Group Treatment of Eating Disorders
• Eating disorders occur with some frequency in clinical practice, but
tend to be under-diagnosed (Flahavan, 2006).
• Binge-eating disorder (BED) is the most prevalent eating disorder and
occurs at equal frequency among Black and White women in the U.S,
whereas bulimia nervosa (BN) and Anorexia Nervosa (AN) occur most
frequently in White women (Striegel-Moore et al., 2003).
• There is some evidence that group-based day treatment programs
may be effective in reducing symptoms in patients with AN (Fittig et al.,
• Group cognitive behavioural therapy (GCBT) is the most studied group
treatment for BN, with good outcomes (Burlingame et al., 2013).
• Some studies suggest that drop-out rates from GCBT for BN may be
reduced if interpersonal or psychodynamic components are integrated into
the GCBT intervention (Burlingame et al., 2013).
• Most randomized trials of group treatments for binge eating disorder
(BED) have tested GCBT with good outcomes (Burlingame et al., 2013).
• In a few trials, group interpersonal psychotherapy (GIPT) and group
psychodynamic interpersonal psychotherapy (GPIP) provide equivalent
outcomes to GCBT for BED (Tasca et al., 2006; Wilfley et al., 2002).
• Patient attachment avoidance may be related to treatment dropout
and attachment anxiety may be related to outcomes among those with
BED (Tasca et al., 2006).
• Treatment approaches in addition to GCBT should be investigated
further to provide more evidence-based group therapy options for BN and
Eating disorders include anorexia nervosa (AN), bulimia nervosa (BN), and binge-eating disorder (BED). AN is characterized by dietary restraint and maintaining a very low body weight, BN is characterized by binge eating and purging at least once a week, and BED is characterized by binge eating at least once a week without purging. Lifetime prevalence among women is 0.9% for AN, 1.5% for BN, and 3.5% for BED (Hudson, Hiripi, Pope, & Kessler, 2007). Eating disorders tend to be comorbid with mood, anxiety, and substance use disorders, and many with eating disorders have experienced trauma (Hudson et al., 2007; Tasca, Ritchie, Zachariades et al., 2013). Researchers report that BN is culture-bound and highly influenced by exposure to Western media; self-starvation, the primary characteristic of AN, appears to exist outside of its social, cultural, and historical context (Keel & Klump, 2003). BED is the most prevalent eating disorder and occurs at equal frequency among Black and White women in the U.S., whereas BN and AN occur most frequently in White women (Striegel-Moore, Dohm, Kraeger, et al., 2003 ). Many general practice group therapists will likely see patients with an eating disorder in clinical practice, but eating disorders tend to be under-diagnosed (Flahavan, 2006).
Individuals with AN often are treated in inpatient or day hospital settings during the acute phase of their illness. Interventions often include group therapy as well as nutritional rehabilitation. Outcomes for these intensive treatments tend to be good, at least at post-treatment (Fittig, Jacobi, Backmund, et al, 2008). There are currently no trials of outpatient group therapy for AN. There exist individual therapy trials that showed modest results for cognitive behavioural therapy (CBT), interpersonal psychotherapy (IPT; McIntosh, Jordan, Carter, et al., 2005), and focal psychodynamic therapy (Zipfel, Wild, Gros et al., 2014). Family based interventions have shown promising results for adolescents with AN (Locke & Le Grange, 2012). Recovery rates tend to be quite low in all individual therapy trials such that less than 33% of patients with AN had good outcomes (Zipfel et al., 2014). The low rates of AN in the population and the extreme ambivalence of these patients to enter treatment reduces outcomes and the ability to conduct many quality studies (Tasca, Keating, Maxwell et al., 2012).
There are several quality group therapy trials for BN. Approximately 23% of individuals with BN receive group treatment in clinical practice (Polnay, James, Hodges, et al., 2014). GCBT has received the most research attention among group treatment approaches for BN (Burlingame, Strauss, & Joyce, 2013). GCBT is more effective than no treatment in reducing binge eating and purging behaviours (Polnay et al., 2014). Burlingame and colleagues (2013) reported on three RCTs that compared GCBT to individual therapy, guided self help, or medications. The results showed equivalent outcomes for GCBT vs. the other interventions. Burlingame and colleagues (2013) also reported on integrated treatments that combined psychodynamic or interpersonal aspects with GCBT. Dropout rates tended to be lower in the combined treatments perhaps due to their emphasis on relational functioning. Group treatment approaches in addition to GCBT should be tested for BN in order to provide alternatives to patients and providers and to attempt to reduce the number of dropouts.
