A Guide to Selecting Evidence-based Psychological Therapies for Eating Disorders

Academy for Eating Disorders® (First edition, 2020) A Guide to Selecting Evidence-based Psychological Therapies for Eating Disorders

Academy for Eating Disorders® (First edition, 2020)

DISCLAIMER: This document, created by the Academy for Eating Disorders’ Psychological Care Guidelines Task Force, is intended as a resource to promote the use of evidence-based psychological treatments for eating disorders. It is not a comprehensive clinical guide. Every attempt was made to provide information based on the best available evidence. For further resources, visit: www.aedweb.org

Members of the AED Psychological Care Guidelines Task Force Lucy Serpell (Co-chair) Laura Collins Lyster-Mensh (Co-chair) Anja Hilbert Carol Peterson Glenn Waller Lucene Wisniewski

A GUIDE TO SELECTING EVIDENCE-BASED PSYCHOLOGICAL THERAPIES FOR EATING DISORDERS ii Table of Contents Background...... 1

Eating Disorders...... 1

Important Facts about Eating Disorders...... 2

Purpose of this Guide...... 2

A Note to Patients and Their Loved Ones and Policymakers...... 3

Evidence-Based Guidelines for Psychological Therapies for Eating Disorders...... 4

Training and Other Resources...... 6

Development of this Guide...... 6

Appendix...... 9

References...... 14

About the Academy for Eating Disorders ...... 15

A GUIDE TO SELECTING EVIDENCE-BASED PSYCHOLOGICAL THERAPIES FOR EATING DISORDERS iii Background intake relative to an individual’s requirements, leading to a significantly low body weight in the All eating disorders (EDs) are serious mental context of age, sex, developmental trajectory illnesses with significant, life-threatening and health status. Disturbance of , medical and psychiatric morbidity and mortality, an intense fear of gaining weight, lack of regardless of an individual’s weight. Patients recognition of the seriousness of the illness, with EDs have among the highest case fatality and/or behaviors that interfere with weight gain rate (i.e., the proportion of all individuals are also present. diagnosed with a disorder who die) of any psychiatric condition For example, the risk of 3. (BN): Binge eating (eating a premature death is 6-12 times higher in women large amount of food in a relatively short period with (AN) as compared to the of time with a concomitant sense of loss of general population, adjusting for age. control) with purging/compensatory behavior Early recognition and timely intervention, (e.g., self-induced vomiting, or based on a developmentally appropriate, abuse, insulin misuse, excessive exercise, diet evidence-based, multidisciplinary team pills) once a week or more for at least 3 months. approach (medical, psychological & nutritional) Disturbance of body image, an intense fear of is the ideal standard of care. Members of gaining weight and lack of recognition of the the multidisciplinary team may vary and will seriousness of the illness may also be present. depend upon the needs of the patient and the availability of these team members in the 4. Binge- (BED): Binge eating, patient’s community. In communities where in the absence of compensatory behavior, once resources are lacking, clinicians, therapists, and a week for at least 3 months. Binge eating dietitians are encouraged to consult with the episodes are associated with eating rapidly, Academy for Eating Disorders (AED) and/or ED when not hungry, until extreme fullness, and/or experts in their respective fields of practice. associated with depression, shame or guilt.

5. Other Specified Feeding and Eating Disorder Eating Disorders (OSFED): An ED that does not meet full criteria for one of the above categories, but has specific For the purpose of this document, we will focus disordered eating behaviors such as restricting on the most common EDs including: intake, purging and/or binge eating as key 1. Avoidant/Restrictive Food Intake Disorder features. Examples include purging disorder and (ARFID): Significant weight loss, nutritional night eating syndrome. deficiency, dependence on nutritional supplement 6. Unspecified Feeding or Eating Disorder or marked interference with psychosocial (UFED): ED behaviors are present, but they are functioning due to caloric and/or nutrient not specified by the care provider. restriction, but without weight or shape concerns. Consult www.aedweb.org, DSM-5, or ICD-10 for 2. Anorexia Nervosa (AN): Restriction of energy full diagnostic descriptions.

