatment (FBT) is recommended (13, 14) and
is effective for approximately 50% of patients.
No pharmacotherapy interventions have proved

efficacious. FBT consists of 20 sessions provided
over 6 months, and is detailed in a treatment manual
(39). In the treatment, parents are considered the
best resources for their child’s recovery and are
urged to take an active role in treatment. Treatment
has three phases including: 1) parents taking charge
of child refeeding and weight gain; 2) transitioning
control over eating back to the child in a de-
velopmentally appropriate way; and 3) establishing
a healthy relationship with parents and addressing
developmental issues problematic to the young
person.
FBT is the most well-evaluated approach to other
psychotherapies, has some evidence of superiority to
other psychotherapies and therefore forms the basis
for clinical recommendations. Despite promise, the
evidence is limited. Of the 11 treatment RCTs for
anorexia nervosa in predominantly youth samples
(11), nine examined family therapy, but only two
compared family therapy to an alternative treatment
(the remainder varied an aspect of family therapy
delivery between the trial arms) (11). In the largest
and most rigorous trial to date (40), there were
no differences in remission between FBT and
adolescent-focused psychotherapy (AFP) at treat-
ment completion (42% versus 23%), but the pro-
portion remitted in FBT was higher at 6-month
(40% versus 18%) and 12-month follow-up (49%
versus 23%). AFP, used as the comparison in the
largest RCT, is an intervention approach that as-
sists the adolescent in adaptively coping with emo-
tions and developmental challenges. It is based in
self-psychology and psychodynamic theory, and con-
siders pathology as arising from unmet developmental
needs. The intervention techniques do not target food,
weight, or body image cognitions directly, but rather
draw on a range of techniques (cognitive, mindfulness,
interpersonal, and behavioral) to manage stressors that
give rise to symptoms. The FBT evidence base at-
tracts criticism by not yet using comparisons that
might be considered reasonable alternatives (i.e., CBT
and IPT).
BULIMIA NERVOSA AND BINGE EATING DISORDER
For bulimia nervosa in adolescents, the research
evidence and clinical guidance are sparse. The pub-
lication of clinical practice guidelines predates the ac-
cumulated RCT evidence. FBT modified for bulimia
nervosa and CBT guided self-help appear to be
reasonable options. FBT is time-limited and involves
20 sessions conducted over 6 months. The phases
mirror those of FBT for anorexia nervosa, with slight
differences. For example, in the first phase parents are
empowered to disrupt binge eating, purging, dieting,
and other unhealthy forms of weight control without
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WATSON AND BULIK
the focus on refeeding. CBT-guided self-help can
be delivered using the same manual used with
adults (41). CBT focuses on the normalization of
eating patterns to reduce binge eating and managing
thoughts, feeling, and situations that serve as trig-
gers for disordered eating behaviors. The comple-
tion of daily self-monitoring records and learning
tools to challenge cognitive distortions are core com-
ponents of treatment.
One RCT among adolescents with bulimia ner-
vosa has been conducted. Significantly more pa-
tients treated with FBT compared with supportive
SYNTHESIS
CLINICAL
psychotherapy were binge- and purge-abstinent at
posttreatment (39% versus 18%) and at 6-month
follow-up (29% versus 10%) (42). In one further
relevant RCT, two-thirds of the overall sample had
bulimia nervosa and the remainder had eating dis-
orders not otherwise specified (43). The abstinence
rate for CBT-guided self-help was significantly higher
than for FBT at posttreatment (42% versus 25%),
although the effects were the same at 6-month follow-
up (52% versus 55%).
No clinical trials have been conducted aimed
specifically at treating binge eating disorder in adoles-
cents, although several have shown positive response
in reducing binge eating behavior (44–46). One trial
is underway comparing CBT with a wait-list control
for binge eating disorder in adolescents (47) and one
integrating components of DBT, such as mindful-
ness and distress tolerance skills training, and CBT
targeting loss of control eating in adolescents (48).
