A comprehensive review of psychodynamic treatments for eating disorders

Inpatient treatments for adults with anorexia nervosa: a systematic review of literature

PURPOSE

Anorexia nervosa (AN) is a mental disorder for which hospitalization is frequently needed in case of severe medical and psychiatric consequences. We aim to describe the state-of-the-art inpatient treatment of AN in real-world reports.

METHODS

A systematic review of the literature on the major medical databases, spanning from January 2011 to October 2023, was performed, using the keywords: "inpatient", "hospitalization" and "anorexia nervosa". Studies on pediatric populations and inpatients in residential facilities were excluded.

RESULTS

Twenty-seven studies (3501 subjects) were included, and nine themes related to the primary challenges faced in hospitalization settings were selected. About 81.48% of the studies detailed the clinical team, 51.85% cited the use of a psychotherapeutic model, 25.93% addressed motivation, 100% specified the treatment setting, 66.67% detailed nutrition and refeeding, 22.22% cited pharmacological therapy, 40.74% described admission or discharge criteria and 14.81% follow-up, and 51.85% used tests for assessment of the AN or psychopathology. Despite the factors defined by international guidelines, the data were not homogeneous and not adequately defined on admission/discharge criteria, pharmacological therapy, and motivation, while more comprehensive details were available for treatment settings, refeeding protocols, and psychometric assessments.

CONCLUSION

Though the heterogeneity among the included studies was considered, the existence of sparse criteria, objectives, and treatment modalities emerged, outlining a sometimes ambiguous report of hospitalization practices. Future studies must aim for a more comprehensive description of treatment approaches. This will enable uniform depictions of inpatient treatment, facilitating comparisons across different studies and establishing guidelines more grounded in scientific evidence.

LEVEL OF EVIDENCE

Level I, systematic review.

Psychological approaches to obesity in young adults: state of the art

Background

Obesity has become a significant health concern among young adults aged 18-35 years. Addressing this issue is crucial, and exploring psychological treatments and perspectives specifically for this population is essential.

Methods

This literature review examines psychological treatments for obesity in young adults over the past decade. It focuses on interventions and discussions particularly relevant to this age group.

Discussion

Research on obesity often overlooks young adults, with most interventions primarily focusing on weight loss and neglecting emotional aspects. Cognitive-behavioral approaches are commonly used for self-regulation and motivation, but psychodynamic perspectives remain underutilized. While group-based methods lack a detailed analysis of benefits, hybrid approaches demonstrate higher engagement compared to technology-only interventions. There is a notable gap in tailoring obesity interventions to meet the unique needs of young adults during this transitional life phase. It's imperative to shift the focus from merely weight loss to a broader consideration of psychological, emotional, and unconscious factors. Integrating group modalities with psychodynamic approaches might offer additional benefits.

Conclusion

This review highlights the need for further research into the psychological well-being of young adults with obesity. A more comprehensive approach is required to address their distinct needs and psychological factors.

A systematic review and meta-analysis of intensive treatment options for adults with eating disorders

Eating disorders (EDs) are complex conditions with one of the highest mortality rates among psychiatric illnesses. While outpatient evidence-based treatments for EDs in adults exist, there is often utilisation of more intensive interventions as part of treatment. However, a comprehensive analysis of the impacts of intensive treatment (inpatient, residential and day program) on physical and psychosocial outcomes is lacking. Thus, the current systematic review and meta-analysis aimed to investigate the effectiveness of intensive treatments in adults with EDs for the outcomes of body mass index (BMI), disordered eating, depression, and quality of life, as well as a moderation analysis investigating a range of clinical characteristics. Overall, 62 studies were included in the meta-analysis. The results revealed that intensive treatment in adults yielded significant improvements in BMI (for underweight patients), disordered eating, depression, and quality of life. Treatment setting, length of stay and geographical region of the study all served as moderators for disordered eating and depression. Nevertheless, given the high heterogeneity in the meta- and moderation analyses, these results should be interpreted with caution. Future high-quality research is needed to determine the most beneficial elements of intensive treatment (compared to outpatient) in adults with EDs.

