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National Collaborating Centre for Mental Health (UK). Eating Disorders: Core Interventions in the Treatment and Management of Anorexia Nervosa, Bulimia Nervosa and Related Eating Disorders. Leicester (UK): British Psychological Society (UK); 2004. (NICE Clinical Guidelines, No. 9.)

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Eating Disorders: Core Interventions in the Treatment and Management of Anorexia Nervosa, Bulimia Nervosa and Related Eating Disorders.

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8Treatment and management of atypical eating disorders (eating disorders not otherwise specified) including binge eating disorder

8.1. Introduction

In the absence of research evidence to guide the management of atypical eating disorders (Fairburn & Harrison, 2003) (also termed Eating Disorders Not Otherwise Specified, EDNOS; APA, 1994), other than binge eating disorder (BED), it is recommended that clinicians treat these patients following the principles advocated for treating the eating disorder that their eating problem most closely resembles.

In addition to the evidence base for anorexia nervosa and bulimia nervosa covered in other chapters of this guideline, BED has a growing evidence base relating to CBT, IPT and self-help approaches. There is also emerging research on antidepressants and appetite suppressants. To date, the research has focused primarily on the treatment of cases with comorbid obesity. It is not known whether equivalent findings would be obtained with patients who do not have obesity. Similar treatment approaches may well be helpful in adolescent cases though this has not been researched. There is no evidence about service setting for the treatment of BED.

8.2. Psychological interventions

8.2.1. Introduction

Psychological treatments for atypical eating disorders have been little studied, although patients with these disorders comprise a very significant proportion of those who present for treatment in the NHS (Fairburn & Harrison, 2003). The past 10 years has seen a growing interest in the treatment of BED with the development of specialised forms of CBT and IPT along with simplified forms of DBT. Behavioural weight management programmes have also been evaluated as a form of treatment for BED when it co-occurs with obesity.

8.2.2. Current practice

As indicated above, although patients with atypical eating disorders comprise a significant percentage of patients with eating disorders in specialist service settings, little is known about their current management. It is clearly a priority that treatment of these patients receives research attention.

8.2.3. Psychological treatments compared with wait-list controls

8.2.3.1. Treatments reviewed

The treatments included in this section are for BED only, usually in the presence of obesity.

The following treatments were included:

The Psychological Topic Group established definitions for each treatment (see Glossary). Two members of the Topic Group assessed each study for eligibility and classified each psychological treatment. Where disagreements arose, they were resolved by discussion.

8.2.3.2. Studies considered19

The review team conducted a new review of psychological treatments compared to wait-list control for BED. Seven trials met the eligibility criteria set by the Psychological Topic Group (Agras, 1995; Eldredge, 1997; Gorin, 2001; Reeves, 2001; Telch, 1990 & 2001; Wilfley, 1993). Of these, four used CBT–BED as the active treatment (Agras, 1995; Eldredge, 1997; Gorin, 2001; Telch, 1990), one used BWC (Reeves, 2001), one used simplified DBT (Telch, 2001), and one used IPT–BED (Wilfley, 1993). Thus, seven RCTs comparing a psychological treatment with a wait-list control group, involving 432 participants, were included in this section.

Full details of studies included in this review and reasons for excluding studies are given in Appendix 18.

8.2.3.3. Evidence statements20

The level of evidence (I, IIa, IIb, III, IV) is given after each statement (see Section 3.4.6 for more information about the classification of evidence).

Effect of treatment on remission from binge eating

There is strong evidence suggesting that there is a clinically significant difference between CBT–BED and wait-list control with CBT–BED being superior in terms of remission (defined as cessation of binge eating) by the end of treatment (N = 4; n = 226; Random Effects RR = 0.64; 95 per cent CI, 0.49 to 0.84; NNT = 3; 95 per cent CI, 2 to 7). [I]

There is strong evidence suggesting that there is a clinically significant difference between simplified DBT and wait-list control with simplified DBT being superior in terms of remission (defined as cessation of binge eating) by the end of treatment (N = 1; n = 44; RR = 0.30; 95 per cent CI, 0.15 to 0.60; NNT = 2; 95 per cent CI, 1 to 3). [I]