OTHER EATING DISORDERS
As for adults, the recommended approach is to use
the treatment guidance for anorexia nervosa or bu-
limia nervosa, depending on which condition the
eating disorder most resembles (14).
QUESTIONS AND CONTROVERSY
Despite the existence of empirically supported
treatments, it is important to be aware that there are
wide ranges of outcomes—many fully successful and
some quite chronic with multiple hospitalizations.
For adults with anorexia nervosa, success at post-
treatment is less than 25%, largely because of sub-
stantial drop out (17). For bulimia nervosa and
binge eating disorder in adults, the symptom re-
mission rate associated with the leading psycho-
therapies is around 50% (for those completing
treatment) (22, 26). About half of the young people
with anorexia nervosa treated with family-based
treatment remit (40).
Few prognostic factors for treatment outcome
have been reliably identified. For anorexia nervosa,
FOCUS Fall 2014, Vol. XII, No. 4 383
 WATSON AND BULIK
a longer duration of illness and longer duration of
treatment and/or need for inpatient hospitaliza-
tion are associated with worse outcomes (49). Pre-
dictors of relapse have included a lower desired body
weight and treatment at a generalist (rather than
specialist) clinic (49). A wide range of dietary choices
is also associated with positive prognosis in anorexia
nervosa suggesting less rigidity associated with food
intake (50). For bulimia nervosa, psychiatric com-
orbidity and comorbid symptom severity predict
poorer outcomes, and as yet, not much is known
about prognostic factors for binge eating disorder
(49). Clearly, there is room for improvement of
treatment outcomes and for understanding prog-
nostic factors.
Treatment refusal among patients with anorexia
nervosa is frequently encountered. Clinical decision-
making in this context involves ethical and medico-
legal considerations that vary from jurisdiction to
jurisdiction. The vantage points are complex: on
the one hand, compelling a person to treatment
(i.e., through a compulsive treatment order or legal
guardianship) deprives liberty and may violate
confidentiality and privacy, yet it is typically a last
resort to preserve life. There is a general consensus
supporting the use of legal interventions if the eating
disorder poses mortal danger (14). Engaging and
retaining adults with anorexia nervosa in treatment
is of primary importance, although challenging
given that the core treatment goal (i.e., weight gain)
is the outcome that they most fear.
A robust debate within the field pertains to the
degree to which FBT has become accepted as the
treatment of choice for anorexia nervosa in children
and adolescents. A recent debate feature captures
some of these viewpoints, which the reader may find
worth exploring (51, 52).
Binge eating disorder is often associated with
overweight and obesity, which leads to a question
about the degree to which psychotherapy should
incorporate weight loss or weight management strat-
egies. The primary clinical outcome for binge eat-
ing disorder is binge abstinence, yet in the context
of overweight and obesity, weight and BMI are im-
portant secondary outcomes. Weight losses with psy-
chotherapy have been modest and variable, with
BWL having a slightly larger effect than CBT (53).
As patients are typically on the path of gaining weight
prior to treatment (54), psychotherapy interventions
appear to prevent additional weight gain at least in
the short term (53, 54). There is no evidence sub-
stantiating the concern that moderate caloric restric-
tion in BWL triggers binge eating (37). Although many
individuals with binge eating disorder seek weight loss
as a therapeutic goal, others believe that a lifelong
focus on weight loss has contributed to and perpet-
384 Fall 2014, Vol. XII, No. 4 FOCUS THE JOURNAL OF LIFELONG LEARNING IN PSYCHIATRY
uated their disorder, and contend that a therapeutic
focus on decreasing weight stigma and healthy life-
styles is preferred (55).
