The Current Status of Treatment for Anorexia Nervosa and Bulimia Nervosa
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1 The Current Status of Treatment for Anorexia Nervosa and Bulimia Nervosa David B. Herzog Martin B. Keller Michael Strober Christine Yeh Sung-Yun Pai (Accepted 1 March 1991) A survey investigating the current status of treatment for anorexia nervosa and bulimia nervosa was distributed at the International Conference on Eating Disorders in 1988 and again in Respondents answered questions regarding treatments they had endorsed for their last patient with anorexia nervosa and/or bulimia nervosa. One hundred and seven medical doctors and psychologists completed the survey in 1988 and 115 in The results indicate that: (1) less than 5 of the respondents believe there is a consensus regarding the treatment of eating disorders; (2) talking therapy is overwhelmingly endorsed for the treatment of both anorexia and bulimia nervosa; (3) there is a trend in clinical practice towards using drug therapy more frequently in treating patients with bulimia nervosa than in treating patients with anorexia nervosa; (4) physicians are more likely than psychologists to endorse drug therapy when treating patients with anorexia and/or bulimia nervosa; and (5) about one third of the respondents endorse drug therapy for treating anorexia nervosa John Wiley & Sons, Inc. Surveys of practicing physicians suggest that somatic therapies proven effective in treating major depression are underused (Keller & Lavori, 1988). Effective treatments for eating disorders may be similarly underused and may not be systematically applied in clinical practice. Although research on anorexia nervosa has not yielded a consistently effective treatment, studies of bulimia nervosa have demonstrated successful therapies: cognitive-behavioral therapy, drug therapy, and group therapy. These research findings should predict the types of treatments that clinicians select in practice. David B. Herzog, M.D., is Director, Eating Disorders Unit, Massachusetts General Hospital and Associate Professor of Psychiatry, Harvard Medical School. Martin B. Keller, M.D., is the Mary E. Zucker Professor and Chairman, Department of Psychiatry and Human Behavior, Brown University. Michael Strober, Ph.D., is Professor of Psychiatry and Director, Teenage Eating Disorders Program, Department of Psychiatry and Biobehavioral Sciences, UCLA Neuropsychiatric Institute. Christine Yeh is Project Coordinator, Eating Disorders Unit, Massachusetts General Hospital. Sung-Yun Pai is Research Assistant, Eating Disorders Unit, Massachusetts General Hospital. Address reprint requests to David B. Herzog, M.D., Director, Eating Disorders Unit, ACC #725, Massachusetts General Hospital, 15 Parkman Street, Boston, MA International Journal of Eating Disorders, Vol. 12, No. 2, (1992) 1992 by John Wiley & Sons, Inc. CCC /92/ $04.00
2 216 Herzogetal. Cognitive-behavioral therapy appears to be the most effective treatment for bulimia nervosa (Garner, Fairburn, & Davis, 1987; Agras, Schneider, Arnow, Raeburn, & Telch, 1989, Fairburn, Jones, Peveler et al., 1991). Drug therapy is not as effective as cognitive-behavioral therapy; however, in short-term, controlled studies, drug therapy has proven significantly superior to placebo in reducing binge-purge frequencies and scores on depression inventories (Agras et al., 1989; Walsh et al., 1988; Fluoxetine Bulima Nervosa Collaborative Study Group, 1991). Group therapy is also useful in treating bulimia nervosa (Kirkley, Schneider, Agras, & Bachman, 1985; Huon, Brown, 1985; Mitchell et al., 1990). Research on the treatment of anorexia nervosa has not produced the promising findings observed in parallel studies on bulimia nervosa. Few antidepressant trials have been conducted, and all report mixed or poor results (Hudson, Pope, Jonas, & Yurgelun- Todd, 1985; Halmi, Eckert, LaDu, & Cohen, 1986). Talking therapy for outpatient anorexics has yet to be demonstrated effective (Hall and Crisp, 1987). To our knowledge, the only study comparing treatment response in restrictive and bulimic anorexics indicates that cyproheptadine is effective in treating restrictive anorexics (Halmi et al., 1986). However, these results are only marginally significant. In order to determine which treatments clinicians are currently using and to what extent this pattern reflects current research findings, clinicians attending a conference on eating disorders were surveyed. This study aimed to: (1) provide a set of descriptive data concerning the treatments presently being used; (2) determine whether clinicians believe there is a consensus regarding the treatment of eating disorders; (3) test the hypothesis that clinicians are more likely to use documented, effective treatments to treat bulimic patients; and (4) test the hypothesis that medical doctors