There is strong evidence suggesting that there is a clinically significant difference between IPT–BED and wait-list control with IPT–BED being superior in terms of remission (defined as cessation of binge eating) by the end of treatment (N = 1; n = 38; RR = 0.56; 95 per cent CI, 0.37 to 0.84; NNT = 3; 95 per cent CI, 2 to 5). [I]

Effect of treatment on frequency of binge eating

There is strong evidence suggesting that there is a clinically significant difference between CBT–BED and wait-list control with CBT–BED being superior on mean frequency of binge eating by the end of treatment (N = 4; n = 214; Random Effects SMD = −1.30; 95 per cent CI, −2.13 to −0.48). [I]

There is insufficient evidence to determine whether simplified DBT has any impact on the frequency of binge eating by the end of treatment. [I]

There is strong evidence suggesting that there is a clinically significant difference between IPT–BED and wait-list control with IPT–BED being superior on mean frequency of binge eating by the end of treatment (N = 1; n = 38; SMD = −1.44; 95 per cent CI, −2.16 to −0.72). [I]

There is limited evidence suggesting that there is a clinically significant difference between BWC and wait-list control with BWC being superior on mean frequency of binge eating by the end of treatment (N = 1; n = 82; SMD = −0.45; 95 per cent CI, −0.89 to −0.01). [I]

Effect of treatment on weight

There is evidence suggesting that it is unlikely there is a clinically significant difference between CBT–BED and wait-list control in terms of mean body weight (BMI where possible) by the end of treatment (N = 3; n = 176; SMD = −0.02; 95 per cent CI, −0.33 to 0.30). [I]

There is insufficient evidence to determine whether BWC has any impact on body weight by the end of treatment. [I]

Other effects of treatment

There is evidence suggesting that it is unlikely there is a clinically significant difference between CBT–BED and wait-list control in terms of mean depression scores by the end of treatment (N = 4; n = 214; SMD = −0.18; 95 per cent CI, −0.46 to 0.10). [I]

There is limited evidence suggesting that there is a clinically significant difference between IPT-BED and wait-list control with IPT-BED being superior on mean depression scores by the end of treatment (N = 1; n = 38; SMD = −0.80; 95 per cent CI, −1.46 to −0.13). [I]

There is insufficient or no evidence to determine whether CBT-BED, simplified DBT or IPT–BED have any impact on general psychiatric state or interpersonal/social functioning by the end of treatment. [I]

Attrition from the study

There is limited evidence suggesting that there is a clinically significant difference favouring the wait-list control group over CBT–BED in terms of the number of people leaving the study early due to any reason by end of treatment (N = 4; n = 222; RR = 1.86; 95 per cent CI, 1.10 to 3.15; NNH = 7; 95 per cent CI, 4 to 34). [I]

There is insufficient evidence to determine whether there is any difference between simplified DBT, IPT–BED or BWC and wait-list control in terms of the number of people leaving the study early due to any reason by the end of treatment. [I]

8.2.4. Psychological treatments compared with other psychological treatments

The treatments included in this section are for BED only, usually in the presence of obesity.

8.2.4.2. Studies considered

The review team conducted a new review of psychological treatments compared to other psychological treatments for BED. Four RCTs met the eligibility criteria set by the Psychological Topic Group (Carter, 1998; Loeb, 2000; Nauta, 2000; Wilfley, 1993 & 2002). Of these, one compared CBT–BED with BWC (Nauta, 2000) using a follow-up period of six months, and two compared CBT–BED with IPT–BED (Wilfley, 1993 & 2002), with only the latter study using a follow-up of 12 months. A further two trials compared GSH with PSH (Carter, 1998; Loeb, 2000), with the former study using a six-month follow-up. Both studies used the book Overcoming Binge Eating (Fairburn, 1995).

Thus, four trials, involving a total of 404 participants, were included in this review.

Full details of studies included in this review and reasons for excluding studies are given in Appendix 18.