A GUIDE TO SELECTING EVIDENCE-BASED PSYCHOLOGICAL THERAPIES FOR EATING DISORDERS 1 Important Facts about Purpose of this Guide Eating Disorders

◗ All EDs are serious disorders with life- The Academy for Eating Disorders (AED) is threatening physical and psychological committed to ensuring that individuals with complications. eating disorders and their carers should have access to the best treatment available. The ◗ All EDs can be associated with serious nature of eating disorders means that their medical complications affecting every organ treatment requires attention to both physical system of the body. and psychological needs. The AED’s Eating ◗ The medical consequences of EDs can go Disorders: A Guide to Medical Care (2016; unrecognized, even by an experienced 3rd Edition) outlines the medical care of such clinician. individuals. This guide is the companion piece to that medical care guide. ◗ EDs do not discriminate. They can affect individuals of all ages, genders, ethnicities, socioeconomic backgrounds, and with a This guide is based on evidence regarding variety of body shapes, weights and sizes. effective psychological treatment of eating disorders. It is the first international guide ◗ Weight is not the only clinical marker of an on evidence-based psychotherapeutic ED. People who are at low, normal or high interventions for eating disorders, designed weights can have an ED, and individuals to inform clinicians anywhere in the world, at any weight may be malnourished and/ particularly in locations without their own or engaging in unhealthy weight control guidelines or without up-to-date guidelines. practices.

◗ Individuals with an ED might not recognize This document identifies the best psychological the seriousness of their illness and/or may be therapies for eating disorders, based on a ambivalent about changing their eating or synthesis of many separate guidelines. The other behaviors. AED believes that therapists, supervisors, ◗ All instances of precipitous weight loss or managers, commissioners, patients, and their gain in otherwise healthy individuals should carers should have access to this information to be investigated for the possibility of an ED, as assist in choice, delivery, and training. However, rapid weight fluctuations can be a potential clinicians should be aware that this guide is marker of an ED. not a substitute for undertaking appropriate training in these manualized interventions or for ◗ In children and adolescents, failure to gain adhering to the methods they describe. expected weight or height, and/or delayed or interrupted pubertal development, should be investigated for the possibility of an ED.

A GUIDE TO SELECTING EVIDENCE-BASED PSYCHOLOGICAL THERAPIES FOR EATING DISORDERS 2 A Note to Patients and Their where legislative attention is most warranted. Loved Ones and Policymakers We also hope, by showing what is known, to spotlight what is yet unknown and where This is the first international guide for research is critically needed. psychological treatment of eating disorders. It is compiled based on published national This guide is based on existing national treatment standards from seven countries guidelines published since 2010, which were and represents the current research-guided developed using the research-based literature. evidence-base for treatment by psychologists Because the evidence base for comparing or and mental healthcare providers. It is best used evaluating eating disorder treatment remains as a companion to the AED’s Eating Disorders: limited in breadth and strength, this guide can A Guide to Medical Care (2016; 3rd Edition), be considered a composite of snapshots, not a which covers the medical aspects of eating full picture. It does not include recommendations disorder management. based on clinical judgement or current practice, or cover the full range of eating disorder The AED is the leading scientific and training diagnoses or types of people affected. This organization in the world focusing on eating document covers treatment modalities only, disorders. As a multi-disciplinary community not settings, or level of care. There is little of clinicians, researchers, and advocates, existing treatment research on some eating we understand the importance of providing disorder diagnoses, and evidence by gender, authoritative information to those treating, culture, and age is often lacking, such that few researching, supporting, and living with eating recommendations exist at such a fine grained disorders. We understand the urgency for level. The solution — more research — is a long- disseminating new research while respecting term goal we all hope to promote. We plan to the clinical judgement and real-world update the guide to incorporate new findings, knowledge in the field. This guide is meant to and expect this guide to evolve as more high- offer a view of the evidence that will be used quality evidence emerges. alongside experience and training to help patients, their families, and policymakers. This guide does not include all existing treatments or approaches, only those that While these guidelines are meant to inform have been methodically researched and found treatment decisions by psychological treatment to be comparatively effective. The treatment providers, we also hope to inform allied modalities listed are only one aspect of professionals who are supporting treatment the professional, personal, and community teams, and to help patients and their families support for those struggling with these understand if and how their treatment options dangerous but treatable disorders. Where no are supported by the literature. Policymakers, recommendations exist for a diagnosis, it is too, can be informed about which treatments generally accepted to adapt the treatments are supported by evidence, and therefore, best supported for the closest diagnosis.

