4th edition as of Aug 2026

 

Module Overview

In Module 10, we will discuss matters related to feeding and eating disorders to include their clinical presentation, epidemiology, comorbidity, etiology, and treatment options. Our discussion will cover anorexia nervosa, bulimia nervosa, and binge eating disorder. Be sure you refer Modules 1-3 for explanations of key terms (Module 1), an overview of the various models to explain psychopathology (Module 2), and descriptions of the therapies (Module 3).

 

Module Outline

• • 10.1. Clinical Presentation

• • 10.2. Epidemiology

• • 10.3. Comorbidity

• • 10.4. Etiology

• • 10.5. Treatment

 

 Module Learning Outcomes

• Describe how feeding and eating disorders present.
• Describe the epidemiology of feeding and eating disorders.
• Describe comorbidity in relation to feeding and eating disorders.
• Describe the etiology of feeding and eating disorders.
• Describe treatment options for feeding and eating disorders.

 

10.1. Clinical Presentation

 

Section Learning Objectives

• Describe how anorexia nervosa presents.
• Describe how bulimia nervosa presents.
• Describe how binge-eating disorder (BED) presents.

 

Feeding and eating disorders are “…characterized by a persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning” (APA, 2022, pg. 371). They are very serious, yet relatively common mental health disorders, particularly in Western society, where there is a heavy emphasis on thinness and physical appearance. In fact, 13% of adolescents will be diagnosed with at least one eating disorder by their 20th birthday (Stice, Marti, & Rohde, 2013). Furthermore, many adolescents will engage in significant disordered eating behaviors just below the clinical threshold (Culbert, Burt, McGue, Iacono & Klump, 2009). While there is no exact cause for eating disorders, the combination of biological, psychological, and sociocultural factors has been identified as major contributors in both the development and maintenance of eating disorders.

Within the DSM 5-TR (APA, 2022), six disorders are classified under the Feeding and Eating Disorders chapter: pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, and binge-eating disorder. In this module, we will cover the latter three whose diagnostic criteria are mutually exclusive, meaning that only one of these diagnoses can be assigned at any given time due to substantial differences in their clinical course, outcome, and treatment needs, despite a number of common psychological and behavioral features. For a discussion of the first three disorders, see Module 16 please.

For more on eating disorders in general, please visit the National Eating Disorders Association website.

 

10.1.1. Anorexia Nervosa

Anorexia nervosa involves the restriction of energy intake, which leads to significantly low body weight relative to the individual’s age, sex, and development. This restriction is often secondary to an intense fear of gaining weight or becoming fat, despite the individual’s low body weight. Altered perception of self and an over-evaluation of one’s body weight and shape contribute to this disturbance of body size.

Typical warning signs and symptoms are divided into two different categories: emotional/behavioral and physical. Some emotional and behavioral symptoms include dramatic weight loss; preoccupation with food, weight, calories, etc.; frequent comments about feeling “fat;” eating a restricted range of foods; making excuses to avoid mealtimes; and not eating in public. Physical changes may include dizziness, difficulty concentrating, feeling cold, sleep problems, thinning hair/hair loss, and muscle weakness, to name a few. When the individual loses weight, they view this as an impressive achievement and a sign of extraordinary discipline, while weight gain is seen as an unacceptable failure of self-control (APA, 2022).

The onset of the disorder typically begins with mild dietary restrictions such as eliminating carbs or specific fatty foods. As weight loss is achieved, the dietary restrictions progress to more severe, e.g., under 500 calories/day.  Symptoms present in adolescence or young adulthood and rarely before puberty or after age 40. The onset of the disorder typically is preceded by a stressful life event such as leaving home for college.

For more on anorexia nervosa, please visit the National Eating Disorders Association website.