8.2.4.3. Evidence statements20

Effect of treatment on remission from binge eating

There is insufficient evidence to determine whether or not there is any difference between CBT-BED and IPT-BED or BWC in terms of remission (defined as cessation of binge eating) by either the end of treatment or post-treatment follow-up. [I]

There is strong evidence suggesting that there is a clinically significant difference between CBT-BED and BWC with CBT-BED being superior in terms of remission (defined as cessation of binge eating) at follow-up (N = 1; n = 37; RR = 0.25; 95 per cent CI, 0.08 to 0.79; NNT = 3; 95 per cent CI, 2 to 8). [I]

There is insufficient evidence to determine whether GSH differs from PSH on remission of binge eating by end of treatment. [I]

Effect of treatment on frequency of binge eating

It is unlikely that CBT–BED and IPT–BED differ with regard to their effect on mean frequency of binge eating by either the end of treatment or follow-up:

  • There is evidence suggesting that it is unlikely there is a clinically significant difference between CBT-BED and IPT-BED on mean frequency of binge eating by the end of treatment (N = 2; n = 194; SMD = −0.07; 95 per cent CI, −0.35 to 0.22). [I]
  • There is evidence suggesting that it is unlikely there is a clinically significant difference between CBT-BED and IPT-BED on mean frequency of binge eating at follow-up (N = 1; n = 138; SMD = 0.14; 95 per cent CI, −0.19 to 0.48). [I]

There is insufficient evidence to determine whether CBT-BED differs from BWC on mean frequency of binge eating by post-treatment follow-up. [I]

There is limited evidence suggesting that there is a clinically significant difference between GSH and PSH with GSH being superior on mean frequency of binge eating by the end of treatment (N = 2; n = 109; SMD = −0.48; 95 per cent CI, −0.86 to −0.09). [I]

There is insufficient evidence to determine whether GSH differs from PSH on mean frequency of binge eating by post-treatment follow-up. [I]

Effect of treatment on weight

There is evidence suggesting that it is unlikely there is a clinically significant difference between CBT-BED and IPT-BED on mean weight (BMI where possible) by the end of treatment (N = 1; n = 158; SMD = 0.06; 95 per cent CI, −0.26 to 0.37). [I]

There is insufficient evidence to determine whether CBT-BED differs from IPT-BED or BWC on mean weight by post-treatment follow-up. [I]

There is evidence suggesting that it is unlikely there is a clinically significant difference between GSH and PSH on mean weight (BMI where possible) by the end of treatment (N = 2; n = 109; SMD = 0.08; 95 per cent CI, −0.30 to 0.46). [I]

There is insufficient evidence to determine whether GSH differs from PSH on mean weight by post-treatment follow-up. [I]

Other effects of treatment

There is insufficient evidence to determine whether CBT-BED differs from IPT-BED or BWC in terms of depression by the end of treatment. [I]

There is evidence suggesting that it is unlikely there is a clinically significant difference between CBT-BED and IPT-BED on mean depression scores at follow-up (N = 1; n = 138; SMD = 0.10; 95 per cent CI, −0.24 to 0.43). [I]

There is insufficient evidence to determine whether CBT-BED differs from BWC in terms of depression by post-treatment follow-up. [I]

There is evidence suggesting that it is unlikely there is a clinically significant difference between CBT-BED and IPT-BED on mean general psychiatric symptom scores by the end of treatment (N = 1; n = 158; SMD = 0.06; 95 per cent CI, −0.25 to 0.37). [I]

There is evidence suggesting that it is unlikely there is a clinically significant difference between CBT-BED and IPT-BED on mean psychosocial/interpersonal functioning scores by the end of treatment (N = 2; n = 194; SMD = 0.06; 95 per cent CI, −0.22 to 0.35). [I]

There is insufficient evidence to determine whether CBT–BED differs from IPT–BED in terms of mean psychosocial/interpersonal functioning scores by post-treatment follow-up. [I]

There is evidence suggesting that it is unlikely there is a clinically significant difference between CBT-BED and IPT-BED on mean general psychiatric scores at follow-up (N = 1; n = 138; SMD = 0.13; 95 per cent CI, −0.20 to 0.47). [I]

There is insufficient evidence to determine whether GSH differs from PSH in terms of mean general psychiatric scores by either the end of treatment or post-treatment follow-up. [I]

Acceptability of treatment

There is insufficient evidence to determine whether CBT-BED is more, or less, acceptable to people with BED than IPT-BED or BWC. [I]

There is insufficient evidence to determine whether GSH is more, or less, acceptable to people with BED than PSH. [I]

8.2.5. Additional considerations in the management of children and adolescents

Nothing is known about the treatment of atypical eating disorders in adolescents. Binge eating disorder does occur in some children and adolescents, especially among those with obesity (e.g. Decaluwe et al., 2003). The prevalence of BED in this age group is not known. There have been no studies of their treatment. This omission needs to be rectified. In the meantime, it is the view of the GDG that child and adolescent patients with BED should receive the same type of treatment as adults but adapted to suit their age, circumstances and level of development and with appropriate family involvement.

