Introduction

The world is polarised between the starving and the overfed. In the prosperous West, while obesity becomes a major public health concern, eating disorders (more accurately 'dieting disorders') are endemic. At the start of the twenty-first century, 4 % of young women meet criteria for bulimia nervosa (BN), 0.5 % have anorexia nervosa (AN) and many more have binge eating disorder (BED). See Figure 10.1.Ten per cent of patients with eating disorders are male. Children and even the elderly are presenting to clinics in greater numbers. The myth persists that this is the self-inflicted behaviour of spoilt middle-class teenage girls who read fashion magazines then go on silly diets, but eating disorders are often chronic, with high morbidity and - for anorexia nervosa - high mortality. Yet in contrast with other severe and enduring psychiatric disorders, complete recovery remains a possibility even after 20 years of illness. Another difference is that psychological therapies, rather than drugs, are acknowledged as the leading treatments. This chapter examines the evidence for psychotherapeutic effectiveness in the treatment of eating disorders.

Interpretation of the evidence base is complicated by changing diagnostic criteria (15 % rather than 25 % weight loss for AN), complex outcome measures (survival, weight gain, failure to meet diagnostic criteria, binge-purge frequency) and shifting epidemiology (increasing co-morbidity, fashions in patterns of diet and exercise). Diagnostic differentiation remains important. Bingeing and vomiting at low weight greatly increase mortality compared with purely restrictive starvation (Herzog et al., 2000). On the other hand, bingeing and vomiting at normal weight are associated with little if any excess mortality (Keel & Mitchell, 1997). Co-morbidity is associated with bleaker prognosis. There is an important gap in the evidence base for treatment of eating disorders with co-morbid substance (including alcohol) abuse. Most clinical trials for bulimia concern out-patients, often American subjects who have responded to advertisements for free treatment. Research into management of severe, 'multi-impulsive' bulimia is more limited. In contrast, anorexia research favours severely affected tertiary referrals, reflecting the middle-class referral bias. Nearly all trial subjects are female.

Handbook of Evidence-based Psychotherapies: A Guide for research and practice. Edited by C. Freeman & M. Power. Copyright © 2007 John Wiley & Sons, Ltd.

below 17.5

19 or above

below 17.5

19 or above

Figure 10.1 Interrelationship of eating disorders.

likely to be in the over weight range +

Even manualised therapies lack the predictable consistency of a drug, and research into eating disorders must take into account setting, relationships with patients, families and other carers, and timing and sequencing of interventions. We need to address not just 'what works for whom' but also by whom, with whom, where, when and for how long.

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