 

10.1.2. Bulimia Nervosa

Unlike anorexia nervosa where there is solely restriction of food, bulimia nervosa involves a pattern of recurrent binge eating behaviors. Binge eating can be defined as a discrete period when the amount of food consumed is significantly more than most people would eat during a similar period. Individuals with bulimia nervosa often report a sense of lack of control overeating during these binge-eating episodes. While not always the case, these binge-eating episodes are followed by a feeling of disgust with oneself, which leads to a compensatory behavior to rid the body of the excessive calories. These compensatory behaviors include vomiting, use of laxatives, fasting (or severe restriction), diuretics or other medications, or excessive exercise. This cycle of binge eating and compensatory behaviors occurs on average, at least once a week for three months (National Eating Disorder Association website; APA, 2022).

It is important to note that while there are periods of severe calorie restriction like anorexia, the two disorders cannot be diagnosed simultaneously. Therefore, it is important to determine the individual’s weight when distinguishing between anorexia and bulimia. If an individual has a significantly low body weight and engages in binge/purging behaviors, the diagnosis is anorexia; if the individual does not have a significantly low body weight and engages in binge/purging behaviors, the diagnosis is bulimia.

Signs and symptoms of bulimia nervosa are similar to anorexia nervosa. These symptoms include but are not limited to hiding food wrappers or containers after a bingeing episode, feeling uncomfortable eating in public, developing food rituals, limited diet, disappearing to the bathroom after eating a meal, and drinking excessive amounts of water or non-caloric beverages. Additional physical changes include weight fluctuations both up and down, difficulty concentrating, dizziness, sleep disturbance, and possible dental problems due to purging post binge eating episode.

 

Making Sense of the Disorders

Though anorexia and bulimia share some common features, they differ as follows:

• Diagnosis anorexia …… if significantly low body weight with severe calorie restriction
• Diagnosis bulimia … if body weight is within normal range but displays calorie restriction AND binge-eating episodes

 

Symptoms of bulimia nervosa typically present later in development – adolescence or early adulthood. Like anorexia nervosa, bulimia nervosa initially presents with mild restrictive dietary behaviors; however, episodes of binge eating interrupt the dietary restriction, causing bodyweight to rise around normal levels. In response to weight gain, patients engage in compensatory behaviors or purging episodes to reduce body weight. This cycle of restriction, binge eating, and calorie reduction often occurs for years before seeking help.

Additionally, those with bulimia are often ashamed of their eating problems and attempt to hide the symptoms. The binge eating occurs in secrecy or as inconspicuously as possible. Common antecedents of binge eating include negative affect; interpersonal stressors; dietary restraint; boredom; and negative feelings linked to body weight, shape, and food.

 

For more on bulimia nervosa, please visit the National Eating Disorders Association website.

 

10.1.3. Binge-Eating Disorder (BED)

Binge-eating disorder is similar to bulimia nervosa in that it involves recurrent binge eating episodes along with feelings of lack of control during the binge-eating episode. The binge-eating episodes are associated with at least three of the following: eating quicker than usual, eating until uncomfortably full, eating large amounts even if not hungry, eating alone, and feeling disgust with oneself or being depressed. Despite the feelings of shame and guilt post-binge, individuals with BED will not engage in vomiting, excessive exercise, or other compensatory behaviors. These binge eating episodes occur on average, at least once a week for 3 months.

Because these binge-eating episodes occur without compensatory behaviors, individuals with BED are at risk for obesity and related health disorders. Individuals with BED report feelings of embarrassment at the quantity of food consumed and thus will often refuse to eat in public. Due to the restriction of eating around others, individuals with BED often engage in secret binge eating episodes in private, followed by discrete disposal of wrappers and containers.

 

Making Sense of the Disorders

Though bulimia and BED are similar, they differ as follows:

• Diagnosis BED …… if binge eating occurs WITHOUT compensatory behaviors
• Diagnosis bulimia … if binge eating occurs AND there are compensatory behaviors to prevent weight gain

 

While much is still being researched about binge-eating disorder, current research indicates that the onset of BED is adolescence to early adulthood but can begin later in life. Those who seek treatment tend to be older than those with either bulimia or anorexia. Binge eating has been found to be common in adolescent and college-age samples and for all, is associated with social role adjustment issues, impaired health-related quality of life and life satisfaction, and increased medical morbidity and mortality (APA, 2022).