would be more likely than psychologists to endorse drug therapy. Data generated from two separate questionnaires administered in 1988 and 1990 are presented. METHOD The first questionnaire was distributed to approximately 450 participants of the 1988 International Conference on Eating Disorders in New York. A total of 148 questionnaires (33%) were completed; 59 respondents (39.9%) were medical doctors, 48 (32.) were psychologists, and 41 (27.7%) were from other disciplines (17 social workers, 12 nurses, 12 others). Subjects completed a 15-item self-report inventory developed by the authors asking: (1) whether or not they believe there is a consensus among their colleagues regarding the treatment of anorexia nervosa abstaining (AN), anorexia nervosa with binge eating (ANB), and bulimia nervosa (BN); and (2) which treatments they endorsed* for their last patient with AN, BN, and ANB. Participants were also requested to note whether or not their bulimic patient fulfilled DSM-III-R (APA, 1987) criteria for major depression. In the data analysis from the first questionnaire, patients were subdivided into the categories bulimics without major depression (BN-No MDD) and depressed bulimics with a major depression (BNMDD). The second questionnaire consisted of eight items and was similar in content and structure to the first one. Participants were specifically asked to use DSM-III-R criteria *The word "endorse" is used to describe what treatment clinicians actually prescribed for their last patient with an eating disorder.
3 Treatment Status 217 for questions about AN, ANB, BN-No MDD and BNMDD. The questionnaire was distributed to approximately 700 participants attending the 1990 International Conference on Eating Disorders in New York. A total of 183 questionnaires (26%) were completed; 67 of the respondents (36.6%) were medical doctors, 51 (27.9%) were psychologists, 35 (19.1%) were social workers, and the remaining 30 (16.) were from other disciplines. Due to the smaller number of respondents in other clinical disciplines, the data presented in this manuscript include responses from only medical doctors and psychologists. Chi-square analyses were performed for each survey: (1) comparing the responses to the consensus question across disorders; (2) comparing the use of drug therapy, group therapy, and cognitive-behavioral therapy across disorders; and (3) comparing the use of drug therapy across disciplines. The use of drug therapy, group therapy, and cognitive-behavioral therapy was also compared between the two surveys. The p-value required for a result to be considered statistically significant was set at.01 because of the large number of tests performed. RESULTS The results indicate that clinicians did not believe that there is a consensus regarding how to treat eating disordered patients. In both surveys, 6 or more of the participants did not believe that there was a consensus for any of the eating-disorder subgroups. There were no significant differences when responses of medical doctors and psychologists were compared. Nearly all of the respondents in both surveys recommended the use of talking therapy for the treatment of all the eating disorder subgroups and more than two-thirds of the respondents indicated that they used a combination of psychodynamic and cognitive-behavioral techniques in their talking therapy. In both surveys, neither cognitive-behavioral therapy nor group therapy was endorsed more often for BN than for AN (see Tables 1 and 2). The clinicians differed significantly in their responses concerning drug therapy (see Tables 1 and 2). Respondents were more likely to endorse drug therapy for ANB than for AN in both survey 1 [corrected x^(l) = 8.2, p <.01] and survey 2 [corrected x^(l) = 7.9, p <.01]. In survey 1, they were also more likely to endorse drug therapy for BNMDD than for BN [corrected x^(l) = 25.1, p <.0001]. Drug therapy, moreover, was advocated for AN as often as it was for BN. Tricyclics were the drugs most often endorsed for all eating disorder subgroups and were more likely to be used for BNMDD than for BN-No MDD or BN [survey 1 corrected x^(l) = 16.8, p <.0001; survey 2 corrected x^(l) , p <.001] Respondents to survey 2 were more likely to use fluoxetine to treat BN than to treat AN [corrected x^(l) = 10.4, p <.01]. Respondents to survey 2 were also more likely to have advocated drug therapy for BN than for AN [corrected x^(l) = 7.7, p <.01], and were more likely than respondents to survey 1 to select drug therapy for treating BN [corrected x^(l) = 10.8, p <.001]. Medical doctors (6) were significantly more likely to endorse drugs for BN than were psychologists (37%) in survey 2 [corrected x^(l) = 7.9, p <.01]. A similar result was found for BNMD; 93% of medical doctors compared to 7 of psychologists endorsed drug treatment [corrected x^(l) - 7.8, p <.01].
