An exploratory study of access to evidence-based therapy for eating disorders

Ashley Higgins


Eating disorders represent serious, complex, and often ego-syntonic psychological conditions with serious medical complications. While evidence-based psychological and pharmacological treatments have been developed in recent years, not all individuals with eating disorders may be able to access these treatments. This study recruited a large sample of individuals with eating disorders and assessed their experiences in treatment, current level of symptoms, and perceptions of treatment efficacy. Most of the sample was not currently in treatment, and a third of participants reported that they had difficulty finding treatment resources for their eating disorder. Of the participants in treatment, many reported that their therapist utilized cognitive-behavioral interventions, though it is possible this evidence-based modality was not being faithfully followed.


eating disorders; patient outcomes; evidence-based care; attitudes

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American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Appolinario, J. C., Bacaltchuk, J., Sichieri, R., Claudino, A. M., Godoy-Matos, A., Morgan, C., ... & Coutinho, W. (2003). A randomized, double-blind, placebo-controlled study of sibutramine in the treatment of binge-eating disorder. Archives of General Psychiatry, 60, 1109–1116. doi:10.1001/archpsyc.60.11.1109

Arkell, J., & Robinson, P. (2008). A pilot case series using qualitative and quantitative methods: Biological, psychological and social outcome in severe and enduring eating disorder (anorexia nervosa). International Journal of Eating Disorders, 41, 650–656. doi:10.1002/eat.20546

Arnold, L. M., McElroy, S. L., Hudson, J. I., Welge, J. A., Bennett, A. J., & Keck, P. E. (2002). A placebo controlled, randomized trial of fluoxetine in the treatment of binge-eating disorder. The Journal of Clinical Psychiatry, 63, 1028–1033. doi:10.4088/JCP.v63n1113

Arnow, B. A. (1999). Why are empirically supported treatments for bulimia nervosa underutilized and what can we do about it?. Journal of Clinical Psychology, 55, 769–779. doi:10.1002/(SICI)1097-4679(199906)55:6<769::AID-JCLP9>3.0.CO;2-H

Bailer, U. F., & Kaye, W. H. (2011). Serotonin: Imaging findings in eating disorders.Current Topics in Behavioral Neurosciences, 6, 59– 79. doi:10.1007/7854_2010_78

Ball, J., & Mitchell, P. (2004). A randomized controlled study of cognitive behavior therapy and behavioral family therapy for anorexia nervosa patients. Eating Disorders, 12, 303–314. doi:10.1080/10640260490521389

Becker, A. E., Hadley Arrindell, A., Perloe, A., Fay, K., & Striegel‐Moore, R. H. (2010). A qualitative study of perceived social barriers to care for eating disorders: Perspectives from ethnically diverse health care consumers. International Journal of Eating Disorders, 43, 633–647. doi:10.1002/eat.20755

Bissada, H., Tasca, G. A., Barber, A. M., & Bradwejn, J. (2008). Olanzapine in the treatment of low body weight and obsessive thinking in women with anorexia nervosa: A randomized, double-blind, placebo-controlled trial. American Journal of Psychiatry, 165, 1281–1288. doi:10.1176/appi.ajp.2008.07121900

Brambilla, F., Garcia, C. S., Fassino, S., Daga, G. A., Favaro, A., Santonastaso, P., . . .Monteleone, P. (2007). Olanzapine therapy in anorexia nervosa: Psychobiological effects. International Clinical Psychopharmacology, 22, 197–204. doi:10.1097/YIC.0b013e328080ca31

Bulik, C., Berkman, N. D., Brownley, K. A., Sedway, J. A., & Lohr, K. N. (2007). Anorexia nervosa treatment: A systematic review of randomized control trials. International Journal of Eating Disorders, 40, 310–320. doi:10.1002/eat

Burket, R. C., & Schramm, L. L. (1995). Therapists' attitudes about treating patients with eating disorders. Southern medical journal, 88, 813–818.

