Towards an ecology of eating disorders: Creating sustainability through the integration of scientific research and clinical practice

VIEWPOINT

Towards an Ecology of Eating Disorders:Creating Sustainability Through theIntegration of Scientific Research andClinical PracticeDavid Clinton*,

Karolinska Institutet, Resource Centre for Eating Disorders, Wollmar Yxkullsgatan, Stockholm, Sweden

Abstract

The field of eating disorders is currently at a crossroads and faces important challenges of sustainability. These

challenges include problems with the current diagnostic classification of eating disorders and the divide between

scientific research and clinical practice. If not addressed, there is a danger that the field will fail to evolve adaptively,

risking increased stagnation and reduced relevance. To meet these challenges, researchers and clinicians must work

toward a more holistic ecology of eating disorders based on the interaction of theory, research and practice. The

present paper proposes six steps towards increased sustainability based on developing clinically relevant diagnosis,

using systematic quality assurance, expanding the scope of treatment research and the definition of evidence,

promoting therapist development, as well as stimulating diversity and discourse. If we rise to the occasion and face

these challenges, then we will be better equipped to meet the evolving needs of clinicians, researchers, and most

importantly patients. Copyright # 2010 John Wiley & Sons, Ltd and Eating Disorders Association.

*Correspondence

David Clinton, M.A., M.App.Sci., Ph.D., Karolinska Institutet, Resource Centre for Eating Disorders, Wollmar Yxkullsgatan 27, 118 50

Stockholm, Sweden.

Email: [email protected]

yAssociate Professor of Medical Psychology, Psychoanalyst (IPA).

Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/erv.986

Introduction

As the year of the 200th anniversary of the birth of

Charles Darwin passes, we might pause to reflect on the

evolution of the field of eating disorders. Darwin died in

1882, only a few years after the publication of the

groundbreaking work of Gull and Lasegue on what we

now call anorexia nervosa. Initially, the field of eating

disorders went through a century of slow growth, only

to expand dramatically from roughly the publication of

Gerald Russell’s influential paper on bulimia nervosa in

1979 (Russell, 1979). Looking back over the prolifer-

ation of scientific research and clinical practice in the

field of eating disorders during the past 30 years, we

Eur. Eat. Disorders Rev. 18 (2010) 1–9 � 2010 John Wiley & Sons, Ltd and Eatin

might be tempted to rest complacent in the thought

that the rapid evolution of our field guarantees

continued growth and productivity. This, however, is

far from certain. Instead, when we pause to reflect on

the continuing evolution of the eating disorders field

there are grounds for serious concern.

Growth and the challenge ofsustainability

I will begin by borrowing a concept from the biological

sciences. Within ecology, sustainability refers to an

ecosystem’s capacity to maintain ecological functions

and processes, retain biodiversity, survive and remain

g Disorders Association. 1

Towards an Ecology of Eating Disorders D. Clinton

productive over the long-term. Today, the continuing

growth of the Earth’s population coupled with rapid

depletion of natural resources and climate change is

generating new environmental challenges. A delicate

balance of natural ecological cycles is threatened, and

we are becoming increasingly faced with a crisis of

sustainability.

Within our own field of eating disorders we are faced

with similar challenges of sustainability. The field has

witnessed a proliferation of scientific research and

treatment literature since the early 1980s. Evidence of

this can be seen in the number of papers on eating

disorders in the psychiatric literature, which was

underlined in Theander’s (2002) analysis of the

literature from Medline and PsycINFO from 1960 to

1999. Although Theander’s analysis helps to put things

in perspective, it does not tell us about the most recent

decade, or put things in a wider historical perspective.

Neither does his study take account of literature

trends in relation to eating disorder not otherwise

specified (EDNOS) or other related psychiatric

disorders.

If we extend Theander’s study both backwards and

forwards in time, and systematically analyse keywords

and topic headings in PsycINFO pertaining to eating

disorders, anorexia, bulimia and related terms from

1900 to the present, we are met with what appears to be

a clear-cut story, illustrated in Figure 1. For these

analyses data from PsycINFO, rather than Medline,

were used since there is more extensive historical

coverage of the literature in PsycINFO.