4 218 Herzog et al. Table 1. Status of treatment for anorexia nervosa (AN), anorexia nervosa with binge eating (ANB), bulimia nervosa without major depression (BN-No MDD) and bulimia nervosa with major depression (BNMDD) 1988 International Conference on Eating Disorders (N = 107) Talk therapy Individual Group Family Drug therapy Maoi Tricyclic Antianxiety Other Nutritional counseling Medical management Cognitivebehavioral Psychodynamic Combination" Other AN (n = 99) % 26% 83% AN (n = 97) 19% 11% 69% 1% ANB (N = 95) % 47% 83% Talking therapy orientation BN-No MDD ANB (n = 93) (n = 68) 2 9% BN (n = 76) 97% 87% 38% 21% 32% 22% 1 69% 8 31% 6% 63% "Refers to a combination of cognitive-behavioral and psychodynamic psychotherapy. BNMDD [n = 28) 93% % 7% 18% 79% 82% BNMDD (n = 26) 8% 1 77% Table 2. Status of treatment for anorexia nervosa (AN), anorexia nervosa with binge eating (ANB), bulimia nervosa (BN), and bulimia nervosa with major depression (BNMDD) 1990 International Conference on Eating Disorders (N = 118) Talk therapy Individual Group Family Drug therapy Maoi Tricyclic Antianxiety Fluoxetine Nutritional counseling Medical management Cognitivebehavioral Psychodynamic Combination" Other AN (n = 112) 97% 92% 4 66% 3 2% 17% 11% 17% 86% 9 AN (n = 108) 23% ANB (n = 106) % 46% % 33% 77% 93% BN (n = 117) 8 42% 31% 53% 13% 8% 37% 71% 86% Talking therapy orientation ANB (n = 100) BN (n = 109) 2 3% 27% 6% 6 3% BNMDD («= 104) 89% 3 31% 83% 3% 38% % BNMD (n = 97) 23% 8% 6 1% "Refers to a combination of cognitive-behavioral and psychodynamic psychotherapy.
5 Treatment Status 219 DISCUSSION The respondents in both surveys did not believe that there was a consensus about the treatment of either anorexia nervosa or bulimia nervosa. However, the descriptive data revealed that a de facto consensus may exist. The use of talking therapy was endorsed almost unanimously, even though, at least for AN, there are no controlled studies to demonstrate its efficacy. The data generated from this study also suggest that the discipline and background of a clinician influence the treatments endorsed. Medical doctors were more likely than psychologists to endorse drug therapy. Our findings also document differential treatment for ANs and ANBs. Both surveys reveal that ANBs are significantly more likely to receive drug therapy than ANs, suggesting that more of the ANB sample may have had depressive symptoms compared to the AN sample. These findings highlight the need for treatment studies specifically aimed at the population with both AN and BN. Since the efficacy of cognitive-behavioral therapy in treating Bn has been empirically demonstrated, the authors predicted that clinicians would endorse its use in clinical practice. Although cognitive-behavioral therapy or a combination of cognitive-behavioral therapy and psychodynamic psychotherapy was the talking therapy most often endorsed, it was selected as often for anorexics as it was for bulimics. In addition, clinicians were more likely to choose cognitive-behavioral therapy in combination with a psychodynamic orientation than cognitive-behavioral therapy alone. The methodological limitations of this study include the low response rate and small sample size, making a comparison to the general population of clinicians problematic. The low response rates in both 1988 and 1990 may be explained by the timing and rigid structure of the conferences' events rather than the actual content of the two surveys. On both occasions, there was no set time designated for completing either questionnaire. The authors have no reason to suspect that the sample was biased. The results of this study suggest that clinical decisions are not influenced primarily by treatment studies in the scientific literature. Anorexics were as likely as bulimics to receive all three treatments proven effective only for BN. Our results also suggest that several treatments are frequently endorsed in clinical practice despite the lack of controlled studies demonstrating their efficacy. The treatments which have proven effective for treating BN are not as highly endorsed by clinicians as the literature would predict. According to Keller and Lavori (1988), clinical decisions are influenced by several