 

For more on binge eating disorder, please visit the National Eating Disorders Association website.

 

 

 

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10.2. Epidemiology

 

Section Learning Objectives

• Describe the epidemiology of anorexia nervosa.
• Describe the epidemiology of bulimia nervosa.
• Describe the epidemiology of binge eating disorder.

 

10.2.1. Anorexia Nervosa

According to the National Eating Disorder Alliance (NEDA) website, at any point in time more women (0.3-0.4%) than men (0.1%) will be diagnosed with anorexia. Anorexia nervosa is most prevalent in postindustrialized, high-income countries such as the United States, Australia, New Zealand, Japan, and many European countries. In the U.S., prevalence is lower among Latinx and non-Latinx Black Americans than non-Latinx Whites (APA, 2022).

 

10.2.2. Bulimia Nervosa

According to the NEDA website, at any point in time, 1.0% of women and 0.1% of men will meet the diagnostic criteria for bulimia nervosa. A study by Stice and Bohon (2012) found that between 1.1% and 4.6% of females and 0.1% to 0.5% of males will develop bulimia and that subthreshold bulimia occurs in 2.0% to 5.4% of adolescent females. The DSM reports that the 12-month prevalence ranges from 0.14% to 0.3% with higher rates in females and high-income countries. Rates are similar across ethnoracial groups across the U.S. (APA, 2022).

 

10.2.3. Binge Eating Disorder

According to the NEDA website (2026), BED is the second most common eating disorder diagnosed and approximately 2.7% of women, 1.7% of men, and 1.8% of adolescents suffer from BED. It has also been found that between 0.2% and 3.5% of females and 0.9% and 2.0% of males will develop binge eating disorder with subthreshold binge eating disorder occurring in 1.6% of adolescent females (Stice & Bohon, 2012). The DSM reports a 12-month prevalence of 0.44% to 1.2% with rates 2-3 times higher in women, similar rates across ethnoracial groups in the United States and between most high-income industrialized countries (APA, 2022).

 

For more on statistics and research related to feeding and eating disorders, please visit the National Eating Disorders Association website.

 

 

 

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10.3. Comorbidity

 

Section Learning Objectives

• Describe the comorbidity of anorexia nervosa.
• Describe the comorbidity of bulimia nervosa.
• Describe the comorbidity of BED.

 

10.3.1. Anorexia Nervosa

Anorexia is rarely a single diagnosis. High rates of bipolar, depressive, and anxiety disorders are common among individuals with anorexia nervosa. Obsessive-compulsive disorder is more often seen in those with the restricting type of anorexia nervosa, whereas alcohol use disorder and other substance use disorders are more commonly seen in those with anorexia who engage in binge-eating/purging behaviors. Unfortunately, there is also a high rate of suicidality, with rates reported to be 18 times greater than in an age- and gender-matched comparison group. It is also estimated that between 9% and 25% of individuals with anorexia have attempted suicide (APA, 2022). The NEDA website (2026) adds that, “In anorexia nervosa’s cycle of self-starvation, the body is denied the essential nutrients it needs to function normally. Thus, the body is forced to slow down all of its processes to conserve energy, resulting in serious medical consequences (Cost et al., 2020).”

 

10.3.2. Bulimia Nervosa

The majority of individuals diagnosed with bulimia nervosa also present with at least one other mental disorder. Similar to anorexia nervosa, there is a high frequency of depressive symptoms (i.e., low self-esteem), as well as bipolar and depressive disorders. While some experience mood fluctuations because of their eating pattern (occurring at the same time or following the development of bulimia), some individuals will identify mood symptoms prior to the onset of bulimia nervosa (APA, 2022).