From symptoms to subjective and bodily experiences: the contribution of the Psychodynamic Diagnostic Manual (PDM-2) to diagnosis and treatment monitoring in eating disorders

PURPOSE

Atheoretical and descriptive conceptualizations of eating disorders (EDs) have faced substantial criticism due to their limited ability to assess patients' subjective characteristics and experiences, as needed to determine the most appropriate treatment options. The present article provides an overview of the clinical and empirical literature supporting the potential contribution of the Psychodynamic Diagnostic Manual (PDM-2) to both diagnostic assessment and treatment monitoring.

METHODS

Following a discussion of the most relevant shortcomings of current diagnostic models of EDs and a description of the rationale and structure of the PDM-2, evidence supporting the core PDM-2 dimensions of ED patients' subjective experiences (i.e., affective states, cognitive processes, relational patterns, somatic/bodily experiences and states) are examined, alongside their relevance to ED diagnosis and treatment.

RESULTS

Overall, the reviewed studies support the diagnostic importance of these patterns of subjective experiences in EDs, highlighting their potential role as either predisposing or maintaining factors to target in psychotherapy. A growing body of multidisciplinary evidence also shows that bodily and somatic experiences are central to the diagnosis and clinical management of ED patients. Moreover, there is evidence that a PDM-based assessment may enable closer monitoring of patient progress during treatment, with regard to both subjective experiences and symptom patterns.

CONCLUSIONS

The study suggests that current diagnostic frameworks for EDs would benefit from the addition of a person-centered perspective that considers not only symptoms, but also patients' full range of functioning-including their deep and surface-level emotional, cognitive, interpersonal, and social patterns-to improve patient-tailored interventions.

LEVEL OF EVIDENCE

Level V, narrative review.

Experiencing eight psychotherapy approaches devoted to eating disorders in a single-day workshop increases insight and motivation to engage in care: a pilot study

PURPOSE

For patients with eating disorders (EDs), early engagement in care is usually considered a positive prognostic factor. The aim of the study was to investigate how a single-day intervention devoted to early, brief, experiential exposure to a variety of psychotherapy approaches might support commitment to change and the decision to engage in care in patients with EDs.

METHODS

One hundred and sixty-nine adult outpatients newly diagnosed with an ED took part in a single-day workshop for groups of up to ten patients, where they experienced eight psychotherapeutic approaches. Motivation to change care and level of insight were assessed at baseline and 10 days after the intervention.

RESULTS

Motivation and commitment to take active steps toward change (expressed by the "Committed Action" composite score) significantly improved after the intervention (p < 0.001), and a significant number of patients specifically moved from "contemplation" to "action" stage (p < 0.001). The improvement of motivation to change was significantly associated with an increase in insight capacity (p < 0.001), and this increase was observed for almost all related dimensions such as recognition of illness or awareness of need for psychological treatment.

CONCLUSION

A single-day session devoted to experiencing a range of group psychotherapies increased patients' insight and motivation to actively engage in care. To confirm potential longer-term benefits of this intervention, further studies are needed to explore the contribution of each approach and process specifically involved in patients' increased motivation for care, as well as the clinical characteristics of patients associated with better outcomes.

LEVEL OF EVIDENCE

V: Opinions of respected authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

Bulimia Symptoms in Russian Youth: Prevalence and Association With Internalizing Problems

BACKGROUND

There has been limited research on bulimia symptoms in adolescents from the general population outside the United States. This study aimed to evaluate the prevalence of bulimia symptoms in Russian youth and explore the associations between a clinical level of self-reported probable bulimia nervosa (BN) and internalizing problems, binge drinking and functional impairment by gender.