A GUIDE TO SELECTING EVIDENCE-BASED PSYCHOLOGICAL THERAPIES FOR EATING DISORDERS 3 For example, for individuals with OSFED, Evidence-based guidelines psychological approaches for anorexia nervosa for psychological therapies or bulimia nervosa are often adapted, based for eating disorders on the patient’s specific symptoms. Treatments are also often drawn from similar non-eating A synthesis of multiple national guidelines disorder diagnoses, such as with ARFID, where appears below, organized by developmental there are no published national guidelines, stage (children/adolescents; adults) and but clinicians can draw from the literature on diagnosis. There are a number of areas anorexia nervosa, sensory processing disorders, where there is currently no evidence-based and anxiety disorders. recommendation made for any psychological therapy. In particular, this applies to the more Similarly, most national guidelines consider recently defined and more diverse disorders young people and adults separately. Where (OSFED and ARFID). In such cases, the there are no recommendations for younger most common recommendation in national patients, adapting the evidence-based guidelines is to treat the individual as if they treatment for adults is often employed. The had the most similar specific eating disorder. lack of research base for the full spectrum of eating disorders, ages, and contributing The evidence-based recommendations from factors requires clinicians and policy makers the seven national guidelines used to create to extrapolate from what is known. Unless the synthesized recommendations here stated, very few treatment approaches in are summarized below, and detailed in the these guidelines are contraindicated for similar Appendix. In order to understand how those diagnoses or ages. source recommendations were reached, the reader is encouraged to consult the specific national guidelines themselves.

Recommendations for Children and Adolescents

FIRST LINE TREATMENTS SECOND LINE TREATMENTS Anorexia nervosa FBT AFT

Bulimia nervosa FBT; CBT-ED None

Binge-eating disorder None CBTgsh; CBT-ED individual or group ARFID, Pica, Rumination, None None OSFED, UFED

A GUIDE TO SELECTING EVIDENCE-BASED PSYCHOLOGICAL THERAPIES FOR EATING DISORDERS 4 Recommendations for Adults

FIRST LINE TREATMENTS SECOND LINE TREATMENTS

Anorexia nervosa CBT-ED; MANTRA; SSCM Focal Psychodynamic Psychotherapy

Bulimia nervosa CBT-ED; CBTgsh IPT; Group psychotherapy

Binge-eating disorder CBT-ED group or individual; IPT CBTgsh

ARFID, Pica, Rumination, None None OSFED, UFED

AFT = Adolescent-Focused Therapy FPT = Focal Psychodynamic Therapy CBT = Cognitive-behavioral Therapy IPT = Interpersonal Psychotherapy CBT-ED = Cognitive-Behavioral Therapy for Eating MANTRA = Maudsley Model of Anorexia Nervosa Disorders Treatment for Adults CBTgsh = Guided Self-Help Cognitive-Behavioral Therapy SSCM = Specialist Supportive Clinical Management FBT = Family-Based Treatment

Recommendations for Special Populations

There are no evidence-supported recommendations that would justify exceptions being made for young people or adults based on: ◗ gender ◗ disability ◗ sociocultural background ◗ race ◗ ethnicity ◗ socioeconomic status ◗ sexual orientation ◗ sexual identity ◗ weight status ◗ psychological co-morbidity (e.g., mood, anxiety, post traumatic stress disorder, obsessive compulsive disorder, personality disorder, substance use disorder) ◗ physical comorbidity ◗ chronicity of illness ◗ trauma ◗ religion