Byford, S., Barrett, B., Roberts, C., Clark, A., & Edwards, V. (2007). Economic evaluation of a randomised controlled trial for anorexia nervosa in adolescents. British Journal of Psychiatry, 191, 436–440. doi:10.1192/bjp.bp.107.036806

Cachelin, F. M., & Striegel‐Moore, R. H. (2006). Help seeking and barriers to treatment in a community sample of Mexican American and European American women with eating disorders. International Journal of Eating Disorders, 39, 154–161. doi:10.1002/eat.20213

Clausen, L. (2008). Time to remission for eating disorder patients: A 2(1/2)-year follow-up study of outcome and predictors. Nordic Journal of Psychiatry, 62, 151–159. doi:10.1080/08039480801984875

Crisp, A., Gelder, M. G., Rix, S., & Meltzer, H. I. (2000). Stigmatisation of people with mental illnesses. The British Journal of Psychiatry, 177, 4–7. doi:10.1192/bjp.177.1.4

Crow, S. J., Peterson, C. B., Swanson, S. A., Raymond, N. C., Specker, S., Eckert, E. D., & Mitchell, J. E. (2009). Increased mortality in bulimia nervosa and other eating disorders. American Journal of Psychiatry, 166, 1342–1346. doi:10.1176/appi.ajp.2009.09020247

Currin, L., Schmidt, U., & Waller, G. (2007). Variables that influence diagnosis and treatment of the eating disorders within primary care settings: A vignette study. International Journal of Eating Disorders, 40, 257–262. doi:10.1002/eat

DiTomasso, R. A., Golden, B. A., & Morris, H. J. (Eds.). (2010). Handbook of Cognitive-Behavioral Approaches in Primary Care. New York, NY: Springer

Donnelly, L. (2017, May 11). Children with eating disorders waiting months for treatment, first official figures show. Retrieved from


Fairburn, C. G. (2008). Cognitive behavior therapy and eating disorders. New York: Guilford Press.

Fairburn, C. G., Cooper, Z., Doll, H. A., O’Connor, M. E., Bohn, K., Hawker, D. M., . . . Palmer, R. L. (2009). Transdiagnostic cognitive-behavioral therapy for patients with eating disorders: A two-site trial with 60-week follow-up. American Journal of Psychiatry, 166, 311–319. doi:10.1176/appi.ajp.2008.08040608

Flament, M. F., Bissada, H., & Spettigue, W. (2012). Evidence-based pharmacotherapy of eating disorders. International Journal of Neuropsychopharmacology, 15, 189–207. doi:10.1017/S1461145711000381

Fleming, J., & Szmukler, G. (1992). Attitudes of medical professionals towards patients with eating disorders. Australian and New Zealand Journal of Psychiatry, 26, 436–443.

Fluoxetine Bulimia Nervosa Collaborative Study Group. (1992). Fluoxetine in the treatment of bulimia nervosa. A multicenter, placebo- controlled, double-blind trial. Archives of General Psychiatry, 49, 139–147. doi:10.1001/archpsyc.1992.01820020059008

Golden, N. H., Katzman, D. K., Kreipe, R. E., Stevens, S. L., Sawyer, S. M., Rees, J., ... & Rome, E. S. (2003). Eating disorders in adolescents. Journal of Adolescent Health, 33, 496–503. doi:10.1016/j.jadohealth.2003.08.004

Goldstein, D. J., Wilson, M. G., Ascroft, R. C., & Al‐Banna, M. (1999). Effectiveness of fluoxetine therapy in bulimia nervosa regardless of comorbid depression. International Journal of Eating Disorders, 25, 19–27. doi:10.1002/(SICI)1098-108X(199901)25:1<19::AID-EAT3>3.0.CO;2-3

Green, H., Johnston, O., Cabrini, S., Fornai, G., & Kendrick, T. (2008). General practitioner attitudes towards referral of eating-disordered patients: A vignette study based on the theory of planned behaviour. Mental Health in Family Medicine, 5, 213–218. Retrieved from

Grilo, C. M., Masheb, R. M., & Salant, S. L. (2005). Cognitive behavioral therapy guided self-help and orlistat for the treatment of binge eating disorder: a randomized, double-blind,

placebo-controlled trial. Biological Psychiatry, 57, 1193–1201.


Grilo, C. M., Masheb, R. M., & Wilson, G. T. (2005). Efficacy of cognitive behavioral therapy and fluoxetine for the treatment of binge eating disorder: A randomized double-blind placebo-controlled comparison. Biological Psychiatry, 57, 301–309. doi:10.1016/j.biopsych.2004.11.002

Gyani, A., Shafran, R., Myles, P., & Rose, S. (2014). The gap between science and practice: How therapists make their clinical decisions. Behavior Therapy, 45, 199–211. doi:10.1016/j.beth.2013.10.004

Haby, M. M., Donnelly, M., Corry, J., & Vos, T. (2006). Cognitive behavioural therapy for depression, panic disorder, and generalized anxiety disorder: A meta-regression of factors that may predict outcome. The Australian and New Zealand Journal of Psychiatry, 40, 9–19. doi:10.1111/j.1440-1614.2006.01736.x

Halmi, K. A. (2009). Anorexia nervosa: An increasing problem in children and adolescents. Dialogues in Clinical Neuroscience, 11, 100–103. Retrieved from

Halmi, K. A., Agras, W. S., Crow, S., Mitchell, J., Wilson, G. T., Bryson, S. W., & Kraemer, H. C. (2005). Predictors of treatment acceptance and completion in anorexia nervosa: Implications for future study designs. Archives of General Psychiatry, 62, 776–781. doi:10.1001/archpsyc.62.7.776

Hay, P. (2013). A systematic review of evidence for psychological treatments in eating disorders: 2005–2012. International Journal of Eating Disorders, 46, 462–469.


