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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.)

Glossary

Adherence

The behaviour of taking medicine according to treatment dosage and schedule as intended by the prescriber. In this guideline, the term ‘adherence’ is used in preference to ‘compliance’, but is not synonymous with ‘concordance’, which has a number of meanings.

Affective disorder

A syndrome in which an individual experiences a significant alteration in affect or mood. Whether depressed or elated, this change of mood is accompanied by alteration in the individual’s activity levels.

Anorexia nervosa

A syndrome in which the individual maintains a low weight as a result of a preoccupation with body weight, construed either as a fear of fatness or pursuit of thinness. Weight is maintained at least 15 per cent below that expected or body mass index (calculated as weight in kilograms divided by height in metres squared) is below 17.5. Weight loss is self-induced by exercise, vomiting or purgation, and avoidance of fattening foods. A widespread endocrine disorder involving the hypothalamo-pituitary-gonadal axis is present. In females this is manifest as amenorrhoea and in males by loss of sexual interest and impotence. Other psychosocial features such as mood disorder, obsessive-compulsive symptoms and social withdrawal are common.

Atypical eating disorder

This term is used to denote eating disorders of clinical severity that do not meet the diagnostic criteria for anorexia nervosa or bulimia nervosa. The equivalent American term is ‘eating disorder not otherwise specified’.

Behavioural weight control (BWC)

Behavioural treatments that have weight loss as their goal.

Behaviour therapy (BT)

Behavioural treatments that include many features of cognitive behaviour therapy for bulimia nervosa (CBT-BN) but have little or no emphasis on the direct modification of ways of thinking.

Binge eating disorder

A syndrome in which an individual experiences repeated uncontrolled episodes of overeating but does not use extreme compensatory weight-control behaviours. It is a provisional new eating disorder diagnosis in DSM-IV.

Bulimia nervosa

A syndrome characterised by recurrent episodes of binge eating and by compensatory behaviour (vomiting, purging, fasting or exercising) in order to prevent weight gain. Binge eating is accompanied by a subjective feeling of loss of control over eating. This is a normal weight syndrome in which the body mass index (BMI) is maintained above 17.5 kg/m2.

Cognitive analytic therapy

A specific time-limited, problem-focused psychotherapy developed by Ryle (Ryle & Kerr, 2002). It integrates cognitive, behavioural and psychodynamic principles.

Cognitive behaviour therapy

A psychological intervention that is designed to enable people to establish links between their thoughts, feelings or actions and their current or past symptoms and to re-evaluate their perceptions, beliefs or reasoning about the target symptoms. The intervention should involve at least one of the following: (1) monitoring thoughts, feelings or behaviour with respect to the symptom; (2) being helped to use alternative ways of coping with the target symptom; (3) reducing stress.

Cognitive behaviour therapy for binge eating disorder (CBT-BED)

A specific form of CBT derived from CBT-BN, and adapted to suit patients with BED.

Cognitive behaviour therapy for bulimia nervosa (CBT-BN)

A specific form of CBT devised for patients with bulimia nervosa. It typically involves 16 to 20 hour-long one-to-one treatment sessions over four to five months. Its focus is not only on helping patients change their eating habits but also on addressing the ways of thinking (most especially the over-evaluation of shape and weight) that maintain them. It has been described in several treatment manuals, the one used in most of the more recent treatment trials being that by Fairburn and colleagues (Fairburn et al., 1993).

Cognitive behaviour therapy plus exposure with response prevention (CBT+ERP)

A treatment that combines elements of CBT-BN with repeated sessions of exposure to situations that would normally trigger either binge eating or purging.

Confidence interval

The range within which the ‘true’ values (e.g. size of effect of an intervention) are expected to lie with a given degree of certainty (e.g. 95 per cent or 99 per cent). Confidence intervals represent the probability of random errors, but not systematic errors – or bias.