A GUIDE TO SELECTING EVIDENCE-BASED PSYCHOLOGICAL THERAPIES FOR EATING DISORDERS 5 Training and Other Training Resources Resources The National Center of Excellence for Eating Manuals and Selected Original Research Disorders (NCEED): a SAMHA-funded initiative to provide resources to the public: Agras W. S. & Apple, R. (2007). Overcoming www.nceedus.org your eating disorder: A cognitive-behavioral therapy approach for bulimia nervosa and The Centre for Research on Eating Disorders binge-eating disorder, guided self-help at Oxford (CREDO): the academic home workbook. Oxford University Press. of Cognitive Behavior Therapy – Enhanced Fairburn, C. G. (2008). Cognitive Behavior (CBT-E) for Eating Disorders with resources for Therapy and Eating Disorders. Guilford Press. health professionals, including in-session guides and handouts: www.credo-oxford.com Fairburn, C. G. (2013). Overcoming binge eating: The proven program to learn why you binge and Training in CBT-E: https://www.cbte.co/for- how you can stop (2nd Ed.). Guilford Press. professionals/training-in-cbt-e/ Lock, J., & Le Grange, D. (2013). Treatment Manual for Anorexia Nervosa: A Family-Based Training in IPT for eating disorders: http:// Approach. The Guilford Press. iptfored.com/home

McIntosh, V. V. W., Jordan, J., Luty, S. E., Carter, Webinars, videos, and other resources: F. A., McKenzie, J. M., Bulik, C. M., & Joyce, www.aedweb.org P. R. (2006). Specialist supportive clinical management for anorexia nervosa. International More general informational videos: Journal of Eating Disorders, 39(8), 625 – 632. https://eatingdisorders.dukehealth.org/education Schmidt, U., Magill, N., Renwick, B., et al. (2015). The Maudsley Outpatient Study of Treatments for Anorexia Nervosa and Related Conditions (MOSAIC): Comparison of the Maudsley Model of Anorexia Nervosa Treatment for Development of this Guide Adults (MANTRA) with specialist supportive clinical management (SSCM) in outpatients There are numerous national guidelines for with broadly defined anorexia nervosa: the evidence-based psychological treatment A randomized controlled trial. Journal of of eating disorders, developed in different Consulting and Clinical Psycholology, 83(4), countries and at different times. However, some 796 – 807. guidelines vary in their recommendations in important ways, often due to methodological Waller, G., Corstorphine, E., Hinrichsen, H., issues (e.g., the emphasis given to clinical Lawson, R., Mountford, V., & Russell, K. (2007). expert opinion; date of evidence-collection; Cognitive Behavioral Therapy for Eating Disorders. Cambridge University Press. context, economic considerations and amount

A GUIDE TO SELECTING EVIDENCE-BASED PSYCHOLOGICAL THERAPIES FOR EATING DISORDERS 6 of evidence needed to support a conclusion). out, clinician judgment is most useful when it The aim of this guideline was not to re- is used to decide how to apply the evidence- review the source literature, but to review and based approach to the individual patient. synthesize the existing guidelines. This guide does not distinguish the wide The AED convened a special Task Force, range of settings where eating disorder selected from an international group of AED treatment takes place, because there is limited members, including clinicians, researchers, and evidence that addresses evidence-based user/family representatives. They reviewed psychological therapies delivered in settings all available national guidelines found by other than outpatient services. However, searching electronic databases, the National given that psychological treatment of eating Guideline Clearinghouse and the International disorders is effective in routine clinical practice Guideline Library, and outreach to colleagues, (provided it adheres to the protocols tested who provided translations where necessary. in research settings), these conclusions and Guidelines published from 2010 onwards recommendations can be assumed to apply to were included, as earlier guidelines were most clinical practice. likely to be based on outdated evidence. This resulted in seven national guidelines While the methodology behind this guide from eight countries (Australia/New Zealand, means that its core conclusions are likely to Denmark, France, Germany, Netherlands, United remain unchanged for several years, much Kingdom, and United States). The Task Force research is needed in some key areas. For sought to identify common evidence-based example, the evidence base for psychological recommendations and synthesize them to treatments for Avoidant Restrictive Food Intake form this document. Recommendations based Disorder (ARFID) and Other Specified Feeding on clinical opinion alone are reported in the and Eating Disorder (OSFED) are insufficient Appendix but are not advocated here due to to guide confident recommendations about their lack of evidence. treating these presentations. It is also important to consider the potential of briefer therapies While the AED does not discount the potential to be effective, in order to ensure wider access value of clinician judgement in supplementing to evidence-based therapies (e.g., NICE, 2017; evidence-based psychological therapies, it Waller et al., 2018). should be stressed that there is very clear evidence from the wider field of psychological This document has been approved by the AED therapies that clinician judgement results in Board of Directors as representing the AED’s substantially poorer outcomes for patients, recommendation for current best practice in the if that judgement is allowed to override the delivery of psychological therapies for eating evidence-based approach (e.g., Bell & Mellor, disorders. The AED intends to update this guide 2009). In short, as Wilson (1996) has pointed regularly to keep it current, as new evidence and updated national guidelines emerge.