METHODS

Data were collected from a representative sample of school students (N = 2,515, 59.5% female) from Northern Russia [age M (SD) = 14.89 ± 1.13 years]. Probable BN and internalizing psychopathology were assessed using self-report scales. Chi-square and independent sample t-tests were used to compare respondents' demographic characteristics and disordered eating behaviors. GLM multivariate analysis of covariance was used to assess the associations between probable BN, functional impairment and mental health problems (MHP) by gender.

RESULTS

Analyses showed that the 3-month prevalence of probable BN was higher in girls (3.9%) than in boys (1.2%). Probable BN was associated with depressive and anxiety symptoms, somatic anxiety, somatic complaints, binge drinking and functional impairment. Boys reported a higher level of problem scores in relation to probable BN.

CONCLUSIONS

Our findings suggest that bulimia symptoms are prevalent in Russian adolescents and are associated with MHP and functional impairment. Timely recognition of bulimia symptoms and associated MHP is important for early prevention and intervention strategies.

Effectiveness of non-pharmacological interventions on individuals with anorexia nervosa: A systematic review and meta-analysis

OBJECTIVE

This study aimed to synthesize the best available evidence regarding the effectiveness of non-pharmacological interventions on body mass index (BMI), body dissatisfaction, depression and anxiety among individuals with anorexia nervosa (AN).

METHODS

Published studies in English were searched using seven databases (such as PubMed). Grey literature was searched using ProQuest and Scopus. Studies were screened, appraised and extracted by two independent reviewers. Meta-analysis was performed and standardized mean difference was used as an effect measure. Heterogeneity was determined by I² statistics and Cochran χ² test. Publication bias was appraised using funnel plots. Sensitivity and subgroup analyses were also conducted.

RESULTS

Nineteen RCTs from eight different countries were included in this review. Behavioral family system therapy (BFST) was found to enhance BMI while conjoint family therapy (CFT) was more effective in ameliorating depression. Studies implementing combined family and individual therapy and those with longer therapeutic durations produced larger effect sizes.

CONCLUSION

This review provided evidence to support BSFT, CFT and combined family and individual therapy for adolescents with AN.

PRACTICAL IMPLICATIONS

Healthcare professionals may offer the two interventions to adolescents with AN in clinical settings. Future research may further investigate the effectiveness of BSFT and CFT on BMI and depression.

Personality as a predictor of symptomatic change in a residential treatment setting for anorexia nervosa and bulimia nervosa

PURPOSE

Although personality has been widely researched in patients with anorexia nervosa (AN) and bulimia nervosa (BN), the nature of this relationship has not yet been clearly articulated. The pathoplasty model theorizes that personality might shape symptomatic presentation and thus affect therapeutic outcomes, but more research is needed. The present study aimed at investigating the predictive value of a broad spectrum of personality traits in determining AN and BN treatment outcomes, considering both the statistical and clinical significance of the therapeutic change.

METHODS

Eighty-four female patients with AN and BN treated in a residential program were evaluated at treatment onset using the Shedler-Westen Assessment Procedure-200-a clinician-rated measure of personality disorders and healthy personality functioning. At both intake and discharge, patients completed the Eating Disorder Inventory-3 to assess eating symptoms and the Outcome Questionnaire-45.2 to evaluate overall impairment.

RESULTS

Considering overall ED symptomatic change, multiple regression analyses showed that, even when controlling for baseline symptoms and DSM-5 categories, schizoid (B = 0.41, p ≤ 0.01), avoidant (B = 0.31, p ≤ 0.05), and paranoid (B = 0.25, p ≤ 0.05) personality features predicted worse therapeutic outcomes. Similar results were found when applying the clinical significance approach, with the emotionally dysregulated factor as an additional negative predictor of significant/reliable change (B =  - 0.09; p < 0.01). Healthy personality functioning predicted better therapeutic outcomes (B =  - 0.34, p ≤ 0.001).

CONCLUSIONS

Pathoplastic models and personality-based research in this clinical population have the potential to inform effective treatment strategies by targeting relevant individual factors.

LEVEL OF EVIDENCE

Level III, longitudinal cohort study.