Hjern, A., Lindberg, L., & Lindblad, F. (2006). Outcome and prognostic factors for adolescent female in-patients with anorexia nervosa: 9- to 14-year follow-up. British Journal of Psychiatry, 189, 428–432. doi:10.1192/bjp.bp.105.018820

Hoek, H. W., & van Hoeken, D. (2003). Review of the prevalence and incidence of eating disorders. International Journal of Eating Disorders, 34, 383–396. doi:10.1002/eat.10222

Hofmann, S. G., & Smits, J. A. J. (2008). Cognitive behavioral therapy for adult anxiety disorders: A meta-analysis of randomized placebo-controlled trials. Journal of Clinical Psychiatry, 69, 621–632. Retrieved from /articles/PMC240

Holliday, J., Wall, E., Treasure, J., & Weinman, J. (2005). Perceptions of illness in individuals with anorexia nervosa: a comparison with lay men and women. International Journal of Eating Disorders, 37, 50–56. doi:10.1002/eat.20056

Holtkamp, K., Konrad, K., Kaiser, N., Ploenes, Y., Heussen, N., Grzella, I., & Herpertz-Dahlmann, B. (2005). A retrospective study of SSRI treatment in adolescent anorexia nervosa: Insufficient evidence for efficacy. Journal of Psychiatric Research, 39, 303–310. doi:10.1016/j.jpsychires.2004.08.001

Hoopes, S. P., Reimherr, F. W., Hedges, D. W., Rosenthal, N. R., Kamin, M., Karim, R., ... & Karvois, D. (2003). Treatment of bulimia nervosa with topiramate in a randomized, double-blind, placebo controlled trial, part 1: Improvement in binge and purge measures. The Journal of Clinical Psychiatry, 64, 1335–1341.

Jackson, C. W., Cates, M., & Lorenz, R. (2010). Pharmacotherapy of eating disorders. Nutrition in Clinical Practice, 25, 143–159. doi:10.1177/0884533610362239

Kahn, C. & Pike, K. M. (2001). In search of predictors of dropout from inpatient treatment for anorexia nervosa. International Journal of Eating Disorders, 30, 237-244. doi:10.1002/eat.1080

Kaye, W. H., Frank, G. K., Bailer, U. F., & Henry, S. E. (2005). Neurobiology of anorexia nervosa: Clinical implications of alternations of the function of serotonin and other neuronal systems. International Journal of Eating Disorders, 37, S15-S19. doi:10.1002/eat.20109

Keel, P. K., & Brown, T. A. (2010). Update on course and outcome in eating disorders. International Journal of Eating Disorders, 43, 195–204. doi:10.1002/eat.20810

Keel, P. K., Dorer, D. J., Eddy, K. T., Franko, D., Charatan, D. L., & Herzog, D. B. (2003). Predictors of mortality in eating disorders. Archives of General Psychiatry, 60, 179–183. doi:10.1001/archpsyc.60.2.179

Keel, P. K., Dorer, D. J., Franko, D. L., Jackson, S. S., & Herzog, D. B. (2005). Postremission predictors of relapse in women with eating disorder. American Journal of Psychiatry, 162, 2263–2268. doi:10.1176/appi.ajp.162.12.2263

Kessler, R. C., Berglund, P. A., Chiu, W. T., Deitz, A. C., Hudson, J. I., Shahly, V., ... & Bruffaerts, R. (2013). The prevalence and correlates of binge eating disorder in the World Health Organization World Mental Health Surveys. Biological Psychiatry, 73, 904–914.doi:10.1016/j.biopsych.2012.11.020

Laederach‐Hofmann, K., Graf, C., Horber, F., Lippuner, K., Lederer, S., Michel, R., & Schneider, M. (1999). Imipramine and diet counseling with psychological support in the treatment of obese binge eaters: A randomized, placebo-controlled double-blind study. International Journal of Eating Disorders, 26, 231–244. doi:10.1002/(SICI)1098-108X(199911)26:3<231::AID-EAT1>3.0.CO;2-6

Linville, D., Benton, A., O’Neil, M., & Sturm, K. (2010). Medical providers’ screening, training and intervention practices for eating disorders. Eating Disorders, 18, 110–131. doi:10.1080/10640260903585532

Ljotsson, B., Lundin, C., Mitsell, K., Carlbring, P., Ramklint, M., & Ghaderi, A. (2007). Remote treatment of bulimia nervosa and binge eating disorder: A randomized trial of Internet-assisted cognitive behavioural therapy. Behaviour Research and Therapy, 45, 649–661.