Anxiety, particularly social anxiety, is often present in those with bulimia nervosa. However, most mood and anxiety symptoms resolve once an effective treatment of bulimia is established. Substance use disorder, and in particular alcohol use disorder, is also prevalent in those with bulimia, with about a 30% prevalence among those with bulimia. The substance abuse begins as a compensatory behavior (e.g., stimulant use is used to control appetite and weight) and over time, as the eating disorder progresses, so does the substance abuse. There is also a percentage of individuals with bulimia nervosa who display personality features that meet the criteria for at least one personality disorder, most often borderline personality disorder. Finally, about one-quarter to one-third of individuals with bulimia have had suicidal ideation and a comparable amount have attempted suicide. NEDA (2026) reports that self-injurious behaviors such as cutting and other forms of self-harm without suicidal intent are common as well as impulse control disorders to include risky sexual behaviors, driving while intoxicated, shoplifting, gambling, and compulsive spending.

 

10.3.3. BED

Research shows that BED shares similar comorbidities with anorexia nervosa and bulimia nervosa. Common comorbidities include major depressive disorder and alcohol use disorder. About 25% of those with BED have shown suicidal ideation (APA, 2022). The NEDA website (2026) reports ADHD, bipolar disorder, and anxiety disorders including generalized anxiety disorder, social anxiety, phobias, panic disorder and PTSD.

 

• Discuss the comorbidity rates among the three main eating disorders.

 

 

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10.4. Etiology

 

Section Learning Objectives

• Describe the biological causes of feeding and eating disorders.
• Describe the cognitive causes of feeding and eating disorders.
• Describe the sociocultural causes of feeding and eating disorders.
• Describe how personality traits are the cause of feeding and eating disorders.

 

What causes eating disorders? While researchers have yet to identify a specific cause of eating disorders, current research supports a biopsychosocial model, which proposes that eating disorders develop through the interaction of biological, psychological, and sociocultural influences. More specifically, research has demonstrated a substantial genetic influence for anorexia nervosa, bulimia nervosa, and binge-eating disorder, while also highlighting the importance of environmental stressors, dieting behaviors, trauma and sociocultural pressures (APA, 2022).  Therefore, eating disorders are best understood as complex conditions that result from multiple interacting risk factors rather than a single cause.

 

10.4.1. Biological

Substantial evidence suggests that eating disorders have a significant genetic component. Family studies consistently demonstrate that first-degree relatives of individuals with anorexia nervosa, bulimia nervosa, or binge-eating disorder are increased risk of developing an eating disorder themselves. More specifically, twin studies suggested heritability estimates ranging from 50-60% for anorexia nervosa, 55-65% for bulimia nervosa, and 40-60% for binge-eating disorder (Bulik et al., 2019; Huckins et al., 2024; Watson et al., 2019).

In addition to genetic vulnerability, researchers have identified differences in several neurobiological systems involved in appetite regulation, reward processing, and emotion regulation. Changes in neurotransmitter systems, including serotonin and dopamine, as well as changes in hormones involved in hunger, have all been associated with eating disorders. More specifically, brain regions including the hypothalamus, amygdala, and prefrontal cortex appear to contribute to abnormal eating behaviors and body image disturbances (Treasure et al., 2020). Given the wide range of neurobiological disruption, current evidence suggests that these biological vulnerabilities interact with psychological and environmental factors to develop and maintain eating disorders.

 

10.4.2. Cognitive

Eating disorders share several psychological features with obsessive-compulsive disorder  (OCD), including rigid thinking, perfectionism, intrusive thoughts, and repetitive behaviors. Despite these similarities, they are considered distinct disorders with overlapping cognitive and neurobiological characteristics rather than variants of OCD (Treasure et al., 2020).

In anorexia nervosa, an overevaluation of body shape and weight often contributes to restrictive eating behaviors. Individuals with bulimia nervosa and binge-eating disorder often report high levels of impulsivity, particularly during binge eating episodes, suggesting a temporary lack of control is responsible for these episodes, followed by feelings of guilt, shame, or disgust (NIHCE, 2020). Because distorted thinking patterns and maladaptive beliefs play a central role in many eating disorders, cognitive-behavioral therapy is considered a first-line psychological treatment for bulimia nervosa and binge-eating disorder.