Evaluating empirically valid and clinically meaningful change in intensive residential treatment for severe eating disorders at discharge and at a 6-month follow-up

PURPOSE

The present study evaluated the statistical and clinical significance of symptomatic change at discharge and after 6 months of an intensive residential treatment for patients with eating disorders (ED), and explored the individual factors that may affect therapeutic outcomes.

METHODS

A sample of 118 female ED patients were assessed at intake and discharge on the following dimensions: BMI, ED-specific symptoms, depressive features, and overall symptomatic distress. A subsample of 59 patients filled out the same questionnaires at a 6-month follow-up after discharge.

RESULTS

Findings evidenced statistically significant changes in all outcome measures at both discharge and follow-up. Between 30.1 and 38.6% of patients at discharge and 35.2-54.2% at the 6-month follow-up showed clinically significant symptomatic change; additionally, 19.8-29.1% of patients at discharge and 22.9-38.3% at follow-up improved reliably. However, 34.9-39.8% remained unchanged and 2-4.8% worsened. At the 6-month follow-up, 21.3-25.9% showed no symptomatic change and 0-3.7% had deteriorated. Unchanged and deteriorated patients had an earlier age of ED onset and were more likely to suffer a comorbid personality pathology and to be following concurrent pharmacological treatment.

CONCLUSIONS

Results suggested that intensive and multimodal residential treatment may be effective for the majority of ED patients, and that therapeutic outcomes tend to improve over time. Prevention strategies should focus on early onset subjects and those with concurrent personality pathology.

LEVEL OF EVIDENCE

Level III, evidence obtained from a longitudinal cohort study.

Evidence-based clinical guidelines for eating disorders: international comparison

PURPOSE OF REVIEW

The current systematic review sought to compare available evidence-based clinical treatment guidelines for all specific eating disorders.

RECENT FINDINGS

Nine evidence-based clinical treatment guidelines for eating disorders were located through a systematic search. The international comparison demonstrated notable commonalities and differences among these current clinical guidelines.

SUMMARY

Evidence-based clinical guidelines represent an important step toward the dissemination and implementation of evidence-based treatments into clinical practice. Despite advances in clinical research on eating disorders, a growing body of literature demonstrates that individuals with eating disorders often do not receive an evidence-based treatment for their disorder. Regarding the dissemination and implementation of evidence-based treatments, current guidelines do endorse the main empirically validated treatment approaches with considerable agreement, but additional recommendations are largely inconsistent. An increased evidence base is critical in offering clinically useful and reliable guidance for the treatment of eating disorders. Because developing and updating clinical guidelines is time-consuming and complex, an international coordination of guideline development, for example, across the European Union, would be desirable.

Cognitive-Behavioral and Psychodynamic Therapy in Female Adolescents With Bulimia Nervosa: A Randomized Controlled Trial

OBJECTIVE

The authors compared cognitive-behavioral therapy (CBT) and psychodynamic therapy (PDT) for the treatment of bulimia nervosa (BN) in female adolescents.

METHOD

In this randomized controlled trial, 81 female adolescents with BN or partial BN according to the DSM-IV received a mean of 36.6 sessions of manualized disorder-oriented PDT or CBT. Trained psychologists blinded to treatment condition administered the outcome measures at baseline, during treatment, at the end of treatment, and 12 months after treatment. The primary outcome was the rate of remission, defined as a lack of DSM-IV diagnosis for BN or partial BN at the end of therapy. Several secondary outcome measures were evaluated.

RESULTS

The remission rates for CBT and PDT were 33.3% and 31.0%, respectively, with no significant differences between them (odds ratio [OR] = 0.90, 95% CI = 0.35-2.28, p = .82). The within-group effect sizes were h = 1.22 for CBT and h = 1.18 for PDT. Significant improvements in all secondary outcome measures were found for both CBT (d = 0.51-0.82) and PDT (d = 0.24-1.10). The improvements remained stable at the 12-month follow-up in both groups. There were small between-group effect sizes for binge eating (d = 0.23) and purging (d = 0.26) in favor of CBT and for eating concern (d = -0.35) in favor of PDT.