8.2.6. Clinical summary

There has been no research specifically directed at the treatment of atypical eating disorders other than BED. The view of the GDG is that clinicians should manage the large number of these cases according to the guidelines for anorexia nervosa or bulimia nervosa depending on the clinical presentation and age of the patient.

With regard to BED, given the apparently good response, at least in the short term, to a range of different psychological interventions including self-help and given the lower level of acute physical and psychiatric risk compared to anorexia and bulimia nervosa, treatment for BED may often be deliverable in primary care through the use of evidence-based self-help manuals. Children and adolescents with binge eating problems should receive the same type of treatment as adults but adapted to suit their age, circumstances and level of development, with appropriate family involvement.

8.2.7. Clinical practice recommendations

8.2.7.1.

In the absence of evidence to guide the management of atypical eating disorders (also known as eating disorders not otherwise specified) other than binge eating disorder, it is recommended that the clinician considers following the guidance on the treatment of the eating problem that most closely resembles the individual patient’s eating disorder. [C]*

8.2.7.2.

As a possible first step, patients with binge eating disorder should be encouraged to follow an evidence-based self-help programme. [B]

8.2.7.3.

Healthcare professionals should consider providing direct encouragement and support to patients undertaking an evidence-based self-help programme as this may improve outcomes. This may be sufficient treatment for a limited subset of patients. [B]

8.2.7.4.

Cognitive behaviour therapy for binge eating disorder (CBT–BED), a specifically adapted form of CBT, should be offered to adults with binge eating disorder. [A]*

8.2.7.5.

Other psychological treatments (interpersonal psychotherapy for binge eating disorder and modified dialectical behaviour therapy) may be offered to adults with persistent binge eating disorder. [B]

8.2.7.6.

Patients should be informed that all psychological treatments for binge eating disorder have a limited effect on body weight. [A]

8.2.7.7.

When providing psychological treatments for patients with binge eating disorder, consideration should be given to the provision of concurrent or consecutive interventions focusing on the management of any comorbid obesity. [C]

8.2.7.8.

Suitably adapted psychological treatments should be offered to adolescents with persistent binge eating disorder. [C]

8.3. Pharmacological interventions

8.3.1. Introduction

Antidepressants, antiepileptics and appetite suppressants have been suggested as possible treatments for BED. The evidence base for such practice is very limited.

8.3.2. Current practice

Little is known about the use of medication in the treatment of BED or other atypical eating disorders in the NHS.

8.3.3. Pharmacological treatment

All the studies reviewed below are on BED.

8.3.3.1. Drugs reviewed

The following drugs were included:

  • Antidepressants
  • Antiepileptics.

Drugs that have had their licences withdrawn from the UK were not included in the guideline.

8.3.3.2. Studies considered for review

The review team conducted a new review of RCTs involving pharmacological treatment in people with BED. Five trials met the eligibility criteria (Arnold, 2002; Hudson, 1998; Laederachhofman, 1999McElroy, 2000; McElroy, in press). Three trials compared a SSRI antidepressant (fluoxetine, fluvoxamine, sertraline) with placebo (Arnold, 2002; Hudson, 1998; McElroy, 2000), one trial compared a tricyclic antidepressant (imipramine) with placebo (Laederachhofman, 1999), and one trial (McElroy, in press) compared an antiepileptic (topiramate) with placebo. Thus, five RCTs comparing a pharmacological treatment with placebo, involving 271 participants, were included for review.

Full details of studies included in this review and reasons for excluding studies are given in Appendix 18.