Controlled trial

An experiment in which investigators allocate eligible people into groups to receive or not to receive one or more interventions that are being compared.

Costing study

This is the simplest economic study, measuring only the costs of given interventions. It does not provide answers to efficiency questions.

Cost-benefit analysis

A type of full economic evaluation that compares alternatives in which the costs and consequences vary. Both costs and benefits are measured in monetary units. If benefits exceed costs, the evaluation would be a basis for recommending the treatment. It can address the question of whether a treatment or policy is socially worthwhile in the broadest sense.

Cost-consequence analysis

An analysis in which both outcomes and costs of alternative treatments or policy options are described. However, multiple outcomes are measured and there is no attempt to reduce everything to a single ratio.

Cost-effectiveness analysis

A type of full economic evaluation that compares competing alternatives of which the costs and consequences vary. The outcomes are measured in the same non-monetary (natural) unit. It expresses the result in the form of an incremental (or average or marginal) cost-effectiveness ratio.

Cost-minimisation analysis

A type of full economic evaluation where the costs of equally effective alternative treatments are compared. The aim is to find the least costly alternative.

Cost-of-illness/economic burden studies

An economic analysis of the total costs incurred by a society due to a specific disease.

Costs (direct)

The costs of all the goods, services and other resources that are consumed in the provision of a health intervention. They can be medical or non-medical.

Costs (indirect)

The lost productivity suffered by the national economy as a result of an employee’s absence from the workplace through illness, decreased efficiency or premature death.

Cost-utility analysis

A type of full economic evaluation that compares competing alternatives of which the costs and consequences vary. It measures and values the impact of a treatment or policy alternative in utility units (see QALY). The result is expressed in the form of a cost-utility ratio.

Decision analysis

An explicit, quantitative, systematic approach to decision making under conditions of uncertainty, in which the probability of each possible event, along with the consequences of those events, is explicitly stated.

Dialectical behaviour therapy (DBT)

A multifaceted and intensive psychological treatment designed for patients with borderline personality disorder (Linehan, 1993a, 1993b). A simplified and abbreviated form of the treatment has been developed for patients with bulimia nervosa or binge eating disorder (Telch et al., 2000, 2001). It primarily focuses on enhancing patients’ emotion regulation skills. It involves 20 two-hour group sessions once a week. Details are provided by Wiser and Telch (1999).

Dietary counselling

Also termed ‘nutritional counselling’. A form of treatment in which the primary goal is the modification of what the patient eats as well as relevant eating habits and attitudes. It is not a well-defined intervention and is practised in a variety of ways. It is usually implemented by dietitians.

Drop out

A term no longer used to indicate leaving a study before its completion (the term ‘leaving the study early’ is now preferred).

Economic evaluation

Technique developed to assess both costs and consequences of alternative health strategies and to provide a decision making framework.

Eating disorder focused family therapy

A specific form of family therapy that focuses on directly addressing the eating disorder in addition to addressing family and individual issues. The best-tested version (sometimes called the ‘Maudsley method’) has been manualised by Lock et al. (2001).

Eating disorders not otherwise specified

Eating disorders that closely resemble anorexia nervosa and bulimia nervosa, but are considered atypical as they do not meet the precise diagnostic criteria for these conditions.

Effectiveness

The extent to which a specific intervention, when used under ordinary circumstances, does what it is intended to do. Clinical trials that assess effectiveness are sometimes called management trials.

Efficacy

The extent to which an intervention produces a beneficial result under ideal conditions. Clinical trials that assess efficacy are sometimes called explanatory trials and are restricted to participants who fully co-operate. The randomised controlled trial is the accepted ‘gold standard’ for evaluating the efficacy of an intervention.