Figure 1 ED literature (numbers of publications) in PsycINFO 1900–20

2 Eur. Eat. Disorders Rev. 18 (2

Data in Figure 1 are based on the number of

publications within the eating disorders field at ten-year

intervals. What, however, is missing is a relevant anchor

point. As Theander (2002) pointed out, it is important

to look at publications on eating disorders relative to

the development of medical databases generally. If we

examine the growth of the eating disorders literature in

relation to publications in the field of psychiatry and

mental disorders as a whole the picture becomes more

complex.

In Figure 2 data on publications relating to eating

disorders are presented as a percentage of the overall

literature on psychiatry or mental disorders in

PsycINFO for the same intervals of time. Figure 2

suggests that, relatively speaking, the initial surge in

eating disorders literature came in fact during the

1970s, with a peak during the 1980s. It was during this

time that eating disorders captured a greater share of

the collective psychiatric consciousness, at least in terms

of publications. Since the 1990s the field of eating

disorders appears to have entered a period of relative

decline compared to publication trends within psy-

chiatry generally. These trends are similar to those

observed by Theander (2002), who talked about the

‘relative stagnation’ in the literature on eating disorders

during the 1990s. This stagnation would appear to have

continued into the present decade.

The picture becomes even more complex if historical

trends in other related psychiatric disorders are

considered. In Figure 3 hysteria and neurasthenia were

included in the analyses, since these disorders have

09

010) 1–9 � 2010 John Wiley & Sons, Ltd and Eating Disorders Association.

Figure 2 ED literature in PsycINFO as a percentage of the literature on psychiatry/mental disorders 1900–2009

D. Clinton Towards an Ecology of Eating Disorders

often characterised young women, and have involved,

at least to some extent, symptoms of disordered eating.

Neurasthenia is even still with us as an official diagnosis

in ICD-10, while the classical symptoms of hysteria

familiar to Charcot and Freud are now largely found

under the heading of dissociative syndromes and

somatoform disorders in DSM-IV.

Despite what we might believe about the fashionable

nature of eating disorders capturing the public imagi-

nation, historically speaking it would appear difficult to

Figure 3 Literature on ED, hysteria and neurasthenia as a percentage

2009


compete with hysteria in terms capturing the collective

consciousness of psychiatry. However, hysteria and

neurasthenia proved to be largely unsustainable as

psychiatric diagnoses. Before pursuing questions of the

sustainability of eating disorders we might pause to

consider the fate of hysteria in particular.

It is interesting that there is such a paucity of

literature on the demise of hysteria, while its discovery

has received considerable attention (Micale, 1990).

Perhaps many would consider hysteria dead. If it is,

of the literature on psychiatry/mental disorders in PsycINFO 1900–



historians have yet to perform the autopsy. Some steps

along these lines have been taken by Borch-Jacobsen

(2001) who has argued that mental illness is not simply

‘out there’, waiting to be described by researchers. He

views diagnostic entities more as interactive phenom-

ena, waxing and waning in accordance with changes in

theory, research, and clinical practice. This means that

it may be quite a natural phenomenon for diagnostic

categories to evolve and change over time.

Following the line adopted by Borch-Jacobsen, and

seeing diagnosis in an interactive and ecological

framework we might conjecture that diagnostic

sustainability will be achieved when there exists a

dynamic and productive interaction between theory,

research and practice. A field that encourages a diversity

of theoretical approaches, research strategies and

treatment techniques, and which promotes exchange

of ideas and findings, will be better fitted to adapt and

meet new challenges, productively integrating new

discoveries with tried and tested knowledge.

Getting back to eating disorders, there are signs that

we are currently facing challenges of sustainability.

These include the problems with the current diagnostic

classification of eating disorders and the lack of

productive interaction between scientific research and

clinical practice. If not addressed through the devel-

opment of more relevant diagnosis and increased

integration of research and practice, then there is a

danger that the field of eating disorders will fail to

evolve adaptively, and the risk may increase of meeting

the same fate as hysteria and neurasthenia.