 

10.4.3. Sociocultural

Eating disorders develop through a complex interaction of biological, psychological, and sociocultural influences. Although they were once believed to occur primarily in Western, industrialized nations, research now demonstrates that eating disorders occur across cultures and geographic regions (Treasure et al., 2020; APA, 2023). Globalization and increased exposure to Western beauty ideals through traditional and social media likely contribute to the rising rates of eating disorders in many countries. With that said, eating disorders also occur in cultures with different beauty standards, indicating that sociocultural pressures likely interact with individual biological and psychological vulnerabilities rather than the sole cause of the disorders. Research also indicates that eating disorders occur across all socioeconomic (SES) groups. Earlier studies suggested that anorexia nervosa was more common among individuals from higher SES backgrounds, but more recent research has found that eating disorders affect individuals across a wide range of SES statuses (APA, 2023).

            10.4.3.1. Media. Media continues to be an important sociocultural influence on body image. Traditional forms of media—television, movies, magazines, and advertising—have long promoted unrealistic beauty standards emphasizing thinness for women and muscularity for men. With the emergence of social media (e.g., Facebook, Snapchat, Instagram), influences have expanded further, exposing users to carefully curated and digitally altered images (Rodgers et al., 2020).  Unlike traditional media, social media encourages continuous comparison through likes, comments, filters, and algorithm-driven content. Increased exposure to idealized images has been associated with greater body dissatisfaction, internalization of unrealistic appearance ideals, disordered eating behaviors and lower self-esteem, especially among adolescents and young adults (Rodgers et al., 2020).

            10.4.3.2. Race and Ethnicity. Eating disorders occur among individuals of every racial and ethnic background. While historically, eating disorders were viewed primarily as disorders affecting White adolescent females, this stereotype has contributed to the under recognition and undertreatment of eating disorders among racial and ethnic minority populations (APA, 2023; Burke et al., 2023).

Cultural ideals regarding body shape and appearance may explain why prevalence of anorexia nervosa and bulimia nervosa varies across populations. For example, some research suggests that exposure to Western thin-ideal beauty standards is associated with increased body dissatisfaction and eating disorder risk (Pike & Dunne, 2015). However, cultural factors are complex; individuals from cultures that traditionally value larger body sizes may still experience eating disorders, particularly as society beauty ideals change and exposure to Western thin-ideal increases (Pike & Dunne, 2015; Treasure et al., 2020).

            10.4.3.3. Gender. Although eating disorders remain more common among females, they do affect individuals of all genders. While it is unclear as to why there is such a discrepancy, men may experience pressures to achieve a lean and muscular physique rather than simply being thin, contributing to restrictive eating, excessive exercise, and other unhealthy behaviors (Cunningham et al., 2021). Gorrell & Murray (2019) report that rates of eating disorders in males are increasing at a faster rate than for females. Individuals participating in sports or occupations that emphasize weight, appearance, or athletic performance (e.g. wrestling, distance running, gymnastics, bodybuilding, dance and jockeying) may be at an increased risk for developing an eating disorder (APA, 2023).

Growing evidence also indicates elevated rates of eating disorders among transgender and gender-diverse individuals. Experiences of gender dysphoria, discrimination, minority stress and attempts to alter one’s body to align with one’s gender identity may contribute to increased risk of developing an eating disorder (Nagata et al., 2024).

            10.4.3.4. Family. Family influences are one of the strongest external factors liked to the development and maintenance of eating disorders. Families that place a strong emphasis on physical appearance, dieting, weight, or perfectionism may inadvertently contribute to body dissatisfaction and unhealthy eating attitudes. Similarly, parents modeling restrictive eating or excessive dieting may also increase a child’s concern about appearance (Treasure et al., 2020).

Family relationships may also influence recovery. More specifically, family characteristics that are common among individuals receiving treatment for eating disorders are enmeshed, intrusive, critical, hostile, or overly concerned with parenting (Polivy & Herman, 2002). While some families experience conflict, criticism, or high levels of expressed emotion, these characteristics are neither universal nor considered the primary cause of an eating disorder (Treasure et al., 2020).