Exposure with response prevention

This form of treatment was originally based on an ‘anxiety reduction’ model of bulimia nervosa according to which self-induced vomiting negatively reinforces binge eating by removing fears of secondary weight gain (Rosen & Leitenberg, 1982). The model on which it is based has evolved over the years (Carter & Bulik, 1994) and various versions of the treatment have been tested (e.g. Rosen & Leitenberg, 1982; Jansen et al., 1989; Schmidt & Marks, 1989). Each involves repeated exposure to cues that precede binge eating or purging with the response (binge eating or purging) being prevented. The treatment is typically combined with elements of cognitive behaviour therapy. Treatment sessions that involve in vivo exposure may last up to three hours. ERP has been describes as ‘time-intensive, expensive and logistically complicated’ (Bulik et al., 1998, p.620).

Family interventions

Family sessions with a treatment function based on systemic, cognitive behavioural or psychoanalytic principles, which may include psychoeducational, problem-solving and crisis management work and specific interventions with the identified patient. With eating disorders, the focus is on the eating disorder and how this impacts family relationships, emphasising in the early stages of treatment the necessity for parents to take a central role in supporting their child’s efforts to eat.

Family therapy

See Family interventions.

Feeding against the will of the patient

Using any method of feeding that requires that the individual be restrained to allow the feeding to take place.

Focal supportive psychotherapy

A collective term used in this Guideline for the various types of supportive psychological treatment that have been evaluated in the treatment of patients with eating disorders. These are varied in nature but they have in common their focus on supporting patients in their attempts to address difficulties in their life. Some have included limited emphasis on changing eating habits. These treatments should not be confused with more general forms of supportive psychotherapy or with counselling.

Forest plot

A graphical display of results from individual studies on a common scale, allowing visual comparison of trial results and examination of the degree of heterogeneity between studies.

Guided self-help

A self-help programme for bulimia nervosa in which a clinical professional provides support and encouragement.

Guideline recommendation

A systematically developed statement that is derived from the best available research evidence, using predetermined and systematic methods to identify and evaluate evidence relating to the specific condition in question.

Insulin purging

The omission or intentional under-dosing with insulin, sometimes done by patients with bulimia nervosa and diabetes.

Interpersonal psychotherapy

A specific form of focal psychotherapy that is designed to help patients identify and address current interpersonal problems. It was originally developed for the treatment of depression (Klerman et al., 1984) but has been adapted for the treatment of bulimia nervosa (IPT-BN; Fairburn, 1997).

Interpersonal psychotherapy for binge eating disorder (IPT-BED)

A specific form of IPT derived from IPT-BN and adapted to suit patients with BED.

Interpersonal psychotherapy for bulimia nervosa (IPT-BN)

A specific form of IPT adapted for the treatment of bulimia nervosa (IPT-BN; Fairburn, 1997). In IPT–BN there is no emphasis on directly modifying eating habits; rather, it is expected that they will change as interpersonal functioning improves. IPT-BN involves the same number and pattern of treatment sessions as CBT-BN.

Meta-analysis

The use of statistical techniques in a systematic review to integrate the results of the included studies. Also used to refer to systematic reviews that use meta-analysis.

Number of people leaving the study early

For the purposes of the guideline, the number of people leaving the study early due to any reason is taken as a proxy for treatment acceptability, whereas the number of people leaving the study early due to adverse events is taken as a proxy for treatment tolerability. An exception to this is when the comparison group is a wait-list control, in which case this assumption is not made.

Number needed to harm

The number of people (calculated statistically) who need to be treated to cause one bad outcome. The lower the number needed to harm, the higher the likelihood of harm.

Number needed to treat

The number of people who need to be treated to prevent one bad outcome (i.e. a good outcome). It is the inverse of the risk difference.

Nutritional counselling

See Dietary counselling.

Odds ratio

A measure of the relative benefit of the experimental treatment that can be obtained by dividing the experimental odds by the control odds.

Patient

The terms ‘patient’ or ‘person with eating disorder, anorexia nervosa, bulimia nervosa or binge eating disorder, etc.’, are used in this guideline to identify the person presently or formerly with the condition and/or receiving services in the present or past.