The diagnostic crisis

Nowhere is the challenge of sustainability more evident

than in the field of eating disorder diagnosis. There is a

manifest lack of correspondence between the DSM and

ICD systems in terms of definitions and criteria. Within

DSM-IV there is a marked dichotomy between the

clear-cut syndromes of anorexia nervosa and bulimia

nervosa, and the amorphous mass of suffering relegated

to the catch-all category of EDNOS, which means that

the DSM system has limited clinical relevance. Several

recent studies bear witness to the overwhelming

number of eating disorder patients who are currently

categorised as EDNOS. Within a community-based

eating disorder service, EDNOS patients have been

found to constitute 67% of presenting cases (Turner &

Bryant-Waugh, 2004). In a two-stage community-


based study of the prevalence of eating disorders among

young females, 0.39% of the sample fulfilled DSM-IV

criteria for anorexia nervosa (AN), 0.30% for bulimia

nervosa (BN), and 2.37% were classified as EDNOS;

among the cases of eating disorders identified in the

study, 77.4% were EDNOS (Machado, Machado,

Goncalves, & Hoek, 2007).

It might be assumed that the largest diagnostic group

of eating disorders would also be the group that receives

greatest attention in the literature. However, this is

far from the case. If a systematic analysis of PsycINFO

is conducted and literature on anorexia, bulimia and

EDNOS are compared, the results are telling. In Figure 4

data on publications dealing with anorexia and

bulimia are contrasted with those dealing with EDNOS,

atypical eating disorders or binge eating disorder

(BED). These figures are presented as percentages, i.e.

numbers of publications relative to the number of

publications relating to eating disorders as a whole.

Note that the given percentages do not always total 100,

especially from the 1960s onwards, due to a general

widening of interest in the literature and an increased

number of studies looking at phenomena such as

‘disordered eating’, ‘eating habits’, ‘purging syndrome’,

etc.

In all fairness, EDNOS, atypical eating disorders and

BED are relatively new concepts compared with

anorexia and bulimia. However, what nonetheless

becomes abundantly clear, especially when we examine

data from the past decade, is that scientific interest in

eating disorders is to be found almost exclusively in

relation to the two classic syndromes of AN and BN.

What’s more, of the 1021 publications to date on

EDNOS during the present decade 822 (80%) dealt with

BED. Coupled with the literature on the overwhelming

prevalence of EDNOS, questions arise about why the

vast majority of patients with eating disorders appear to

receive relatively little scientific attention. Perhaps the

sufferers of eating disorders are not the only ones to fall

victim to unrealistic, glamorised ideals. Even though

EDNOS patients may suffer from equally serious clinical

conditions as full-syndrome patients, and despite the

increased attention shown to bulimia from the 1980s

onwards, researchers still seem to see AN as the ‘sexy’

eating disorder.

There are one or two other interesting trends in

Figure 4 that deserve comment. The dramatic dearth of

publications on anorexia from 1910–1919 likely reflects

the prevailing interest in anorexia as a purely medical


Figure 4 Literature on AN, BN and EDNOS as a percentage of the literature on ED in PsycINFO 1900–2009


condition at that time, following Simmonds (1914)

influential paper on anorexia as a form of pituitary

insufficiency. Since the purely endocrinological litera-

ture is lacking in PsycINFO, the data give a somewhat

distorted picture of paucity of interest in AN during this

period. Nevertheless, there is a dramatic surge of

interest in AN from the 1930s and into the 60s, when it

dominated the eating disorder literature completely.

This coincides with the period of psychoanalytic

dominance in the field. It is also interesting that although

there is a dramatic surge of publications relating to bulimia

during the 1980s, the phenomenon is by no means absent

from the literature in previous decades. Nevertheless,

despite various developments in the field of eating

disorders, it is striking that anorexia still dominates our

collective consciousness, and that the ‘discovery’ of

bulimia in the 1980s has not been matched by the same

degree of interest during the present decade.