GCBT tends to be the most studied group intervention for BED as well, though several trials have compared GCBT to other group interventions. GCBT is an effective treatment for BED, consistently outperforming no-treatment control conditions (Burlingame et al., 2013). Alternatives have included group dialectical behaviour therapy (Safer & Jo, 2010), group psychodynamic interpersonal psychotherapy (Tasca, Ritchie, Conrad et al., 2006), and group interpersonal psychotherapy (Wilfley, Welch, Spurrell, et al., 2002), among others. In general, outcomes tend to be equivalent among the group treatment approaches, with group therapies outperforming no-treatment control conditions. Tasca and colleagues (2006) demonstrated that patient attachment avoidance was associated with dropping out of GCBT. Attachment anxiety was associated with poorer outcomes in GCBT but better outcomes in GPIP. The findings suggested that this interpersonal psychodynamic treatment was particularly effective for patients with BED who had problems with affect regulation and who were highly preoccupied with relationships. Patients and providers would benefit from more research testing GCBT and alternative group treatment approaches.
Burlingame, G., Strauss, B., & Joyce, A. (2013). Change mechanisms and effectiveness of small group treatments. In M.J. Lambert (Ed.) Bergin and Garfields Handbook of Psychotherapy and Behavior Change (6th edition), (pp. 640-689). Wiley: New York.
Fittig, E., Jacobi, C., Backmund, H., Gerlinghoff, M., & Wittchen, H. U. (2008). Effectiveness of day hospital treatment for anorexia nervosa and bulimia nervosa. European Eating Disorders Review, 16(5), 341-351. DOI: 10.1002/erv.883
Flahavan, C. (2006). Detection, assessment and management of eating disorders; how involved are GPs? Irish Journal of Psychological Medicine, 23(3), 96-99. DOI: 10.1017/S079096670000971X.
Hudson, J. I., Hiripi, E., Pope, H. G. & Kessler, R. C. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 61(3), 348-358. DOI: 10.1016/j.biopsych.2006.03.040
Keel, P. K., & Klump, K. L. (2003). Are eating disorders culture-bound syndromes? Implications for conceptualizing their etiology. Psychological bulletin, 129(5), 747-769. DOI: 10.1037/0033-2909.129.5.747
Lock, J., & Le Grange, D. (2012). Treatment manual for anorexia nervosa: A family-based approach. New York: Guilford Press.
McIntosh, V. V., Jordan, J., Carter, F. A., Luty, S. E., McKenzie, J. M., Bulik, C. M., ... & Joyce, P. R. (2005). Three psychotherapies for anorexia nervosa: a randomized, controlled trial. American Journal of Psychiatry, 162(4), 741-747. DOI: 10.1176/appi.ajp.162.4.741
Polnay, A., James, V. A. W., Hodges, L., Murray, G. D., Munro, C., & Lawrie, S. M. (2013). Group therapy for people with bulimia nervosa: Systematic review and meta-analysis. Psychological Medicine, 1-14. DOI: 10.1017/S0033291713002791
Safer, D. L., & Jo, B. (2010). Outcome from a randomized controlled trial of group therapy for binge eating disorder: comparing dialectical behavior therapy adapted for binge eating to an active comparison group therapy. Behavior Therapy, 41(1), 106-120. DOI: 10.1016/j.beth.2009.01.006
Striegel-Moore, R. H., Dohm, F. A., Kraemer, H. C., Taylor, C. B., Daniels, S., Crawford, P. B., & Schreiber, G. B. (2003). Eating disorders in white and black women. American Journal of Psychiatry, 160(7), 1326-1331. DOI: 10.1176/appi.ajp.160.7.1326
Tasca, G. A., Ritchie, K., Conrad, G., Balfour, L., Gayton, J., Lybanon, V., & Bissada, H. (2006). Attachment scales predict outcome in a randomized controlled trial of two group therapies for binge eating disorder: An aptitude by treatment interaction. Psychotherapy Research, 16(1), 106-121. DOI: 10.1080/10503300500090928
Tasca, G. A., Ritchie, K., Zachariades, F., Proulx, G., Trinneer, A., Balfour, L., ... & Bissada, H. (2013). Attachment insecurity mediates the relationship between childhood trauma and eating disorder psychopathology in a clinical sample: A structural equation model. Child Abuse & Neglect, 37(11), 926-933. DOI: 10.1016/j.chiabu.2013.03.004
Tasca, G. A., Keating, L., Maxwell, H., Hares, S., Trinneer, A., Barber, A. M., ... & Bissada, H. (2012). Predictors of treatment acceptance and of participation in a randomized controlled trial among women with anorexia nervosa. European Eating Disorders Review, 20(2), 155-161. DOI: 10.1002/erv.1133
Wilfley, D. E., Welch, R. R., Stein, R. I., Spurrell, E. B., Cohen, L. R., Saelens, B. E., ... & Matt, G. E. (2002). A randomized comparison of group cognitive-behavioral therapy and group interpersonal psychotherapy for the treatment of overweight individuals with binge-eating disorder. Archives of General Psychiatry, 59(8), 713-721. DOI: 10.1001/archpsyc.59.8.713
Zipfel, S., Wild, B., Groß, G., Friederich, H. C., Teufel, M., Schellberg, D., ... & Herzog, W. (2014). Focal psychodynamic therapy, cognitive behaviour therapy, and optimised treatment as usual in outpatients with anorexia nervosa (ANTOP study): Randomised controlled trial. The Lancet, 383, 127-137. DOI: 10.1016/S0140-6736(13)61746-8