Psychodynamic psychotherapy

Regular individual therapy sessions with a trained psychotherapist, or a therapist under supervision, based on a psychodynamic or psychoanalytic model, which use a variety of strategies, including exploratory insight-oriented, supportive or directive activity, applied flexibly, working with transference, but with the therapists using a less strict technique than that used in psychoanalysis.

Psychological treatment not otherwise specified

A residual category that is used for psychological treatments other than those individually specified.

Pure self-help

A self-help programme for bulimia nervosa which patients follow on their own without the support of a professional.

Quality-adjusted life years (QALY)

A form of utility measure, calculated by estimating the total life-years gained from a treatment and weighting each year with a quality-of-life score in that year.

Randomisation

A method used to generate a random allocation sequence, such as using tables of random numbers or computer-generated random sequences. The method of randomisation should be distinguished from concealment of allocation, because if the latter is inadequate selection bias may occur despite the use of randomisation. For instance, a list of random numbers may be used to randomise participants, but if the list were open to the individuals responsible for recruiting and allocating participants, those individuals could influence the allocation process, either knowingly or unknowingly.

Randomised controlled trial

Also termed ‘randomised clinical trial’. An RCT is an experiment in which investigators randomly allocate eligible people into groups to receive or not to receive one or more interventions that are being compared. The results are assessed by comparing outcomes in the different groups. Through randomisation, the groups should be similar in all aspects apart from the treatment they receive during the study.

Refeeding

Increasing nutritional intake and restoring weight to within a normal range in the treatment of anorexia nervosa

Relative risk

Also known as risk ratio; the ratio of risk in the intervention group to the risk in the control group. The risk (proportion, probability or rate) is the ratio of people with an event in a group to the total in the group. A relative risk (RR) of 1 indicates no difference between comparison groups. For undesirable outcomes, an RR that is less than 1 indicates that the intervention was effective in reducing the risk of that outcome.

Relaxation therapy

A psychological treatment that focuses on enhancing patients’ ability to relax physically and psychologically.

Selective serotonin reuptake inhibitors)

Medicines that inhibit the reuptake of serotonin into the presynaptic neurone thus increasing neurotransmission. Although they ‘selectively’ inhibit serotonin reuptake, they are not serotonin specific. Some of the drugs in this class also inhibit the reuptake of noradrenaline and/or dopamine. As a class, these drugs are associated with less anticholinergic side effects and are less likely to cause postural hypotension or sedation.

Self-help

This involves following a self-help programme for bulimia nervosa, either with support and encouragement from a clinical professional (guided self-help) or on one’s own (pure self-help). The self-help programmes studied to date have taken the form of self-help books (Cooper, 1995; Fairburn, 1995; Schmidt & Treasure, 1995).

Sensitivity analysis

Sensitivity analysis is a technique used in economic analysis or decision making to allow for uncertainty by testing whether plausible changes in the values of the main variables affect the results of the analysis.

Simplified dialectical behaviour therapy (simplified DBT)

A simplified and abbreviated version of DBT.

Social skills training

A psychological treatment that focuses on enhancing patients’ social skills.

Standard dosage

The recommended dosage range listed in the British National Formulary; this normally reflects the information contained in the manufacturers’ Summary of Product Characteristics as well as advice from an external panel of experts.

Stepped-care model

A sequence of treatment options to offer simpler and less expensive interventions first and more complex and expensive interventions if the patient has not benefited, based on locally agreed protocols.

Supportive therapy

A non-specific form of supportive psychotherapy.

Weighted mean difference

A method of meta-analysis used to combine measures on continuous scales (such as weight), where the mean, standard deviation and sample size in each group are known. The weight given to each study (e.g. how much influence each study has on the overall results of the meta-analysis) is determined by the precision of its estimate of effect and, in the statistical software used by the NCCMH, is equal to the inverse of the variance. This method assumes that all of the trials have measured the outcome on the same scale.

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.

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

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