CONCLUSION

CBT and PDT were effective in promoting recovery from BN in female adolescents. The rates of remission for both therapies were similar to those in other studies evaluating CBT. This trial identified differences with small effects in binge eating, purging, and eating concern. Clinical trial registration information-Treating Bulimia Nervosa in Female Adolescents With Either Cognitive-Behavioral Therapy (CBT) or Psychodynamic Therapy (PDT). http://isrctn.com/; ISRCTN14806095.

The Effect of Abuse History on Adolescent Patients with Feeding and Eating Disorders Treated through Psychodynamic Therapy: Comorbidities and Outcome

OBJECTIVES

The first aim of our study was to compare the characteristics and comorbidities of patients with eating disorders between those who suffered from a childhood abuse and those who did not. Our second aim was to analyze the differences in the outcome of the psychodynamic therapy between abused and not abused patients.

METHODS

Twenty-six adolescent patients with eating disorders were assessed. Adolescent were evaluated by a single expert psychiatrist by checklists and questionnaires: EDI 3, SCL 90, BIS11, Dissociative Experiences Scale, Global Assessment of Functioning, SCID II, and CTQ-Self control (SF). According to the results of CTQ-SF (cut-off ≥ 8), patients were divided into two groups: those who had experienced a history of abuse and those who had not. They underwent a psychodynamic psychotherapy and were assessed again after 12 months.

RESULTS

Eleven patients (42.3%) had a history of abuse according to CTQ score. No significant differences were found in abused and not abused patients in their demographic, clinical, and comorbid characteristics (sex, age, type of eating disorder, comorbid impulse control, personality, and addictive disorders). Abused patients showed a significantly higher score in many scale. The psychotherapeutic intervention in patients with a history of abuse resulted only in a significant decrease in symptom checklist-90 (SCL-90) psychoticism dimension (p < 0.05), whereas in patients with no history of abuse a significant decrease was found for SCL-90 somatization, obsessive-compulsive and phobic anxiety dimensions, the SCL-90 Global Severity Index, the Eating Disorder Inventory-3 interceptive deficits, and the dissociative experience scale.

CONCLUSION

Regarding the first aim of our study, we proved that history of abuse is not significantly related to patient comorbidities. Regarding our second aim, history of abuse was related to patient improvement only for psychotic symptoms; whereas patients who had not experienced an abuse improved in a variety of symptoms. Thus, abuse history can be considered as a negative prognostic factor for patients with eating disorders undergoing dynamic psychotherapy. However, this psychotherapy may have a role in preventing early psychotic disorders in patients with and without an history of abuse.

Is Anorexia Nervosa a Disorder of the Self? A Psychological Approach

The debate concerning the pathogenesis and the maintaining factors of eating disorders, anorexia nervosa in particular, is ongoing especially since therapeutic interventions do not result in satisfactory and enduring rates of remission. This paper presents a model for the pathogenesis of eating disorders, based on the hypothesis of a deficiency in the development of the self. We present the theory in light of new evidence concerning the role of attachment insecurity in the development and maintenance of eating disorders. In particular, we define the self in eating disorders in a comprehensive way by taking into account recent evidence from experimental psychology and neurobiology. The paper considers the development of the self in terms of its synchronic (i.e., experienced in the moment) and diachronic (i.e., experienced as continuous over time) aspects. Both synchronic and diachronic aspects of the self are relevant to the expression of eating disorder symptoms. Further, the maturation of the self is interwoven with the development of attachment functioning from infancy to adolescence. This interplay between these developmental processes of the self and of attachment could be crucial in understanding the pathogenesis of eating disorders. The final part of the paper suggests a neurobiological link between the theory of the self in the eating disorders and the spatiotemporal functioning of the brain. Disturbances in spatiotemporal functioning may represent the neurobiological pathway by which deficiencies in the self is related to attachment functions in individuals with eating disorders.