Eating disorders: What's the most effective treatment?

Eating disorders are serious mental illnesses that can severely disturb a person’s eating behaviour, have a negative effect on body image and can ultimately be fatal.  But for sufferers of conditions like bulimia nervosa, anorexia nervosa, and binge-eating disorder, one tried and tested therapy stands out as the most effective evidence-based treatment.  

It is estimated that around one in 10 Australians experiences a form of eating disorder, which are commonly associated with health complications like heart failure, kidney failure, seizures and food intolerances. 

Yet those who’ve suffered from illnesses like bulimia nervosa, anorexia nervosa and binge-eating disorder often speak of the stigma of an affliction that is too often misunderstood by the wider community. 

Up to three-quarters of people with an eating disorder do not seek professional help, according to the Butterfly Foundation, and those who do are faced with the daunting task of finding the right treatment, with a myriad of therapies touted as the most effective. 

However, researchers from ACU’s Body Image, Eating and Weight Clinical Research Team and Flinders University recently conducted a wide-ranging review of Cognitive-Behavioral Therapy (CBT) trials and found it out-performed a range of other psychological and drug-based treatments.   

 What is Cognitive-Behavioral Therapy and how does it work?

CBT is the most widely investigated treatment for eating disorders and is also used to treat other conditions including insomnia, anxiety and depression. 

ACU PhD student Jake Linardon, who led the review of CBT trials, said the therapy used a range of techniques to help the patient develop new ways of thinking and behaving. This includes changing self-defeating thought patterns and eating more regularly.

“CBT is not necessarily interested in what caused the eating disorder, it's really concerned about the things that are keeping the eating disorder going, what’s making the binge-eating behaviour and the purging persist,” Mr Linardon said. 

“They’ve identified a couple of things, one being rigid dieting, the other being extreme concerns about weight and shape, so CBT devotes most of its attention towards targeting those two processes — dietary restraint and shape and weight concerns.”

The idea is that if the treatment is able to address or eliminate those two things, it can reduce the severity of the core symptoms sufferers typically seek treatment for (binge-eating and purging) or almost entirely eliminate the eating disorder altogether. 

“CBT uses a whole range of techniques to try to target extreme dieting and concerns, including exposure-based treatment, the prescription of regular eating and a variety of body image techniques,” Mr Linardon said. 

The review found that the positive effects of CBT were strongest when delivered by a therapist, but that other methods including guided self-help were also effective. 

Examining the evidence on Cognitive-Behavioral Therapy

The review, which was published in the Journal of Consulting and Clinical Psychology, investigated 79 randomised control trials of CBT. Mr Linardon said CBT was considered by international and national practice guidelines as “the gold standard treatment for basically every type of eating disorder in adults”. 

“This is the most comprehensive review to date on Cognitive-Behavioral Therapy … and our findings basically reinforced the practice guidelines and the view that CBT is the best evidence-based treatment we have,” Mr Linardon said.  

“What we found is for bulimia and binge-eating disorder, CBT was far more effective than alternative interventions in terms of reducing the amount of binge-eating and purging behaviours, and also more effective in reducing extreme concerns about weight and shape. On the other hand, we found no evidence that CBT was more effective than other interventions in anorexia nervosa.”  

Alternatives to CBT — are they evidence-based and do they work? 

In recent years, many new-wave therapies for eating disorders have become popular amongst clinicians, including acceptance and commitment therapy, dialectical behaviour therapy, schema therapy, mindfulness-based interventions and compassion-focused therapy. 

Mr Linardon recently teamed up with ACU’s Associate Professor Leah Brennan and other researchers to investigate the empirical status of these “third wave behaviour therapies”.

“Particularly in Australia but probably worldwide, or in Western countries at least, there's been a big uptake in these newer therapies and I think an assumption that newer treatments are more effective than the existing therapies,” Associate Professor Brennan said. 

“This paper really came about because of discussions we were having with clinicians who were assuming that if they were doing these experimental, novel treatments they were doing better things for their clients and getting better outcomes. 

“That wasn't consistent with our reading of the literature, so we thought, ‘let's look at the literature systematically to see what it tells us about whether these new experimental treatments are actually more effective than cognitive behaviour therapy which has a really strong evidence base for’.” 

The study found that, although these newer treatments seem promising for treating people with eating disorders, none of them meet the established criteria for an evidence-based treatment for eating disorders. 

“Although some people with eating disorders improve when they follow some of these treatments, we found that they don't constitute an empirically supported treatment, so it's probably not wise or prudent for clinicians to recommend these particular treatments for treating eating disorders just yet, at least not as the first approach” Mr Linardon said. 

Associate Professor Brennan said more research investigating the efficacy and safety of third-wave behaviour therapies was needed before they're offered as an evidence-based alternative to CBT. 

ACU’s Body Image, Eating and Weight Clinical Research Team, led by Associate Professor Leah Brennan, conducts clinical research examining the psychological aspects of eating, weight and body image. Learn more. 

For free information and advice on binge-eating behaviour, visit Jake Linardon's website.