As new technologies develop and the Inter-
net grows, technology is increasingly being used
to enhance the delivery, accessibility, and cost-
effectiveness of psychotherapy (56). Internet-based
therapies for eating disorders, virtual reality-based
treatments, telemedicine, and smartphone applica-
tions (e.g., self-monitoring records), are examples
of current applications in either research or prac-
tice. Benefits are foreseeable for individuals or
health professionals with limited access to special-
ists, or when treatment experience can be enhanced
by technology integration, such as making home-
work more convenient and reducing stigma around
treatment-seeking.
RECOMMENDATIONS FROM THE AUTHORS
A physician should always be part of the treatment
team to manage general medical issues related to an
eating disorder, and pharmacotherapy may play
a crucial role in some presentations, delivered by
a primary care practitioner or psychiatrist when more
severe or recalcitrant pathology and/or psychiatric
comorbidity are present (13, 14). The preferred
setting for psychotherapy is the least restrictive set-
ting, to reduce disruption to the patient’s family,
social, academic, and work activities. However,
clinical deterioration should raise attention to the
need for a higher level of care.
Currently, for adults with anorexia nervosa, there
is no clear evidence for the efficacy of any approach,
and reasonable choices include CBT, IPT, cognitive
analytic therapy, or supportive interventions such as
specialist supportive clinical management—bearing
in mind that psychotherapy may be optimally ef-
fective after renourishment is well underway and
that supportive therapy may be optimal in the un-
derweight state. For bulimia nervosa and binge
eating disorder, CBT and/or antidepressant medi-
cation are considered to be first line treatments, and
IPT and DBT (and BWL for binge eating disorder)
are acceptable second line approaches. For anorexia
nervosa in young people, FBT or family interven-
tions that specifically target the eating disorder are
appropriate.
Beyond the specific components of the inter-
ventions, the therapeutic stance should balance
empathy and therapeutic firmness. Many eating dis-
order behaviors are perplexing, for instance, intense
and seemingly irrational anxiety regarding forbidden
foods and secrecy and deception regarding binge
eating. Clinicians should guard against their own
preconceptions and misperceptions. It is helpful to
 WATSON AND BULIK

Figure 1. Further Resources

SYNTHESIS
CLINICAL

understand the ambivalence and fears the patient
holds regarding recovery, and to reframe treatment
resistance as part of the illness, not part of the in-
dividual (57). Working with people with eating
disorders can be a very rewarding experience, despite
being challenging at times, with treatment offering
abundant prospects for the long-term physical and
psychological health of these individuals. Additional
resources are listed in Figure 1.
ACKNOWLEDGMENTS
We thank Karina Limburg, a research assistant at Princess Margaret Hospital for
Children Eating Disorders Program, Perth, Western Australia, for collating and
summarizing information used to prepare this manuscript.

focus.psychiatryonline.org FOCUS Fall 2014, Vol. XII, No. 4 385

 WATSON AND BULIK
REFERENCES
1. American Psychiatric Association: Diagnostic and statistical manual of
mental disorders, 4th ed. Washington, DC, American Psychiatric Associa-
tion, 2000
2. Hudson JI, Hiripi E, Pope HG Jr, Kessler RC: The prevalence and correlates of
eating disorders in the National Comorbidity Survey Replication. Biol Psy-
chiatry 2007; 61:348–358
3. Beck D, Casper R, Andersen A: Truly late onset of eating disorders: a study
of 11 cases averaging 60 years of age at presentation. Int J Eat Disord 1996;
20:389–395
4. Arcelus J, Mitchell AJ, Wales J, Nielsen S: Mortality rates in patients with
anorexia nervosa and other eating disorders. A meta-analysis of 36 studies.
Arch Gen Psychiatry 2011; 68:724–731
5. Bulik CM: Anxiety and depression in eating disorders, in Eating disorders
and obesity: A comprehensive handbook. Edited by Brownell K. New York,
Guilford Press, 2001, pp 193–198
6. American Psychiatric Association: Diagnostic and statistical manual of
mental disorders (DSM-V), 5th ed, Washington, DC, American Psychiatric
Association, 2013
7. Kessler RC, Berglund PA, Chiu WT, et al. (2013) The prevalence and corre-
lates of binge eating disorder in the World Health Organization World Mental
Health Surveys. Biol Psychiatry 73: 904–914.
