What are the non-medical treatments for anorexia nervosa and bulimia?

Non-Medical Treatment for Anorexia Nervosa and Bulimia Nervosa

For anorexia nervosa, eating disorder-focused psychotherapy delivered by a multidisciplinary team is the cornerstone of treatment, with family-based therapy being first-line for adolescents and specialized psychotherapy for adults; for bulimia nervosa, cognitive-behavioral therapy (CBT) is the definitive first-line psychological treatment. 1

Core Treatment Framework

Multidisciplinary Team Approach

• All patients with eating disorders should be treated by a coordinated multidisciplinary team that incorporates medical, psychiatric, psychological, and nutritional expertise to optimize outcomes related to morbidity, mortality, and quality of life. 1

The essential team members include:

• A mental health practitioner who delivers specialized eating disorder-focused psychotherapy, which is the cornerstone of treatment 1
• A registered dietitian/nutritionist who provides nutritional rehabilitation, meal planning, and education on healthy eating patterns 1
• A primary care or sports medicine physician for medical monitoring, physical examinations, laboratory assessments, and coordination of care 1

Additional specialists may be needed for complex cases, including psychiatrists for medication management, endocrinologists for hormonal complications, cardiologists for cardiac complications, and exercise physiologists for appropriate physical activity guidance 1.

Anorexia Nervosa: Age-Specific Psychological Treatments

Adolescents and Emerging Adults

• Family-based treatment (Maudsley approach) is the recommended first-line psychological treatment when caregivers can be involved, with emphasis on caregiver education to normalize eating behaviors and restore weight 1, 2
• This approach has the most established evidence base for youth with anorexia nervosa 2

Adults

• Eating disorder-focused psychotherapy is recommended, focusing on normalizing eating behaviors, weight restoration, and addressing psychological aspects like fear of weight gain and body image disturbance 1
• Interestingly, a 2005 randomized controlled trial found that nonspecific supportive clinical management was superior to specialized psychotherapies (CBT and interpersonal psychotherapy) in adults with anorexia nervosa, challenging assumptions about treatment ingredients 3
• No single specialist treatment has been definitively shown to be superior for adults with anorexia nervosa 2

Important caveat: Even the most effective interventions for anorexia nervosa fail to help a substantial number of patients, and better treatments are urgently needed 4, 5.

Bulimia Nervosa: Evidence-Based Psychological Treatments

First-Line Treatment

• Eating disorder-focused cognitive-behavioral therapy (CBT) is the definitive first-line psychological treatment for adults with bulimia nervosa 1, 6, 2
• CBT remains the most established treatment with the strongest evidence base 2, 5
• Interpersonal psychotherapy is also an established alternative treatment option 2, 5

Adolescents

• Family-based treatment is suggested when an involved caregiver is available 6
• Family-based therapy may be efficacious for youth with bulimia nervosa 2

Stepped-Care Approaches

• Stepped-care approaches show promise for bulimia nervosa, allowing for treatment intensity to be matched to patient needs 2

Nutritional Rehabilitation (Non-Pharmacological Component)

Anorexia Nervosa

• Nutritional rehabilitation should include individualized goals for weekly weight gain and target weight 1
• This is delivered by a registered dietitian as part of the multidisciplinary team approach 1

Bulimia Nervosa

• Nutritional rehabilitation and meal planning are essential components delivered by a registered dietitian 6

Technology-Based Psychological Interventions

Evidence for Bulimia Nervosa

• Guided computer-based and internet-based CBT interventions show efficacy, particularly for compliant patients, and can improve access to care when specialized providers are unavailable 7, 6
• Videoconferencing represents a promising delivery method for CBT when in-person treatment is not feasible 7, 6
• These technology-based interventions can show improvements in core bulimia symptoms 6

Evidence for Anorexia Nervosa

• Technology-based interventions show preliminary promise but have insufficient evidence at this stage 7
• Internet-based relapse prevention for anorexia nervosa inpatients may be effective for stabilizing treatment success and bridging the gap between inpatient and outpatient therapy 7

Important Limitations

• Unguided computer-based interventions cannot be recommended for treatment of anorexia nervosa or bulimia nervosa 7
• Patient compliance remains a major challenge for technology-based interventions to work effectively 7

Treatment Monitoring and Documentation

• Regular monitoring is essential, including assessment of vital signs, weight, laboratory values, and cardiac function 1
• Comprehensive treatment plans should be documented, culturally appropriate, and person-centered 1

Common Pitfalls to Avoid

• Failing to screen for eating disorders during initial psychiatric evaluations 6
• Not weighing patients due to sensitivity concerns 6
• Overlooking medical complications 6
• Focusing solely on weight rather than on eating behaviors and psychological aspects 6
• Neglecting to assess for co-occurring psychiatric disorders 6

Barriers to Treatment Access

• Treatment barriers including shame, stigma, long waiting times, and shortage of specialized providers must be addressed 1
• Widespread access to effective eating disorder treatments remains limited, and increasing implementation of psychological treatments beyond research settings into clinical practice has strong potential to reduce the burden of these disorders 2