A GUIDE TO SELECTING EVIDENCE-BASED PSYCHOLOGICAL THERAPIES FOR EATING DISORDERS 7 Guidelines used to create this document

Australia and New Zealand guidelines United Kingdom guidelines published by published by the Royal Australian and New the National Institute for Health and Care Zealand College of Psychiatrists (https://www. Excellence (https://www.nice.org.uk/guidance/ ranzcp.org/practice-education/guidelines-and- ng69) resources-for-practice/eating-disorders-cpg- and-associated-resources) United States guidelines published by the American Psychiatric Association (http:// Denmark guidelines published by the Danish psychiatryonline.org/pb/assets/raw/ Health Authority (2016) for anorexia nervosa sitewide/practice_guidelines/guidelines/ (https://www.sst.dk/da/udgivelser/2016/~/me- eatingdisorders.pdf) dia/36D31B378C164922BCD96573749AA206. ashx) and bulimia nervosa (https://www.sst. See also Hilbert, Hoek, and Schmidt (2017) dk/-/media/Udgivelser/2015/NKR-Bulimi/ for additional information on eating disorder EN_194413_Quick-Guide-NKR-Bulimi_print. treatment guidelines across countries. ashx?la=da&hash=54B13E57E7515B317B889C- CFD1B9F7725F72C69F)

French guidelines published by Haute Autorite´ de Sante´ (https://www.has-sante.fr/plugins/ ModuleXitiKLEE/types/FileDocument/doXiti. jsp?id=c_1546479)

German guidelines published by the Association of the Scientific Medical Societies (https://www.awmf.org/leitlinien/detail/ll/051- 026.html)

Netherlands guidelines published by the Dutch Foundation for Quality Development in Mental Healthcare (https://www.ggzstandaarden.nl/ zorgstandaarden/eetstoornissen/introductie)

A GUIDE TO SELECTING EVIDENCE-BASED PSYCHOLOGICAL THERAPIES FOR EATING DISORDERS 8 Appendix Evidence-Based Psychological Therapies for Children and Adolescents

COUNTRY EVIDENCE- EVIDENCE-BASED UNEVIDENCED PRIMARY OUTCOME SECONDARY OUTCOME SOURCE OF EVIDENCE BASED SECOND-LINE ALTERNATIVE VARIABLES VARIABLES RECOMMENDED THERAPY POSSIBILITIES, WEAK FIRST-LINE RECOMMENDATION, THERAPY CLINICAL CONSENSUS ANOREXIA NERVOSA UK FBT; AFT BMI, eating attitudes, Quality of life, NICE 2017 body image, bulimic anxiety, depression behaviors Germany FBT BMI AWMF German S3-Guideline Diagnosis and Therapy of Eating Disorders France Family HAS Clinical therapies Practice Guidelines Denmark FBT-AN Consider adding Weight gain (using Additional focus on Danish Health physical exercise specific targets), broader symptoms Authority 2016 during weight gain eating disorder (unspecified), phase symptoms assessed normalize weight across therapy to 50th centile or to previous point on growth curve Australia and FBT Alternate Avoid ‘treatment Weight gain, Dietary change, RANZCP New Zealand (manualized) family-based as usual’ approach biological enhanced body guideline 2014 approach; normalization image, reduced Adolescent- compensatory Focused behaviors Therapy USA FBT-AN Avoid conjoint APA Practice family therapy Guideline 2012 where there are high levels of parental criticism Netherlands FBT CBT-ED; Practice Adolescent guideline for Focused the treatment of Therapy eating disorders 2017 BULIMIA NERVOSA UK FBT; CBT-ED Eating attitudes, Quality of life, NICE 2017 body image; bulimic anxiety, depression behaviors Germany Age-adapted FBT Abstinence from Eating pathology, AWMF German CBT binge eating and depression S3-Guideline compensatory Diagnosis and behaviors, remission Therapy of from bulimia nervosa, Eating Disorders reduction of symptom severity