factors other than research findings. The clinical experiences of clinicians can have a major impact on the treatments they endorse. They suggest that some clinicians may not believe that the results of a controlled trial apply to their patients; for example, a particular trial may involve an unrealistic selection of patients or treatment protocols. Therefore, many clinicians may not be able to incorporate the results of these studies into their clinical experiences. Keller and Lavori (1988) also suggest that patients play an important role in determining the type of treatment received. Patients may have a specific type of treatment in mind when they approach a clinician, seek a clinician who advocates a certain type of treatment, choose to follow a modified treatment in lieu of the original recommendation, or refuse certain modalities altogether. The results of this study have implications for both clinical practice and research. For treating AN, ANB, and BN, with or without MDD, talking therapy was endorsed almost unanimously, and clinicians tended to use cognitive-behavioral therapy or a com-
6 220 Herzog et al. bination of cognitive-behavioral and psychodynamic techniques in their approaches. Comparing the 1988 & 1990 surveys, we found an increasing trend in the use of pharmacotherapy for treating bulimia nervosa. Future research efforts should investigate the efficacy of cognitive-behavioral therapy in combination with psychodynamic therapy and/or pharmacotherapy in the treatment of AN and BN. The authors thank Phil Lavori, Ph.D., and Janine Stasior, M.S., for their help in methodological design, Debbie Offner, B.A., and Julie Hopkins for their assistance in the editing and preparation of the manuscript, and Isabel Bradburn, Ed.M., for her help in data collection. REFERENCES Agras, W. S., Schneider, J. A., Arnow, B., Raeburn, S. D., & Telch, C. F. (1989). Cognitive-behavioral and response-prevention treatments for bulimia nervosa. Journal of Consulting and Clinical Psychology, 57, American Psychiatric Association (1987). Diagnostic and statistical manual of mental disorders (3rd ed., revised). Washington, D.C: APA. Fairburn, C. G., Kirk, J., O'Connor, M., & Cooper, P. J. (1986). A comparison of two psychological treatments for bulimia nervosa. Behaviour Research and Therapy, 24, Fairburn, C. G., Jones, R., Peveler, R. C, Carr, S. J., Solomon, R. A., O'Connor, M. E., Burton, J., & Hope, R. A. (1991). Three psychological treatments for bulimia nervosa. Archives of General Psychiatry, 48, Fluoxetine Bulimia Nervosa Collaborative Study Group, (in press, 1991) Fluoxetine in the treatment of bulimia nervosa: A multi-center, placebo-controlled, double-blind trial. Archives in General Psyschiatry. Garner, D. M., Fairburn, C. G., & Davis, R. (1987). Cognitive-behavioral treatment of bulimia nervosa. Behavior Modification, 11, Hall, A., & Crisp, A. H. (1987). Brief psychotherapy in the treatment of anorexia nervosa: Outcome at one year. British Journal of Psychiatry, 151, Halmi, K. A., Eckert, E., LaDu, T. J., & Cohen, J. (1986). Anorexia nervosa: Treatment efficacy of cyproheptadine and amitriptyline. Archives of General Psychiatry, 43, Hudson, J. I., Pope, H. G., Jonas, J. M., & Yurgelun-Todd, D. (1985). Treatment of anorexia nervosa with antidepressants. Journal of Clinical Psychopharmacology, 5, Huon, G. F., & Brown, L. B. (1985). Evaluating a group treatment for bulimia. Journal of Psychiaric Research, 19, Keller, M. B., & Lavori, P. W. (1988). The adequacy of treating depression. Journal of Nervous and Mental Disease, 176, Kirkley, B. G., Schneider, J. A., Agras, W. S., & Bachman, J. A. (1985). Comparison of two group treatments for bulimia. Journal of Consulting and Clinical Psychology, 53, Mitchell, J. E., Pyle, P. L., Eckert, E. D., Hatsukami, D., Pomeroy, C, & Zimmerman, R. (1990). A comparison study of antidepressants and structured intensive group psychotherapy in the treatment of bulimia nervosa. Archives of General Psychiatry, 47, Walsh, B. T., Gladis, M., Roose, S. P., Stewart, F. W., Stetner, F., & Glassman, A. H. (1988). Phenelzine vs. placebo in 50 patients with bulimia. Archives of General Psychiatry, 45,
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