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A Systematic Review of the Efficacy of Psychodynamic Treatments for DSM-5 Eating Disorders

Internet Editor’s Note: Portions of this article were presented by Ms. Lopez at the 2014 annual American Psychological Association convention held in Washington, D.C.

Introduction

Given the recent changes to the diagnostic criteria of eating and feeding disorders in the DSM-5, specifically the addition of Binge Eating Disorder (BED), I aimed to examine the current research supporting effective psychodynamic treatment of eating disorders (EDs) and how DSM-5 modifications will affect diagnosis, treatment, and awareness of EDs.

There is a dearth of research that focuses on psychodynamic psychotherapy treatment for these complex disorders and even less research on how the DSM-5 diagnostic changes will affect diagnosis and treatment planning.

The few randomized controlled trials (RCTs) and pilot studies of psychodynamic psychotherapy for EDs suggest that dynamic therapies, when determined to perform as active treatments, rather than inert controls, are as efficacious as other forms of outpatient psychotherapy for EDs (Thompson-Brenner et al., 2009).

Given the new DSM-5 diagnostic changes, it is useful to examine how these modifications will change diagnosis and treatment of EDs. The DSM-IV residual category ‘eating disorder not otherwise specified’ (EDNOS) accounted for more than half of the ED cases in clinical settings, prompting me to explore the implications for new DSM-5 EDs criteria on the prevalence, treatment, and outcome of the revised EDs category (Hoek, 2013). I intended for this research to highlight the need for more research pertaining to the efficacy of psychodynamic psychotherapy with EDs and changes within the DSM-5 category (Ebneter and Latner, 2013).

The objective of this current review is to demonstrate how various psychodynamic treatment modalities will inform treatment of BED as well as treatment of Anorexia Nervosa, Bulimia Nervosa (BN), and other forms of disordered eating. Further, it lends itself to a deeper conversation regarding the effects of DSM-5 diagnostic changes on EDs.

I evaluated the relevance and worth of psychodynamic psychotherapy for the treatment of EDs in studies from the last ten years. Hypotheses were not developed because the nature of the research was qualitative and exploratory (Creswell & Clark, 2011). The main intent was to review and present the most recent evidence concerning the utility of psychodynamic psychotherapy for treating EDs. Taking into account the stigmatization and current beliefs about eating and feeding disorders, I wondered how the DSM-5 changes would affect patients with EDs undergoing treatment.

Method

I searched numerous electronic databases and examined full text psychotherapy peer review journals as well as research reports on psychotherapy treatment, EDs, and changes to the DSM-5. I systematically applied exclusion and inclusion criteria to the search using the keywords: binge eating disorder; anorexia nervosa; BN; EDNOS; psychodynamic psychotherapy; and treatment. As seen in Figure 1, I used the PRISMA Statement (Preferred Reporting Items for Systematic reviews and Meta-Analyses) as a general guide for the process of reviewing studies (Moher et al., 2009).

Inclusion criteria for this study were broad and included studies:

  • Published since 2004
  • Written in English
  • Included a no treatment or treatment as usual group
  • Comprised of participants with EDs meeting diagnostic criteria
  • Where the primary or secondary outcomes were decrease in ED-specific psychopathology or symptoms
  • Compared psychodynamic treatments

Exclusion criteria included studies:

  • Published prior to 2004
  • Involving family therapy
  • Including psychopharmacological interventions

The search identified 6 articles that met the inclusion and exclusion criteria, one pilot study, and one naturalistic study. The collected data were descriptive in nature and evaluated the efficacy of psychodynamic psychotherapy compared to other types of treatment and/or control groups in the treatment of EDs. I placed emphasis on studies that involved psychodynamic treatment modalities.

Data Collection and Analysis

Through Medline, PubMed, PsycINFO, Google Scholar, and other similar database searches, I sought to review the psychodynamic contributions to understanding and treating EDs. The collection of peer reviewed journal articles enabled me to compare psychodynamic treatment techniques with alternative treatment approaches. I applied the PRISMA Statement checklist with the goal of finding and evaluating significance among recent studies that dealt with the psychodynamic treatment of EDs (Moher et al., 2009). I paid special attention to recent writings to capture the most up-to-date thinking on knowledge, prevalence, and treatment of EDs.