A GUIDE TO SELECTING EVIDENCE-BASED PSYCHOLOGICAL THERAPIES FOR EATING DISORDERS 9 Evidence-Based Psychological Therapies for Children and Adolescents (continued)

COUNTRY EVIDENCE-BASED EVIDENCE-BASED UNEVIDENCED PRIMARY OUTCOME SECONDARY OUTCOME SOURCE OF EVIDENCE RECOMMENDED FIRST- SECOND-LINE ALTERNATIVE VARIABLES VARIABLES LINE THERAPY THERAPY POSSIBILITIES, WEAK RECOMMENDATION, CLINICAL CONSENSUS BULIMIA NERVOSA (continued) Denmark CBT-BN; FBT-BN Individual Do not use Eating disorder Danish Health or group motivational symptoms Authority 2016 psychotherapy enhancement assessed across therapy therapy USA FBT-BN Motivational APA Practice therapy ineffective Guideline 2012 in changing eating pathology Netherlands FBT CBT/CBT-E Practice guideline for the treatment of eating disorders 2017 BINGE-EATING DISORDER UK CBTgsh; CBT group Germany Psychotherapy Binge-eating Eating disorder AWMF German with parental episodes, psychopathology, S3-Guideline involvement abstinence from depression, BMI Diagnosis and binge eating Therapy of Eating Disorders Avoidant/ restrictive food intake disorder Germany Mealtime structure, Eating disorder Not specified AWMF German cognitive- symptoms S3-Guideline behavioral Diagnosis and interventions Therapy of with parental Eating Disorders involvement Netherlands CBT for fear based Practice problems, dietetic guideline for advice, speech the treatment of therapy eating disorders 2017 PICA Germany Cognitive- Eating disorder Not specified AWMF German behavioral symptoms S3-Guideline interventions Diagnosis and Therapy of Eating Disorders

A GUIDE TO SELECTING EVIDENCE-BASED PSYCHOLOGICAL THERAPIES FOR EATING DISORDERS 10 Evidence-Based Psychological Therapies For Adults

COUNTRY EVIDENCE-BASED EVIDENCE-BASED UNEVIDENCED ALTERNATIVE PRIMARY OUTCOME SECONDARY OUTCOME SOURCE OF EVIDENCE RECOMMENDED SECOND-LINE POSSIBILITIES, WEAK VARIABLES VARIABLES FIRST-LINE THERAPY RECOMMENDATION, CLINICAL THERAPY CONSENSUS ANOREXIA NERVOSA UK CBT-ED; Focal psycho- BMI, eating attitudes, Quality of NICE 2017 SSCM; dynamic body image, bulimic life, anxiety, MANTRA therapy behaviors depression Germany FPT; CBT-E; Nutritional counseling, BMI AWMF German MANTRA; not as monotherapy S3-Guideline SSCM Diagnosis and Therapy of Eating Disorders France Supportive therapies; Not specified Not specified HAS Clinical Psychodynamic Practice therapies, or Guidelines those related to psychoanalysis; CBT; Systemic and strategic therapies; Motivational approaches Denmark Individual Weight gain (using Additional focus Danish Health or group specific targets), on broader Authority 2016 psycho- eating disorder symptoms therapy symptoms assessed (unspecified), across therapy normalize BMI in the 20-25 range (21-26 for men) Australia and CBT-ED; Do not use CBTgsh or Weight gain; Dietary change, RANZCP New Zealand SSCM; web-based therapies; biological enhanced body guideline 2014 MANTRA Motivational normalization image, reduced enhancement therapy compensatory ineffective behaviors USA None Motivational therapy APA Practice ineffective in changing Guideline 2012 eating pathology Netherlands CBT / CBT-E Practice individual guideline for or group; the treatment of MANTRA; eating disorders SSCM 2017 BULIMIA NERVOSA UK CBTgsh; CBT- Eating attitudes, Quality of NICE 2017 ED body image, bulimic life, anxiety, behaviors depression Germany CBT IPT Psychodynamic Abstinence from Eating AWMF German (including therapy; CBTgsh binge eating and pathology, S3-Guideline DBT) compensatory depression Diagnosis behaviors, remission and Therapy from bulimia of Eating nervosa, reduction of Disorders symptom severity