8. Johnson J, Spitzer R and Williams J. (2001) Health problems, impairment
and illnesses associated with bulimia nervosa and binge eating disorder
among primary care and obstetric gynaecology patients. Psychol Med 31:
1455–1466.
9. Zipfel S, Reas DL, Thornton C, Olmsted MP, Williamson DA, Gerlinghoff M,
Herzog W, Beumont PJ: Day hospitalization programs for eating dis-
orders: a systematic review of the literature. Int J Eat Disord 2002; 31:
105–117
10. American Psychiatric Association: Practice guideline for the treatment of
patients with eating disorders, 3rd ed. Washington, DC, American Psychi-
atric Association, 2006
11. Watson HJ, Bulik CM: Update on the treatment of anorexia nervosa: review
of clinical trials, practice guidelines and emerging interventions. Psychol
Med 2013; 43:2477–2500
12. Geist R, Heinmaa M, Stephens D, Davis R, Katzman DK: Comparison of
family therapy and family group psychoeducation in adolescents with an-
orexia nervosa. Can J Psychiatry 2000; 45:173–178
13. National Institute for Clinical Excellence: Eating disorders. Core interven-
tions in the treatment and management of anorexia nervosa, bulimia ner-
vosa and related eating disorders. London, NHS, 2004
14. American Psychiatric Association Work Group on Eating Disorders: Practice
guideline for the treatment of patients with eating disorders (revision). Am J
Psychiatry 2000; 157(Suppl):1–39
15. Zipfel S, Wild B, Groß G, Friederich H-C, Teufel M, Schellberg D, Giel KE,
de Zwaan M, Dinkel A, Herpertz S, Burgmer M, Löwe B, Tagay S, von
Wietersheim J, Zeeck A, Schade-Brittinger C, Schauenburg H, Herzog W;
ANTOP study group: Focal psychodynamic therapy, cognitive behaviour
therapy, and optimised treatment as usual in outpatients with anorexia
nervosa (ANTOP study): randomised controlled trial. Lancet 2014; 383:
127–137
16. Carter FA, Jordan J, McIntosh VV, Luty SE, McKenzie JM, Frampton CM,
Bulik CM, Joyce PR: The long-term efficacy of three psychotherapies for
anorexia nervosa: a randomized, controlled trial. Int J Eat Disord 2011; 44:
647–654
17. McIntosh VV, Jordan J, Carter FA, Luty SE, McKenzie JM, Bulik CM, Frampton
CM, Joyce PR: Three psychotherapies for anorexia nervosa: a randomized,
controlled trial. Am J Psychiatry 2005; 162:741–747
18. Fairburn C, Marcus M, Wilson G: Cognitive-behavioral therapy for binge-
eating: a comprehensive treatment manual, in Binge eating: Nature, as-
sessment and treatment. Edited by Fairburn CG, Wilson GT. New York,
Guilford Press, 1993, pp 361–404
19. Carter JC, Fairburn CG: Cognitive-behavioral self-help for binge eating
disorder: a controlled effectiveness study. J Consult Clin Psychol 1998;
66:616–623
20. Hay PP, Bacaltchuk J, Stefano S, Kashyap P: Psychological treatments for
