Interpersonal Psychotherapy and Ea2ng Disorders

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1 Interpersonal Psychotherapy and Ea2ng Disorders Christopher G Fairburn Centre for Research on Ea2ng Disorders at Oxford credo- oxford.com

2 IPT AND EATING DISORDERS Structure of the Talk 1. What is IPT? 2. Overview of the ea2ng disorders and their response to treatment 3. Review the RCTs of IPT in the treatment of ea2ng disorders 4. Describe a use of IPT that you may not be familiar with 5. Draw specific and general conclusions

3 INTERPERSONAL PSYCHOTHERAPY What is IPT? Term appears to refer to a single treatment IPT has differen2ated over the years to match... Different forms of psychopathology (depression, bipolar disorder, etc) Different demographic groups (e.g., age, culture, etc) Different formats (group IPT, online IPT) Term IPT now refers to a class of treatments Common goal Common strategy Common core procedures

4 EATING DISORDERS (ADULTS) Anorexia nervosa Bulimia nervosa Binge ea2ng disorder Other ea2ng disorders (OEDs) OEDs BED AN BN

5 EATING DISORDERS Anorexia nervosa Bulimia nervosa Binge ea2ng disorder Other ea2ng disorders (OEDs) Anorexia Nervosa Sustained and selec2ve under- ea2ng Low weight Driven by extreme concerns about shape and weight Mainly young women OEDs BED AN BN

6 EATING DISORDERS Anorexia nervosa Bulimia nervosa Binge ea2ng disorder Other ea2ng disorders (OEDs) Bulimia Nervosa Sustained and selec2ve under- ea2ng Punctuated by repeated binge ea2ng Same extreme concerns about shape and weight Unremarkable weight Mainly young women OEDs BED AN BN

7 EATING DISORDERS Anorexia nervosa Bulimia nervosa Binge ea2ng disorder Other ea2ng disorders (OEDs) Other Ea2ng Disorders Same psychopathology as AN and BN Comparable in severity to BN Unremarkable weight Mainly young women OEDs BED AN BN

8 EATING DISORDERS Anorexia nervosa Bulimia nervosa Binge ea2ng disorder Other ea2ng disorders (OEDs) BED AN Binge Ea2ng Disorder Recurrent binge ea2ng General tendency to overeat O^en co- occurs with obesity Broad age range; one third male OEDs BN

9 EATING DISORDERS AN, BN and the OEDs are self- perpetua2ng states that develop in adolescence or early adulthood People move between them ( diagnos2c migra2on ) In adults, the average dura2on of disorder at presenta2on is over five years of unremi`ng symptoms In treatment the task is to address the processes that are maintaining the ea2ng disorder; these processes may, or may not, overlap with those that contributed to its onset Many different interac2ng processes appear to be involved (e.g., physiological, cogni2ve, behavioural, interpersonal); and they differ in their rela2ve contribu2ons from individual to individual In CBT the focus is on the behavioural and cogni2ve maintaining processes In IPT the focus is on the interpersonal maintaining processes

10 EATING DISORDERS OEDs BED AN BN Anorexia Nervosa Famously difficult to treat Egosyntonic No evidence- based treatment (for adults)

11 EATING DISORDERS BED AN OEDs BN Bulimia Nervosa Originally viewed as intractable Now known to be treatable, but treatment is difficult

12 EATING DISORDERS BED AN Other Ea2ng Disorders Neglected un2l recently Two treatment studies OEDs BN

13 EATING DISORDERS Binge Ea2ng Disorder Highly treatment responsive BED AN OEDs BN

Disorders Fairburn et al, 2009 Fairburn et al, 2015 OEDs BN Bulimia Nervosa

14 THE RCTs Binge Ea)ng Disorder Wilfley et al, 1993 Wilfley et al, 2002 Wilson et al, 2010 BED AN Anorexia Nervosa McIntosh et al, 2004 Other Ea)ng Disorders Fairburn et al, 2009 Fairburn et al, 2015 OEDs BN Bulimia Nervosa Fairburn et al, 1993 Agras et al, 2000 Fairburn et al, 2009 Fairburn et al, 2015

15 BINGE EATING DISORDER Binge Ea2ng Disorder (Wilfley et al, 2002) RCT comparing group IPT with group CBT Female pa2ents with BED and obesity

16 BINGE EATING DISORDER Binge Ea2ng Disorder Substan2al and equivalent change in both treatment condi2ons Concern about specificity of treatment effect given... Iden2cal response to the two treatments Substan2al placebo response in pharmacological studies High remission rate in a study of the natural course of BED

17 BINGE EATING DISORDER Binge Ea2ng Disorder (Wilson et al, 2010) RCT comparing IPT (20 sessions, individual IPT) Behavioural weight loss programme (20 sessions) Guided CB self- help (10 brief sessions) Women with BED and obesity

18 BINGE EATING DISORDER Binge Ea2ng Disorder Substan2al change in all three condi2ons Greatest improvement in the guided self- help and IPT condi2ons No difference between them Concluded that guided self- help is the leading treatment for BED Some evidence that IPT might be preferable for pa2ents with marked ED psychopathology and very low self- esteem