 

10.4.4. Personality

There are many personality characteristics that are common in individuals with eating disorders. While it is unknown if these characteristics are inherent in the individual’s personality or a product of personal experiences, research suggests that these personality traits interact with biological vulnerabilities, environmental experiences and sociocultureal influences to increase risk of developing eating disorders (Treasure et al., 2023; APA, 2023).

            10.4.4.1. Perfectionism. Perfectionism is one of the most consistently identified personality characteristic associated with eating disorders, particularly anorexia nervosa. Researchers have suggested that perfectionism involves the setting of excessively high standards combined with overly critical self-evaluation when those standards are not met. Individuals with maladaptive perfectionism may experience a strong need for control and a fear of inadequacy when they perceive themselves as falling short (Sederlund et al., 2020). More specifically, individuals with anorexia nervosa may use perfectionistic tendencies to reinforce rigid dietary rules, thus making treatment more difficult and increasing risk of relapse (Egan et al., 2011).

            10.4.4.2. Self-Esteem. Self-esteem, or one’s belief in their worth or ability, has routinely been identified as a moderator in the development and maintenance of eating disorders. More specifically, research has suggested that individuals with eating disorders often experience low self-esteem. While low self-esteem alone does not lead to an eating disorder, individuals whose primary self-worth focuses on overreliance on weight, shape, eating control and appearance may be at an increased risk of developing an eating disorder (Fairburn, 2008).

One theory, the transdiagnostic model of eating disorders, suggests that individuals whose self-evaluation is overly influenced by body shape, weight, and eating behaviors, may be at an increased risk for developing an eating disorder (Fairburn et al., 2003; Fairburn, 2008). More specifically, this overevaluation can lead to restrictive eating, binge eating, compensatory behaviors and continued preoccupation with appearance, which further reinforces negative self-evaluation and disordered eating habits.

 

 

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10.5. Treatment

 

Section Learning Objectives

• Describe treatment options for anorexia nervosa.
• Describe treatment options for bulimia nervosa.
• Describe treatment options for binge eating disorder.
• Discuss the outcome of treatment for feeding and eating disorders.

 

10.5.1. Anorexia Nervosa

The immediate goal for the treatment of anorexia nervosa is medical stabilization, nutritional rehabilitation, and restoration of a healthy body weight. Because anorexia nervosa can result in serious medical complications, a comprehensive medical evaluation should be completed at start of treatment to determine appropriate course of treatment. If the individual is medially stable, treatment is often started via an outpatient therapy, intensive outpatient program, or partial hospitalization; if medically unstable, the individual may require a higher level of care via an inpatient hospitalization program where caloric intake can be managed and controlled (APA, 2023).

Treatment typically involves a multidisciplinary team that may include physicians, psychologists, psychiatrists, dietitians, and nurses. In addition to restoring nutritional health, treatment also focuses on reducing restrictive eating, improving psychological functioning and preventing relapse (APA, 2023).

            10.5.1.1. Enhanced Cognitive Behavioral Therapy (CBT-E). A central component of CBT-E is self-monitoring, in which an individual records meals, eating behaviors, thoughts, emotions, and situations surrounding eating. This process helps identify patterns such as restrictive eating, maladaptive thoughts, rigid dietary rules, and emotional triggers. Rather than focusing on calorie counting, self-monitoring increases cognitive awareness of the cognitive and behavioral factors maintaining the disorder (Dalle Grave, 2023; Dalle Grave et al., 2016). Treatment also focuses on modifying maladaptive beliefs regarding body weight, body shape, perfectionism, and self-worth. Individuals learn to challenge rigid thinking, reduce the overevaluation of weight and appearance, and develop healthier coping strategies for managing anxiety, and fear of weight gain.