Maier, A., Ernst, J. P., Müller, S., Gross, D., Zepf, F. D., Herpertz-Dahlmann, B., & Hagenah, U. (2014). Self-perceived stigmatization in female patients with anorexia nervosa-Results from an explorative retrospective pilot study of adolescents. Psychopathology, 47, 127 –132. doi:10.1159/000350505

Mayer, L. E. S., Schebendach, J., Bodell, L. P., Shingleton, R. M., & Walsh, B. T. (2012). Eating behavior in anorexia nervosa: Before and after treatment. International Journal of Eating Disorders, 45, 290–293. doi:10.1002/eat.20924

McElroy, S. L., Guerdjikova, A. I., Mori, N., & O’Melia, A. M. (2012). Current pharmacotherapy options for bulimia nervosa and binge eating disorder. Expert Opinion on Pharmacotherapy, 13, 2015–2026. doi:10.1517/14656566.2012.721781

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, 741–747. doi:10.1176/appi.ajp.162.4.741

Mitchell, J. E., Crosby, R. D., Wonderlich, S. A., Crow, S., Lancaster, K., Simonich, H., ... & Myers, T. C. (2008). A randomized trial comparing the efficacy of cognitive–behavioral therapy for bulimia nervosa delivered via telemedicine versus face-to-face. Behaviour Research and Therapy, 46, 581–592. doi:10.1016/j.brat.2008.02.004

National Eating Disorders Coalition. (2016, October 13). Breaking down barriers. Retrieved from

National Institute for Clinical Excellence. (2004). Eating disorders: Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders (clinical guideline no. 9). London, UK: Author. Retrieved from

Peterson, C. B., Becker, C. B., Treasure, J., Shafran, R., & Bryant-Waugh, R. (2016). The three-legged stool of evidence-based practice in eating disorder treatment: Research, clinical, and patient perspectives. BMC Medicine, 14, 69–76. doi:10.1186/s12916-016-0615-5

Pike, K. M., Walsh, B. T., Vitousek, K., Wilson, G. T., & Bauer, J. (2003). Cognitive behavior therapy in the posthospitalization treatment of anorexia nervosa. American Journal of Psychiatry, 160, 2046–2049. doi:10.1176/appi.ajp.160.11.2046

Romano, S. J., Halmi, K. A., Sarkar, N. P., Koke, S. C., & Lee, J. S. (2002). A placebo-controlled study of fluoxetine in continued treatment of bulimia nervosa after successful acute fluoxetine treatment. American Journal of Psychiatry, 159, 96–102. doi:10.1176/appi.ajp.159.1

Satir, D. A., Thompson‐Brenner, H., Boisseau, C. L., & Crisafulli, M. A. (2009). Countertransference reactions to adolescents with eating disorders: Relationships to clinician and patient factors. International Journal of Eating Disorders, 42, 511–521. doi:10.1002/eat.20650

Serfaty, M. A., Turkington, D., Heap, M., Ledsham, L., & Jolley, E. (1999). Cognitive therapy versus dietary counseling in the outpatient treatment of anorexia nervosa: Effects of the treatment phase. European Eating Disorders Review, 7, 334–350.


Shafran, R., Clark, D. M., Fairburn, C. G., Arntz, A., Barlow, D. H., Ehlers, A., ... & Salkovskis, P. M. (2009). Mind the gap: Improving the dissemination of CBT. Behaviour Research and Therapy, 47, 902–909. doi:10.1016/j.brat.2009.07.003

Stewart, M. C., Keel, P. K., & Schiavo, R. S. (2006). Stigmatization of anorexia nervosa. International Journal of Eating Disorders, 39, 320–325. doi:10.1002/eat.20262

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, 1326–1331. doi:10.1176/appi.ajp.160.7.1326

Strober, M. (2004). Managing the chronic, treatment-resistant patient with anorexia nervosa. International Journal of Eating Disorders, 36, 245–255. doi:10.1002/eat.20054