bulimia nervosa and binging. Cochrane Database Syst Rev 2009; (4):
CD000562
21. Shapiro JR, Berkman ND, Brownley KA, Sedway JA, Lohr KN, Bulik CM:
Bulimia nervosa treatment: a systematic review of randomized controlled
trials. Int J Eat Disord 2007; 40:321–336
22. Wilson GT: Treatment of bulimia nervosa: when CBT fails. Behav Res Ther
1996; 34:197–212
23. Fluoxetine Bulimia Nervosa Collaborative Study Group: Fluoxetine in the
treatment of bulimia nervosa. A multicenter, placebo-controlled, double-
blind trial. Arch Gen Psychiatry 1992; 49:139–147
386 Fall 2014, Vol. XII, No. 4 FOCUS THE JOURNAL OF LIFELONG LEARNING IN PSYCHIATRY
24. Von Ranson KM, Farstad SM: Self-help approaches in the treatment of
eating disorders, substance use disorders, and addictions, in Eating dis-
orders, addictions, and substance use disorders: research, clinical and
treatment perspectives. Edited by Brewerton TD, Dennis AB, Berlin,
Springer-Verlag, 2014, pp 587–608
25. Brownley KA, Berkman ND, Sedway JA, Lohr KN, Bulik CM: Binge eating
disorder treatment: a systematic review of randomized controlled trials. Int J
Eat Disord 2007; 40:337–348
26. Hay P: A systematic review of evidence for psychological treatments in
eating disorders: 2005-2012. Int J Eat Disord 2013; 46:462–469
27. Fairburn CG: Cognitive behavior therapy and eating disorders. New York,
Guilford Press, 2008
28. Fairburn CG, Jones R, Peveler RC, Carr SJ, Solomon RA, O’Connor ME,
Burton J, Hope RA: Three psychological treatments for bulimia nervosa. A
comparative trial. Arch Gen Psychiatry 1991; 48:463–469
29. Wilfley DE, Agras WS, Telch CF, Rossiter EM, Schneider JA, Cole AG, Sifford
LA, Raeburn SD: Group cognitive-behavioral therapy and group interper-
sonal psychotherapy for the nonpurging bulimic individual: a controlled
comparison. J Consult Clin Psychol 1993; 61:296–305
30. Agras WS, Walsh T, Fairburn CG, Wilson GT, Kraemer HC: A multicen-
ter comparison of cognitive-behavioral therapy and interpersonal
psychotherapy for bulimia nervosa. Arch Gen Psychiatry 2000; 57:
459–466
31. Linehan M: Skills training manual for treating borderline personality disor-
der. New York, Guilford Press, 1993, 563 pp
32. Linehan M: Cognitive-behavioral treatment of borderline personality disor-
der. New York, Guilford Press, 1993, 563 pp
33. Safer DL, Telch CF, Chen EY: Dialectical behavior therapy for binge eating
and bulimia. New York, Guilford Press, 2009
34. Telch CF, Agras WS, Linehan MM: Dialectical behavior therapy for binge
eating disorder. J Consult Clin Psychol 2001; 69:1061–1065
35. Safer DL, Robinson AH, Jo B: Outcome from a randomized controlled trial of
group therapy for binge eating disorder: comparing dialectical behavior
therapy adapted for binge eating to an active comparison group therapy.