            10.5.1.2. Family based therapy (FBT). FBT is also an effective treatment approach, often used as a component of individual CBT, especially for children and adolescents with anorexia nervosa. FBT typically involves 16-18 sessions which are divided into 3 phases: (1) Parents take charge of weight restoration, (2) Gradual control over eating is returned to the adolescent, and (3) Address normal developmental issues including increasing independence, strengthening family relationships, and developing relapse-prevention strategies.

FBT has shown to be effective in treating adolescents with anorexia nervosa with higher rates of weight restoration, fewer hospitalizations, and improved long-term recovery (APA, 2023). For adults, both FBT and CBT-E have been effective in treating symptoms equally.

 

10.5.2. Bulimia Nervosa

Unlike anorexia nervosa, where initial treatment often focuses on nutritional education and weight gain, treatment for bulimia nervosa primarily focuses on reducing binge-eating episodes and compensatory behaviors. The primary goal is to interrupt the cycle of dietary restriction, binge eating, and compensatory behaviors that maintain the disorder.  One of the most effective ways to establish this is through Enhanced Cognitive Behavioral Therapy.

            10.5.2.1. Enhanced Cognitive Behavioral Therapy (CBT-E). CBT-E is considered the first-line psychological treatment for bulimia nervosa. Like anorexia nervosa, a central component of CBT-E for bulimia nervosa is self-monitoring of eating patterns, binge episodes, compensatory behaviors, emotions, and thoughts related to food, weight and body image. The focus of this recording is to help individuals identify patterns that maintain the disorder for a more personalized treatment approach. More specifically, treatment will focus on establishing regular eating patterns, reducing dietary restraint, and challenging maladaptive beliefs related to weight, shape, and self-worth (Agras, Fitzsimmons-Craft & Wilfley, 2017; Dalle Grove, 2023; Fairburn et al., 2015).

CBT-E also includes behavioral interventions designed to reduce binge eating and compensatory behaviors. These strategies may include exposure to feared foods, reducing avoidance behaviors, and learning alternative methods of coping with distress.

Exposure-based strategies are also useful when individuals avoid certain foods due to fear of weight gain, which can reinforce restrictive eating (Fairburn, 2008). These exposure-based techniques may be incorporated into CBT-E when individuals experience anxiety surrounding specific foods, eating situations, or body-related concerns (APA, 2023).

            10.5.2.2. Interpersonal Psychotherapy (IPT). IPT is an evidenced-based treatment for bulimia nervosa (and binge eating disorder) that focuses on improving interpersonal functioning and addressing relationship difficulties that may contribute to the development and maintenance of an eating disorder. Originally developed as a treatment for depression, IPT was adapted for eating disorders to address the social isolation and self-esteem problems that contribute to the maintenance of negative eating behaviors (Murphy et al., 2012; APA, 2023).

Unlike CBT-E, which directly targets eating disorder thoughts and behaviors, IPT does not focus primarily on food, weight, or body image concerns. Instead, IPT targets disordered eating patterns through the improvement of interpersonal functioning and reduced relationship stress (Murphy et al., 2012). IPT-E has 3 phases typically covered in weekly sessions over 4-5 months.

Phase One: Assessment and Engagement. This first phase consists of engaging the patient in treatment and providing psychoeducation about their disease and the treatment program. This phase also includes identifying interpersonal problems that are maintaining the disease. Common interpersonal problems include interpersonal conflict, role transitions, grief, social isolation or interpersonal deficits (Murphy et al., 2012).

Phase Two: Addressing Interpersonal Difficulties. The second phase represents the main treatment component. In this phase, the primary focus is on identifying and problem-solving interpersonal issues through communication skills, emotional expression, and relationship-building strategies. Rather than treating specific skills, the therapist works in collaboration with the individual to support them in making changes in their relationships and social environments. The central idea behind this method is that by having the individual lead the changes, they will better understand their problems, and as a result, make more profound changes (Murphy et al., 2012).

