Early Response to Eating Disorder Treatment

Source: Photo by Priscilla Du Preez on Unsplash

Does it matter how quickly eating disorder symptoms decrease when starting treatment? Yes, it absolutely does.

An abundance of evidence accumulated over the last 20 years reinforces that early response to treatment is a strong predictor of a good outcome. Those who experience symptomatic improvement within the first few weeks of treatment fare better overall. For example, if we see a reduction in binge eating or purging – or in the case of anorexia nervosa, an increase in weight – within eight weeks of initiating therapy, chances are the individual will:

• require significantly fewer treatment sessions to complete treatment
• have lower scores (a good thing) on symptom measures at the end of treatment
• be twice as likely to achieve full remission
• be more likely to maintain recovery long term

Slow and steady doesn’t necessarily “win the race.” Rather, a sprint at the start sets patients up for a better outcome.

This is a big deal. To think that people can actually have a sense in the first few weeks of treatment, that they’re achieving a greater potential for a full recovery. Consider how this knowledge might motivate individuals to jump into treatment and push through the inevitable challenges of early therapy. Think about the confidence that might come along with traction in these early weeks, knowing that there is a brighter future ahead.

What time frame is considered early for change in treatment?

There is some debate in the field. Studies vary in their definitions of these early weeks, with most studies referencing between three to 10 weeks from the start of treatment as the early period (e.g., Haas, Hill, Lambert & Morell, 2002; Hilbert et al., 2019; Lock, Couturier, Bryson, & Agras, 2006; MacDonald, McFarlane, Dionne, David, & Olmsted, 2017). The strong predictive effect of early response has been established across a wide age range – adolescents, adults, and geriatric populations (e.g., Gunlicks-Stoessel & Mufson, 2011) – and within both psychological and pharmacological treatments (e.g., Hofmann, Schulz, Meuret, Moscovitch, & Suvak, 2006). Of note, early change can predict outcomes across multiple diagnostic groups, including individuals with depression, anxiety, and eating disorders (e.g., Aderka, Nickerson, Bøe, & Hofmann, 2012; Gunlicks-Stoessel & Mufson, 2011; Lutz, Stulz, & Köck, 2009; Beard & Delgadillo, 2019).

What kind of symptom reduction would be considered a rapid response to treatment?

There are different approaches to defining the amount of symptom reduction that represents “early change.” Many providers consider a percentage of reduction of symptoms from the baseline. For example, if someone is binge eating seven days a week when they start treatment and, by week eight, they’ve dropped by 60 percent or more – to, let’s say, two to three times per week – we would consider that a nice initial response to treatment and good early change. In the case of anorexia nervosa, weight gain at the start of treatment is associated with a better prognosis longer term.

How do you achieve early change in eating disorder treatment?

First, it’s essential for patients to be matched with an evidence-based treatment structured to meet their individual needs. There are well-studied treatments for eating disorders, including cognitive behavioral therapy, Maudsley anorexia nervosa treatment for adults (MANTRA), anorexia nervosa-focused family therapy for children and young people (FT-AN), and specialist supportive clinical management (National Institute for Health and Care Excellence [NICE], 2017). Interpersonal psychotherapy (e.g., Hilbert, Hildebrandt, Agras, Wilfley, & Wilson, 2015), dialectical behavioral therapy (e.g., Safer & Joyce, 2011), and eating disorder-focused focal psychodynamic therapy (NICE, 2017) are among second-line treatments with promising results. All of these treatments may be implemented in routine outpatient clinical practice.

CBT, MANTRA, and FT-AN are particularly focused on pushing for nourishment shifts right at the start of treatment. A signature feature of Christopher Fairburn’s CBT-E (considered the gold standard first-line eating disorder treatment) is “starting well” with swift patient engagement and commitment, front-loaded education, and the use of tried-and-true behavioral principles; all of which support prompt behavior change. Treatment breaks or holidays are discouraged since they slow down and interrupt the process, which is especially concerning early on.

Additional considerations for psychotherapy that will encourage early change:

• A thorough assessment is critical when starting treatment so as to identify the most appropriate and ultimately, most effective, intervention. It’s important to consider co-occurring issues like depression, OCD and borderline personality disorder since the presence of diagnoses alongside the ED may impact the type of therapy provided.
• Change-focused treatment can lead to higher levels of anxiety that patients and providers alike should be prepared to tolerate. Consider thinking about anxiety as a positive sign of disruption to the status quo; a sign that things may really be shaking up – in a good way.
• It’s important for providers to track patient response to treatment, particularly in the early weeks. Using a reliable symptom measure tool for tracking progress—preferably with frequent delivery (weekly)—can allow for treatment modifications when needed early in the treatment. Inadequate progress by week four should prompt the provider to either augment the treatment or switch modalities (Chang P. et al., 2021).
• Ideally, providers should be trained in a range of treatment modalities and follow protocols. To achieve the best results, modifications to evidence-based treatments are made only when there is documented evidence of poor early response to first-line treatments at the four-week mark.
• The involvement of family members is encouraged whenever possible with adult patients. Parent-caregiver involvement is generally required for child-adolescent patients. Research tells us that behavioral health outcomes improve when parents are included in the treatment process.

Given the prognostic importance of early change, encouraging rapid response should be front and center in any psychotherapy treatment.

You can see the field has moved away from months (or years!) of the kind of psychotherapy that accepts subtle shifts and micro steps forward over a long period of time. It’s in the interest of all psychotherapy patients – not just those with eating disorders – to jump into the process, starting off with a sprint, to maximize progress in the early weeks of treatment.