Best Practices for Evidence-Based Eating Disorder Treatments in 2022

Evidence-based eating disorder treatment refers to interventions or therapies that are supported by published research and demonstrate effectiveness or evidence of success. These treatment approaches are well-tested and produce the best outcomes when compared to other established treatments. Below, we take a closer look at evidence-based eating disorder treatment for the most common eating disorders, including anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), other specified feeding and eating disorder (OSFED) and avoidant/restrictive food intake disorder (ARFID).

A Guide to Selecting Evidence-Based Psychological Therapies for Eating Disorders

The Academy of Eating Disorders (AED) recently released a companion guide for their medical care guide that focuses on evidence-based psychotherapeutic interventions for eating disorders. It is designed to inform clinicians worldwide, particularly those in areas without their own guidelines. It is important to note that it does not include all existing treatments or approaches and instead focuses on those carefully researched and found to be effective. If no recommendation exists for an exact diagnosis, it is generally acceptable to adapt the best supported treatments for the closest diagnosis.The recommendations are as follows.

Evidence-Based Eating Disorder Treatments for Children and Adolescents

• For anorexia nervosa in adolescents, the first line treatment is family-based treatment (FBT) and the second line treatment is adolescent-focused therapy (AFT).
• For bulimia nervosa in adolescents, the first line treatments are FBT and cognitive-behavioral therapy for eating disorders (CBT-ED). There is no recommendation for second line treatment. 
• For binge eating disorder in adolescents, there is no first line treatment recommendation. Guided self-help cognitive-behavioral therapy (CBTgsh) and CBT-ED (either individual or group) are recommended for second line treatments.
• For ARFID and OSFED in adolescents, there are no recommendations for first line or second line treatments.

Cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT) are two proposed, alternative treatments to the first-line family-based approaches in teens. A 2021 study published in the Journal of Eating Disorders determined that both treatments are “feasible, acceptable, and possibly effective” for adolescent eating disorders across various diagnoses and levels of care. Additional trials are needed to establish efficacy, particularly when comparing these options to other leading approaches. Another 2021 study looked at third-wave interventions for eating disorders in adolescence. Third-wave cognitive behavioral therapies are a group of emerging approaches to psychotherapy that represent an evolution and/or extension of traditional CBT methods. Ultimately, researchers were unable to determine the efficacy of third-wave interventions due to the need for more empirical evidence. Although notable progress has been made in specialized treatments of adolescent eating disorders, there is still much room for improvement regarding treatment retention, outcomes, and dropout rates.

Evidence-Based Eating Disorder Treatments for Adults

• For anorexia nervosa in adults, the first treatment recommendations are CBT-ED; Maudsley Model of anorexia nervosa treatment for adults (MANTRA); and specialist supportive clinical management (SSCM. The second line treatment recommendation includes focal psychodynamic psychotherapy (FPT).
• For bulimia nervosa in adults, first line treatments include CBT-ED and CBTgsh, while second line treatments include interpersonal psychotherapy (IPT) and group psychotherapy.
• For binge eating disorder in adults, the first line treatment recommendations include CBT-ED (either individual or group) and CBTgsh. The recommendation for second line treatment includes IPT.
• For ARFID and OSFED in adults, there are no recommendations for first line or second line treatments.

“Second-Line” Treatments of Interest

The first-line evidence-based treatments invariably will not be effective for all patients so we need viable alternatives. A treatment that is front and center as a potential game changer for individuals with more complex or challenging-to-treat condition is dialectical behavior therapy (DBT). DBT may be used with adolescents and adults; some providers are using modifications of DBT with children, too.Patients who present with a bit more complexity, such as those with chronic suicidality/self-harm behaviors, emotion regulation difficulties, or substance abuse, may not reliably respond to the treatments like cognitive behavioral therapy or interpersonal psychotherapy. In adolescent patients, there is research suggesting poorer outcomes using FBT for patients with psychiatric co-morbidities, parent psychiatric history, emotion regulation deficits, and/or emerging borderline personality characteristics.  DBT is an established treatment designed specifically to address these more complex presentations:

• DBT focuses on increasing motivation and commitment to change, which makes it a superb intervention for those with eating disorders since often there are aspects of the ED that are reinforcing and hard to let go of (i.e. extreme thinness or control of food).
• DBT also has very well-developed strategies for managing therapy-interfering behaviors (we call them “TIBs”) that can emerge with some frequency in eating disorder treatment. A great example of a TIB might be concealing or downplaying certain behaviors or avoiding things in therapy that are hard to talk about.
• DBT is designed to target multiple challenges or problem areas at the same time which is very helpful when there is more complexity to someone’s ED. For example, DBT can help with depression, self-harm, and disordered eating all together, while CBT-ED may view some of these co-existing difficulties as blockers to a successful treatment.

No Challenge Too Challenging

At Columbus Park, we’re comfortable delivering first-line, evidence-based eating disorder treatments as well as second-line alternatives like DBT when needed. We have a clear process for identifying which treatment approach will be most appropriate and effective so we can dive in promptly without wasting time, energy, and money on false starts. Columbus Park is among a minority of practices nationally that integrates DBT specifically for eating disorders with strong adherence to the DBT treatment model.   If you or a loved one is struggling with an eating disorder, please reach out to our team at info@columbuspark.com to discuss treatment options.