8.3.3.3. Evidence statements20

Effect of treatment on remission

There is limited evidence suggesting that there is a clinically significant difference between antidepressants (SSRIs) and placebo with antidepressants being superior in terms of remission (defined as cessation of binge eating) by the end of treatment (N = 3; n = 179; RR = 0.77; 95 per cent CI, 0.63 to 0.93; NNT = 6; 95 per cent CI, 4 to 17). [I]

There is limited evidence suggesting that there is a clinically significant difference between topiramate and placebo with topiramate being superior in terms of remission (defined as cessation of binge eating) by the end of treatment (N = 1; n = 61; RR = 0.56; 95 per cent CI, 0.34 to 0.92; NNT = 4; 95 per cent CI, 2 to 15). [I]

Effect of treatment on symptoms

There is limited evidence suggesting that there is a clinically significant difference between antidepressants and placebo with antidepressants being superior on mean frequency of binge eating by the end of treatment (N = 3; n = 91; SMD = -0.61; 95 per cent CI, −1.04 to −0.18). [I]

Effect of treatment on weight

There is insufficient evidence to determine whether antidepressants have any impact on weight when compared with placebo at the end of treatment. [I]

Other effects of treatment

There is strong evidence suggesting that there is a clinically significant difference between antidepressants and placebo with antidepressants being superior on mean depression scores by the end of treatment (N = 2; n = 65; SMD = −0.78; 95 per cent CI, −1.30 to −0.27). [I]

Acceptability of treatment

There is insufficient evidence to determine whether antidepressants or antiepileptics are more, or less, acceptable to people with BED. [I]

Tolerability of treatment

There is insufficient evidence to determine whether antidepressants or antiepileptics produce side effects in people with BED. [I]

8.3.4. Clinical summary

There have been no studies of the use of drugs to treat atypical eating disorders other than BED. In BED there is limited evidence that by the end of treatment antidepressants can bring about improved remission from binge eating, reduced frequency of binge eating and improved mood. One small trial has demonstrated a positive impact of an antiepileptic (topiramate) on remission. No long-term follow-up data exists for any drug.

8.3.5. Clinical practice recommendations

8.3.5.1.

As an alternative or additional first step to using an evidence-based self-help programme, consideration should be given to offering a trial of a SSRI antidepressant drug to patients with binge eating disorder. [B]

8.3.5.2.

Patients with binge eating disorders should be informed that SSRIs can reduce binge eating, but the long-term effects are unknown. Antidepressant drugs may be sufficient treatment for a limited subset of patients. [B]

8.4. Management of physical aspects

The predominant long-term risks for patients with BED are with the physical consequences of any comorbid obesity. As current treatment programmes for BED appear to have minimal or no impact on weight, appropriate physical monitoring, advice and management strategies for obesity should be adopted. The physical consequences and management of obesity is beyond the scope of this guideline.

Binge eating disorder is the predominant eating disorder to occur in Type 2 diabetes and this usually occurs in the context of obesity. In nearly 90 per cent of cases the eating disorder preceded the onset of the diabetes (Herpertz et al., 1998).

The management of physical complications accompanying atypical eating disorders other than BED (e.g. severe underweight, electrolyte disturbance) should follow the guidance specified for anorexia nervosa and bulimia nervosa.

8.5. Service level interventions

Little is known about the optimal management of people with atypical eating disorders (including BED) in the NHS. Sometimes the strict use of referral criteria specifying full syndrome eating disorders may mean that they are excluded from specialised services. Most patients with atypical eating disorders referred to secondary care are treated as outpatients unless the management of comorbid states required admission to hospital. The GDG considered any evidence that certain levels of service provision – outpatient, day patient or inpatient – were associated with better outcomes in atypical eating disorders. No additional data relating specifically to atypical eating disorders (including BED) were identified. Therefore, it was agreed that the recommendations concerning the general approach for bulimia nervosa and anorexia nervosa be also applied to the atypical eating disorders. This should be borne in mind when considering the recommendations for this group of patients.

Here and elsewhere in the guideline, each study considered for review is referred to by a study ID (primary author and date of study publication, except where a study is in press or only submitted for publication, then a date is not used).

Footnotes

19

Here and elsewhere in the guideline, each study considered for review is referred to by a study ID (primary author and date of study publication, except where a study is in press or only submitted for publication, then a date is not used).

20

The full list of all evidence statements generated from meta-analyses (and the associated forest plots) accompany the guideline.

Copyright © 2004, The British Psychological Society & The Royal College of Psychiatrists.

All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Enquiries in this regard should be directed to the British Psychological Society.

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