19 ANOREXIA NERVOSA Anorexia Nervosa Small RCT (N=56) comparing: CBT (generic) IPT Specialist TAU 20 sessions Women with subthreshold AN or mild- to- moderate AN

20 ANOREXIA NERVOSA Anorexia Nervosa Poor overall outcome 70% either did not complete treatment or made li2le or no gains. Lille evidence of differen2al treatment effects Concluded that treatment as usual is the preferred op2on for AN

21 BULIMIA NERVOSA Bulimia Nervosa (Fairburn et al, 1993) RCT comparing: CBT for BN Dismantled CBT for BN (minus the focus on body image) IPT for BN (closely adherent to the Klerman et al manual) Women with BN

22 BULIMIA NERVOSA Bulimia Nervosa CBT > Dismantled CBT Due to rapid relapse No difference between CBT and IPT at 8 and 12- month follow- up, or at 6- year follow- up IPT 8 months slower to achieve its full effects

23 BULIMIA NERVOSA Bulimia Nervosa (Agras et al, 2000) Two- centre repeat of the Oxford RCT (Stanford- Columbia) comparing: CBT for BN IPT for BN Women with BN

24 BULIMIA NERVOSA Bulimia Nervosa Response rate (%) Stanford-Oxford-Columbia CBT-IPT study CBT IPT Close replica2on of the Oxford findings CBT = IPT at 8 and 12- month follow- up But IPT 8 months slower to achieve its full effects Need for both treatments to be more potent 0 Beginning End 4 months 8/12 months

25 TAKING A TRANSDIAGNOSTIC PERSPECTIVE In the late 1990s our group changed its view on the ea2ng disorders, and started to see them from a transdiagnos2c perspec2ve. Simultaneously we tried to make CBT more potent CBT- E.

26 TAKING A TRANSDIAGNOSTIC PERSPECTIVE Underweight pa2ents Non- underweight pa2ents

27 TAKING A TRANSDIAGNOSTIC PERSPECTIVE Underweight Ea)ng Disorders BED AN Non- Underweight Ea)ng Disorders Fairburn et al, 2009 Fairburn et al, 2015 OEDs BN

28 NON- UNDERWEIGHT EATING DISORDERS Bulimia Nervosa and the OEDs

29 NON- UNDERWEIGHT EATING DISORDERS Bulimia Nervosa and the OEDs (Fairburn et al, 2015) RCT comparing CBT- E IPT Pa2ents with any form of Ea2ng Disorder (BMI 17.5 to 39.9)

treat response rate of 65% to 70% IPT also effec2ve (45%)

30 NON- UNDERWEIGHT EATING DISORDERS Bulimia Nervosa and the OEDs (Fairburn et al, 2015) Consistent CBT- E intent- to- treat response rate of 65% to 70% IPT also effec2ve (45%) but slower to achieve its full effects Moderators? Mediators?

31 credo BROAD CBT- E More complex form of CBT- E with addi2onal strategies and procedures Designed for pa2ents who have one or more of the following problems to an extreme degree: Clinical perfec2onism Core low self- esteem Marked interpersonal problems Broad CBT- E is designed to address both the ED and the associated psychopathology at the same 2me

32 credo BROAD CBT- E Broad CBT- E uses IPT to address the accompanying interpersonal problems Requires combining CBT- E and IPT, BUT... The therapeu2c styles are incompa2ble Like oil and water, the treatments are immiscible But oil and water can sit beside each other In broad CBT- E an IPT session is embedded within a CBT- E one

33 NON- UNDERWEIGHT EATING DISORDERS Bulimia Nervosa and the OEDs (Fairburn et al, 2009) RCT comparing: Focused CBT- E Broad CBT- E Delayed treatment Two sites Pa2ents with any form of Ea2ng Disorder (BMI 17.5 to 39.9)

34 100 Normalisa2on of ED Features Response (%) Less complex cases Focused CBT- E Broad CBT- E 20 0 Pre- treatment Post- treatment 20 weeks 40 weeks 60 weeks

35 100 Normalisa2on of ED Features 80 Response (%) More complex cases Broad CBT- E Focused CBT- E 0 Pre- treatment Post- treatment 20 weeks 40 weeks 60 weeks

36 100 Normalisa2on of ED Features Response (%) Less complex cases More complex cases Focused CBT- E Broad CBT- E Focused CBT- E 0 Pre- treatment Post- treatment 20 weeks 40 weeks 60 weeks

37 IPT AND EATING DISORDERS Conclusions 1. IPT has a definite place in the treatment of the ea2ng disorders 2. It is the alterna2ve to CBT- E for 85% of ED cases (adults) 3. Whether there are moderators to guide treatment choice is not yet known 4. IPT can be combined with CBT- E in the treatment of very complex cases Requires therapists to be well trained in both treatments and pa2ents to be well prepared Pa2ents understand this use of two treatments and like the combina2on

Contents. Eating Disorders: Introduction. Who Gets Eating Disorders? What is Anorexia Nervosa?

Contents. Eating Disorders: Introduction. Who Gets Eating Disorders? What is Anorexia Nervosa? Contents Eating Disorders: Introduction Who Gets Eating Disorders? What is Anorexia Nervosa? Physical and Psychological Effects What is Bulimia Nervosa? Physical Effects What is Eating Disorders Not Otherwise