Lopez Figure 1

Conclusions

Through this systematic literature review, I closely examined eight research studies conducted in the past ten years and organized these findings and my evaluations in Table 1.

Lopez Table 1a

Lopez - Table 1b

Though psychodynamic psychotherapy for EDs has not been sufficiently studied in RCTs, findings show that active dynamic interventions, especially interpersonal psychotherapy, may be useful for EDs.

My research showed that interpersonal psychotherapy was the most prominent psychodynamic approach to EDs, as it is a more structured, manualized form of typical practice that evaluates the development of ED symptoms in the context of relationships (Thompson-Brenner et al., 2009).

A few of the studies I reviewed in Table 1 showed no significant difference between CBT and psychodynamic therapies for the treatment of BN, anorexia nervosa, and BED, which suggests that research focusing on the integration of CBT and psychodynamic treatment approaches may prove fruitful to symptom remission and better treatment outcome. Many of the studies I reviewed discussed the development of a more structured and symptom-focused version of psychodynamic psychotherapy (Poulsen et al., 2014).

The Murphy et al. (2005) pilot study implemented an integrative and time-limited approach to the outpatient treatment of BN and BED, in which psychodynamic principles were used concurrently with behavioral changes among patients. The preliminary findings of their study indicated that some EDs could be treated effectively using an integrative approach.

The present data suggest that more structured and manualized forms of psychodynamic interventions may be clinically useful in the treatment of EDs, especially BED.

Limitations of the present review include the use of published data only, extraction and preparation by a single author, possible publication bias, and broad inclusion and exclusion criteria.

My thorough review of the current research highlighted relevant and promising data that I hope will spark a larger conversation regarding the efficacy of psychodynamic treatment modalities for the treatment of EDs, as well as other complex comorbid conditions. Identifying efficacious treatments for patients with EDs represents a critical future direction in the field of clinical psychology.

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Cite This Article

Lopez, J. (2014, October). A systematic review of the efficacy of psychodynamic treatments for DSM-5 eating disorders. [Web article]. Retrieved from: http://www.societyforpsychotherapy.org/a-systematic-review-of-the-efficacy-of-psychodynamic-treatments-for-dsm-5-eating-disorders

References

Creswell, J. W., & Clark, V. L. P. (Eds.). (2011). Designing and Conducting Mixed Methods Research. SAGE.

Hilbert, A., Bishop, M.E., Stein, R.I., Tanofsky-Kraff, M., Swenson, A.K., Welch, R.R., & Wilfley, D.E. (2012). Long-term efficacy of psychological treatments for binge eating disorder. The British Journal of Psychiatry, 200(3), 232-237.

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.

Moher, D., Liberati, A., Tetzlaff, J., & Altman, D.G. (2010). Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. International Journal of Surgery, 8(5), 336-341.

Murphy, S., Russell, L., & Waller, G. (2005). Integrated psychodynamic therapy for bulimia nervosa and binge eating disorder: theory, practice and preliminary findings. European Eating Disorders Review, 13(6), 383-391.

Poulsen, S., Lunn, S., Daniel, S.I., Folke, S., Mathiesen, B.B., Katznelson, H., & Fairburn, C.G. (2014). A randomized controlled trial of psychoanalytic psychotherapy or cognitive-behavioral therapy for bulimia nervosa. American Journal of Psychiatry, 171(1), 109-116.

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.

Thompson-Brenner, H., & Westen, D. (2005). A naturalistic study of psychotherapy for bulimia nervosa, part 2: therapeutic interventions in the community. The Journal of nervous and mental disease, 193(9), 585-595.

Thompson-Brenner, H., Weingeroff, J., & Westen, D. (2009). Empirical support for psychodynamic psychotherapy for eating disorders. In R. A. Levy, J. Ablon (Eds.) , Handbook of evidence-based psychodynamic psychotherapy: Bridging the gap between science and practice (pp. 67-92). Totowa, NJ, US: Humana Press.

Wilson, G.T., Wilfley, D.E., Agras, W. S., & Bryson, S.W. (2010). Psychological treatments of binge eating disorder. Archives of general psychiatry, 67(1), 94-01.

Zipfel, S., Wild, B., Groß, G., Friederich, H.C., Teufel, M., Schellberg, D., … & Herzog,(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(9912), 127-137.

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