Behav Ther 2010; 41:106–120
36. Womble LG, Wadden TA, McGuckin BG, Sargent SL, Rothman RA,
Krauthamer-Ewing ES: A randomized controlled trial of a commercial in-
ternet weight loss program. Obes Res 2004; 12:1011–1018
37. Wilson GT: Treatment of binge eating disorder. Psychiatr Clin North Am
2011; 34:773–783
38. Vander Wal JS: The treatment of night eating syndrome: a review and
theoretical model. Curr Obes Rep 2014; 3:137–144
39. Lock J, Le Grange D, Agras W, Dare C: Treatment manual for anorexia
nervosa: a family-based approach. New York, Guilford Press, 2001
40. Lock J, Le Grange D, Agras WS, Moye A, Bryson SW, Jo B: Randomized
clinical trial comparing family-based treatment with adolescent-focused
individual therapy for adolescents with anorexia nervosa. Arch Gen Psychi-
atry 2010; 67:1025–1032
41. Fairburn CG: Overcoming binge eating. New York, Guilford, 1995
42. le Grange D, Crosby RD, Rathouz PJ, Leventhal BL: A randomized con-
trolled comparison of family-based treatment and supportive psycho-
therapy for adolescent bulimia nervosa. Arch Gen Psychiatry 2007; 64:
1049–1056
43. Schmidt U, Lee S, Beecham J, Perkins S, Treasure J, Yi I, Winn S,
Robinson P, Murphy R, Keville S, Johnson-Sabine E, Jenkins M, Frost
S, Dodge L, Berelowitz M, Eisler I: A randomized controlled trial of family
therapy and cognitive behavior therapy guided self-care for adolescents
with bulimia nervosa and related disorders. Am J Psychiatry 2007; 164:
591–598
44. Debar LL, Wilson GT, Yarborough BJ, Burns B, Oyler B, Hildebrandt T, Clarke
GN, Dickerson J, Striegel RH: Cognitive behavioral treatment for recurrent
binge eating in adolescent girls: a pilot trial. Cognit Behav Pract 2013; 20:
147–161
45. Jones M, Luce KH, Osborne MI, Taylor K, Cunning D, Doyle AC, Wilfley DE,
Taylor CB: Randomized, controlled trial of an Internet-facilitated intervention
for reducing binge eating and overweight in adolescents. Pediatrics 2008;
121:453–462
46. Tanofsky-Kraff M, Wilfley DE, Young JF, Mufson L, Yanovski SZ, Glasofer
DR, Salaita CG, Schvey NA: A pilot study of interpersonal psychotherapy for
preventing excess weight gain in adolescent girls at-risk for obesity. Int J
Eat Disord 2010; 43:701–706
47. Hilbert A: Cognitive-behavioral therapy for binge eating disorder in ado-
lescents: study protocol for a randomized controlled trial. Trials 2013; 14:
312
48. Mazzeo SE, Kelly NR, Stern M, Palmberg AA, Belgrave FZ, Tanofsky-Kraff M,
Latzer Y, Bulik CM: LIBER8 design and methods: an integrative intervention
for loss of control eating among African American and White adolescent
girls. Contemp Clin Trials 2013; 34:174–185
 WATSON AND BULIK

49. Keel PK, Brown TA: Update on course and outcome in eating disorders. Int J
Eat Disord 2010; 43:195–204
50. Schebendach JE, Mayer LE, Devlin MJ, Attia E, Contento IR, Wolf RL, Walsh 54.
BT: Food choice and diet variety in weight-restored patients with anorexia
nervosa. J Am Diet Assoc 2011; 111:732–736
51. Strober M. Proposition: family based treatment is overvalued. Position: 55.
proposer in Advances in eating disorders: theory, research and practice.
New York, Routledge, 2014, pp. 1–21 56.
52. Lock J, Le Grange D: Proposition: family-based treatment is overvalued.
Position: opposed in Advances in eating disorders: theory, research and
practice. New York, Routledge, 2014, pp. 21–32 57.
53. Grilo CM, Masheb RM, Wilson GT, Gueorguieva R, White MA: Cognitive-
behavioral therapy, behavioral weight loss, and sequential treatment for
obese patients with binge-eating disorder: a randomized controlled trial. J
Consult Clin Psychol 2011; 79:675–685
Masheb RM, White MA, Grilo CM: Substantial weight gains are common
prior to treatment-seeking in obese patients with binge eating disorder.
Compr Psychiatry 2013; 54:880–884
Bacon L, Aphramor L: Weight science: evaluating the evidence for a para-
digm shift. Nutr J 2011; 10:9
Shingleton RM, Richards LK, Thompson-Brenner H: Using technology within
the treatment of eating disorders: a clinical practice review. Psychotherapy
(Chic) 2013; 50:576–582
Vitousek K, Watson S, Wilson GT: Enhancing motivation for change in
treatment-resistant eating disorders. Clin Psychol Rev 1998; 18:391–
420

NOTES

SYNTHESIS
CLINICAL

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