A GUIDE TO SELECTING EVIDENCE-BASED PSYCHOLOGICAL THERAPIES FOR EATING DISORDERS 11 Evidence-Based Psychological Therapies for Adults (continued)

COUNTRY EVIDENCE-BASED EVIDENCE-BASED UNEVIDENCED ALTERNATIVE POSSIBILITIES, PRIMARY SECONDARY OUTCOME SOURCE OF EVIDENCE RECOMMENDED SECOND-LINE WEAK RECOMMENDATION, CLINICAL CONSENSUS OUTCOME VARIABLES FIRST-LINE THERAPY VARIABLES THERAPY BULIMIA NERVOSA (continued) Denmark CBT-BN Individual Do not use motivational Eating Danish Health or group enhancement therapy; consider disorder Authority 2016 psychotherapy adding physical exercise during symptoms weight gain phase assessed across therapy Australia and CBT-ED CBTgsh If no access to CBT-ED, then RANZCP New Zealand consider: IPT; DBT guideline 2014 USA CBT-ED CBTgsh using Motivational therapy ineffective APA Practice structured in changing eating pathology Guideline 2012 manuals; IPT if CBT-ED is not effective Netherlands CBT/CBT-E IPT DBT Practice guideline for the treatment of eating disorders 2017 BINGE-EATING DISORDER UK CBTgsh; Eating Quality of life, NICE 2017 Group attitudes, body image CBT-ED; bulimic individual; behaviors CBT-ED Germany CBT IPT Psychodynamic Therapy; Binge- Eating disorder AWMF German (including Humanistic Therapy; Behavioral eating S3-Guideline DBT) Weight Loss Treatment in episodes; Diagnosis case of comorbid obesity; Abstinence and Therapy Combination of psychotherapy from binge of Eating with or without Behavioral eating Disorders Weight Loss Treatment and with or without pharmacotherapy in case of insufficient monotherapeutic treatment Australia and CBT-ED CBTgsh If no access to CBT-ED, then RANZCP New Zealand consider: IPT; DBT; mindfulness guideline 2014 USA CBT-ED; DBT; IPT APA Practice Group CBT- Guideline 2012 ED Netherlands CBT/CBT-E IPT DBT Practice guideline for the treatment of eating disorders 2017

A GUIDE TO SELECTING EVIDENCE-BASED PSYCHOLOGICAL THERAPIES FOR EATING DISORDERS 12 Evidence-Based Psychological Therapies for Adults (continued)

COUNTRY EVIDENCE-BASED EVIDENCE-BASED UNEVIDENCED PRIMARY OUTCOME SECONDARY SOURCE OF EVIDENCE RECOMMENDED SECOND-LINE ALTERNATIVE VARIABLES OUTCOME VARIABLES FIRST-LINE THERAPY POSSIBILITIES, WEAK THERAPY RECOMMENDATION, CLINICAL CONSENSUS

BINGE-EATING DISORDER (continued) UK As per the nearest BMI, eating Quality of NICE 2017 full diagnosis attitudes, body life, anxiety, image, bulimic depression behaviors Germany As per the nearest Eating disorder Not specified AWMF German S3-Guideline full diagnosis symptoms Diagnosis and Therapy of Eating Disorders NIGHT EATING SYNDROME Germany CBT; Progressive Eating disorder Not specified AWMF German S3-Guideline Muscle Relaxation symptoms Diagnosis and Therapy of Eating Disorders PURGING DISORDER Germany As with bulimia Eating disorder Not specified AWMF German S3-Guideline nervosa symptoms Diagnosis and Therapy of Eating Disorders RUMINATION DISORDER Germany EMG Biofeedback Eating disorder Not specified AWMF German S3-Guideline symptoms Diagnosis and Therapy of Eating Disorders