Phase Three: Consolidation and Relapse Prevention. The goal of this final phase is to prepare the individual for future interpersonal challenges. To achieve this, treatment sessions are spaced out, allowing individuals more time to engage in their changed behavior. Additionally, relapse prevention (i.e., problem-solving ways not to relapse) is also discussed to ensure long term results. In doing this, the individual reviews the progress they have made throughout treatment, as well as identifying potential interpersonal issues that may arise, and how their treatment can be adapted to address those issues (Murphy et al., 2012).

Research supports IPT as an effective treatment for bulimia nervosa and binge-eating disorder, however, CBT-E generally produces more rapid improvement in eating disorder symptoms. Therefore, while IPT is considered an evidence-based treatment for individuals with eating disorders, it is generally only used when interpersonal difficulties play a significant role in the maintaining of symptoms (APA, 2023; NICE, 2020).

 

10.5.3. Binge Eating Disorder

Given the similar presentations of BED and bulimia nervosa, it should not be surprising that the most effective treatments for BED are similar to that of bulimia nervosa. With that said, treatment goals for BED differ from those of bulimia nervosa because individuals with BED do not engage in regular compensatory behaviors. The primary goal of treatment is to reduce binge-eating episodes, establish regular and flexible eating patterns and reduce stress related to eating and body image (APA, 2023).

CBT-E is among the most effective treatment option for BED. CBT-E targets the cognitive and behavioral factors that maintain the disorder, including dietary restraint, rigid food rules, negative beliefs about weight and shape, and difficulties coping with emotions (Fairburn, 2008; APA, 2023). IPT and dialectical behavioral therapy (DBT), have also been effective in reducing binge-eating episodes. IPT focuses on improving interpersonal functioning whereas DBT emphasizes emotion regulation skills and coping strategies. While these treatments can reduce binge eating, they have not been effective in helping individuals lose weight (Guerdjikova, Mori, Casuto, & McElroy, 2017).

Although many individuals with BED have higher body weight, current treatment approaches avoid focusing solely on weight reduction. Weight stigma and repeated dieting attempts may contribute to the maintenance of binge-eating behaviors and weight-focused interventions may not adequately address the underlying psychological mechanisms (APA, 2023).

            10.5.3.1. Antidepressant medications. Given the high comorbidity between eating disorders and depressive symptoms, antidepressants have been a primary method of treatment for years. Selective serotonin reuptake inhibitors (SSRIs) may reduce binge-eating frequncey and improve depressive symptoms; however, effects are generally smaller than the psychological interventions discussed above (APA, 2023).

 

10.5.4. Outcome of Treatment

Although evidence-based treatments have improved outcomes for individuals with eating disorders, recovery can vary vastly depending on illness severity, comorbid conditions, access to effective treatment and family support. Early identification and intervention are among the most important predictors of improved outcomes across eating disorders (APA, 2023; Treasure et al., 2020).

Research has indicated that favorable prognostic features for anorexia nervosa include early age of onset, short duration of illness, and early restoration of health eating patterns. Conversely, long history of symptoms prior to treatment, severe weight loss, medical complications and binge eating and vomiting are associated with poorer outcomes (APA, 2023; Treasure et al., 2020). Anorexia nervosa has one of the highest mortality rates of any psychiatric disorder. Mortality may result from medical complications related to malnutrition, including cardiovascular complications and electrolyte disturbances, as well as suicide risk (van Eeden et al., 2021).

Treatment outcomes for bulimia nervosa are generally more favorable than those for anorexia nervosa, particularly with treatments such as CBT-E. Many individuals experience reductions in binge-eating and compensatory behaviors following treatment; however, relapse and residual symptoms remain common (APA, 2023).

Individuals with BED often demonstrate higher rates of symptoms relief after treatment than individuals with anorexia and bulimia. Overall, evidence-based treatments are effective in reducing disordered eating patterns, however, some individuals continue to experience chronic symptoms or require ongoing care to manage symptoms.

 

 

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Module Recap

Module 10 covered eating disorders in terms of their clinical presentation, epidemiology, comorbidity, etiology, and treatment options. In Module 11, we will discuss substance-related and addictive disorders, which will conclude this part.

 

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End Module 4

4th edition as of Aug 2026