Sundblad, C., Landen, M., Eriksson, T., Bergman, L., & Eriksson, E. (2005). Effects of the androgen antagonist flutamide and the serotonin reuptake inhibitor citalopram in bulimia nervosa: A placebo-controlled pilot study. Journal of Clinical Psychopharmacology, 25, 85–88. doi:10.1097/

Surgenor, L. J., Maguire, S., & Beumont, P. J. V. (2004). Drop-out from inpatient treatment for anorexia nervosa: Can risk factors be identified at point of admission? European Eating Disorders Review, 12, 94–100. doi:10.1002/erv.539

Swanson, S. A., Crow, S. J., Le Grange, D., Swendsen, J., & Merikangas, K. R. (2011). Prevalence and correlates of eating disorders in adolescents: Results from the national

comorbidity survey replication adolescent supplement. Archives of General Psychiatry, 68, 714–723. doi:10.1001/archgenpsychiatry.2011.22

Sysko, R., Sha, N., Wang, Y., Duan, N., & Walsh, B. T. (2010). Early response to antidepressant treatment in bulimia nervosa. Psychological medicine, 40, 999–1005. doi:10.1017/S0033291709991218

Tavakol, M., & Dennick, R. (2011). Making sense of Cronbach's alpha. International Journal of Medical Education, 2, 53–56. doi:10.5116/ijme.4dfb.8dfd

Thompson-Brenner, H., & Westen, D. (2005). A naturalistic study of psychotherapy for bulimia nervosa, Part 1: Comorbidity and treatment outcome. Journal of Nervous and Mental

Disease, 193, 573–584.

Tollefson, G. D., Beasley, C. M., Tran, P. V., Street, J. S., Krueger, J. A., Tamura, R. N.,. . . Thieme, M. E. (1997). Olanzapine versus haloperidol in the treatment of schizophrenia and schizoaffective and schizophreniform disorders: Results of an international collaborative trial. American Journal of Psychiatry, 154, 457–465. Retrieved from

Treasure, J., Schmidt, U., & Hugo, P. (2005). Mind the gap: Service transition and interface problems for patients with eating disorders. British Journal of Psychiatry, 187, 398–400. doi:10.1192/bjp.187.5.398

Vocks, S., Tuschen‐Caffier, B., Pietrowsky, R., Rustenbach, S. J., Kersting, A., & Herpertz, S. (2010). Meta‐analysis of the effectiveness of psychological and pharmacological

treatments for binge eating disorder. International Journal of Eating Disorders, 43, 205–217. doi:10.1002/eat.20696

Von Ranson, K. M., Wallace, L. M., & Stevenson, A. (2013). Psychotherapies provided for eating disorders by community clinicians: Infrequent use of evidence-based treatment. Psychotherapy Research, 23, 333–343. doi:10.1080/10503307.2012.735377

Walker, S., Lloyd, C., Waghorn, G., & Reid, M. (2011). Barriers and attitudes health professionals working in eating disorders experience. International Journal of Therapy & Rehabilitation, 18, 383–391.

Waller, G., & Turner, H. (2016). Therapist drift redux: Why well-meaning clinicians fail to deliver evidence-based therapy, and how to get back on track. Behaviour research and therapy, 77, 129–137. doi:10.1016/j.brat.2015.12.005

Wallier, J., Vibert, S., Berthoz, S., Huas, C., Hubert, T., & Godart, N. (2009). Dropout from inpatient treatment for anorexia nervosa. International Journal of Eating Disorders, 42, 636–647. doi:10.1002/eat.20609

Warren, C. S., Crowley, M. E., Olivardia, R., & Schoen, A. (2008). Treating patients with eating disorders: An examination of treatment providers' experiences. Eating Disorders, 17, 27–45. doi:10.1080/10640260802570098

Wein, D., & Foord-May, L. (2009). Obesity, healthy eating, and eating disorders: Definitions, education, and treatment. In A. J. Lowenstein, L. Foord, & J. C. Romano (Eds.), Teaching strategies for health education and health promotion: Working with patients, families, and communities (pp. 379–401). Sudbury, MA: Jones & Bartlett.

Wilson, G. T., Grilo, C. M., & Vitousek, K. M. (2007). Psychological treatment of eating disorders. American Psychologist, 62, 199–216. doi:10.1037/0003-066X.62.3.199

Zwickert, K., & Rieger, E. (2013). Stigmatizing attitudes towards individuals with anorexia nervosa: An investigation of attribution theory. Journal of Eating Disorders, 1, 5–14.




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