Note: AFT = Adolescent-Focused Therapy MANTRA = Maudsley Model of Anorexia Nervosa Treatment for Adults CBT = Cognitive-behavioral Therapy SSCM = Specialist Supportive Clinical Management CBT-ED = Cognitive-Behavioral Therapy for Eating Disorders DBT = dialectical behavior therapy CBTgsh = Guided Self-Help Cognitive-Behavioral BMI = body mass index Therapy EMG = electromyography FBT = Family-Based Treatment For sources see “Guidelines used to create this FPT = Focal Psychodynamic Therapy document” in the “Training and Other Resources” section. IPT = Interpersonal Psychotherapy

A GUIDE TO SELECTING EVIDENCE-BASED PSYCHOLOGICAL THERAPIES FOR EATING DISORDERS 13 References

Academy for Eating Disorders (2016). Eating Schmidt, U., Magill, N., Renwick, B., et al. (2015). Disorders: A guide to Medical Care. Academy for The Maudsley Outpatient Study of Treatments Eating Disorders. www.aedweb.org/resources/ for Anorexia Nervosa and Related Conditions publications/medical-care-standards (MOSAIC): Comparison of the Maudsley Model of Anorexia Nervosa Treatment for Agras W. S. & Apple, R. (2007). Overcoming Adults (MANTRA) with specialist supportive your eating disorder: A cognitive-behavioral clinical management (SSCM) in outpatients therapy approach for bulimia nervosa and with broadly defined anorexia nervosa: binge-eating disorder, guided self-help A randomized controlled trial. Journal of workbook. Oxford University Press. Consulting and Clinical Psychology, 83(4), Bell, I. & Mellor, D. (2009). Clinical judgments: 796 – 807. Research and practice. Australian Psychologist, Waller, G., Corstorphine, E., Hinrichsen, H., 44(2), 112 – 121. Lawson, R., Mountford, V., & Russell, K. (2007). Fairburn, C. G. (2008). Cognitive Behavior Cognitive Behavioral Therapy for Eating Therapy and Eating Disorders. Guilford Press. Disorders. Cambridge University Press.

Fairburn, C. G. (2013). Overcoming binge eating: Waller, G., Tatham, M., Turner, H., Mountford, V. The proven program to learn why you binge and A., Bennetts, A., Bramwell, K., Dodd. J., Ingram, how you can stop (2nd Ed.). Guilford Press. L. (2018). A 10-session cognitive-behavioral therapy (CBT-T) for eating disorders: Outcomes Hilbert, A., Hoek, H. W., & Schmidt, R. (2017). from a case series of non-underweight adult Evidence-based clinical guidelines for eating patients. International Journal of Eating disorders: International comparison. Current Disorders, 51, 262 – 269. doi: 10.1002/eat.22837 Opinion in Psychiatry, 30(6), 423 – 437. Wilson, G. T. (1996). Empirically validated Lock, J., & Le Grange, D. (2013). Treatment treatments: Reality and resistance. Clinical Manual for Anorexia Nervosa: A Family-Based Psychology Science and Practice, 3(3), Approach. The Guilford Press. 241 – 244. McIntosh, V. V. W., Jordan, J., Luty, S. E., Carter, F. A., McKenzie, J. M., Bulik, C. M., & Joyce, P. R. (2006). Specialist supportive clinical management for anorexia nervosa. International Journal of Eating Disorders, 39(8), 625 – 632.

A GUIDE TO SELECTING EVIDENCE-BASED PSYCHOLOGICAL THERAPIES FOR EATING DISORDERS 14 About the Academy for Eating Disorders (AED)

The AED is a global multidisciplinary professional association committed to leadership in promoting EDs research, education, treatment, and prevention. The AED provides cutting-edge professional training and education, inspires new developments in the field of EDs, and is the international source for state-of-the-art information on EDs.

JOIN THE AED: Become a member of a global community dedicated to ED research, treatment, education, and prevention. Join online at www.aedweb.org.

A GUIDE TO SELECTING EVIDENCE-BASED PSYCHOLOGICAL THERAPIES FOR EATING DISORDERS 15 EE2046 AED