The research-practice divide

Knowledge of eating disorders has increased signifi-

cantly since the 1970s. At the same time, specialist

services have expanded to an extent that would have

been difficult to imagine 40 years ago. For example, in

Stockholm, where I work, specialist services have grown

from a handful of pioneers in the mid 1980s to well over

100 specialists currently involved in publicly and

privately operated care for eating disorders. These

developments have, of course, benefited patients.


However, even though research and clinical practice

have grown, they have also tended to grow apart.

The divide between scientific research and clinical

practice is evident in many ways. One such way

concerns the difficulties in integrating evidence-based

treatment into clinical practice. Since the mid-1980s

important strides have been made in the development

and evaluation of evidenced-based treatment for eating

disorders. The treatment of choice is often cognitive

behavioural therapy for adults, at least in the case of BN,

or family therapy in the case of adolescent AN. These

developments have resulted in the adoption of national

guidelines for treatment provision in various countries

(e.g. NICE, 2004; RCP, 2001; APA, 2006). Despite the

promotion of such guidelines, many clinicians appear

not to use them or even be aware of them. In a survey of

primary care physicians Currin and colleagues (2007)

found that only 4% of those surveyed reported using

published ‘best practice’ guidelines for eating disorders.

And they found no evidence that guidelines on ‘best

practice’ promote evidence-based management of eating

disorders. What’s more, adoption of ‘best practice’

provides no guarantee that patients will get better. As

Vanderlinden (2008) has pointed out, evidence-based

approaches to eating disorders are unsuccessful in

treating many patients. For example, systematic long-

term studies suggest that CBT is successful in treating

approximately 45–50% of bulimics (Gowers et al., 2007).

Part of the problem may be that cases seen in the

community bear little resemblance to those used in the



randomised controlled trials that form the backbone of

practice guidelines. This makes the research in question

less relevant for clinicians. Remember that the majority

of eating disorder cases being seen by therapists are

EDNOS, whereas randomised controlled trials are

based on full-syndrome patients. Using four common

exclusion criteria from randomised controlled trials,

Thompson-Brenner and Westen (2005a) found that

40% of bulimics treated in the community would have

been excluded from randomised controlled trials. The

same researchers found that among those patients in

the community receiving CBT, treatment was sub-

stantially longer than that prescribed in manuals (i.e. on

average 69 sessions).

It might be argued that practitioners are simply not

applying tested therapeutic techniques, as they should,

at least as regards the full-syndrome patients where

there is more evidence of efficacy. However, it could

also be argued that researchers are not sufficiently in

touch with clinical reality, and are not testing their

treatments on clinically relevant samples of patients. It

is also interesting that Thompson-Brenner and Westen

(2005b) found that although CBT and psychodynamic

therapists treating BN in the community used

substantially different forms of treatment, distinguish-

able in terms of their differing theoretical orientations,

they both tended to practice more integrative inter-

ventions than those prescribed in manuals. Examples of

integrative approaches to eating disorders can be found

in the literature. Schaffner and Buchanan (2008)

combined cognitive-behavioural therapy with clinical

experience and strategies such as group, family and

individual therapy. Murphy, Russell and Waller (2005)

have described an integrative form of treatment for BN

and BED based on the combination of psychodynamic

and behavioural principles.

Another important part of the research-practice

divide concerns the way results from empirical research

tends to be interpreted. Systematic treatment research

focuses on statistical analysis of means and variance

between groups. When significant differences are found

between treatment and control groups in randomised

studies, inferences are made about the efficacy of

particular therapeutic techniques. However, what is

often not discussed or systematically analysed is the vast

reservoir of within-group variance in these studies.

Regardless of the form of treatment used in a study,

there will always be variability within a particular

treatment group. The problem for researchers involves


systematically tapping into within-group variance to

better understand how and why patients respond the

way they do.

Contemporary ‘best practice’ guidelines are often

assumed to suggest that good treatment results will

follow provided clinicians use good (i.e. evidence-

based) techniques. Here the underlying implication is

that it is technique that results in change. Although

technique is one variable in the change equation, it is by

no means the only one. As early as 1936 Rosenzweig

discussed the importance of common factors in

psychotherapy (Rosenzweig, 1936). Over the years

the contribution of general and specific factors to

outcome has received considerable attention in meta-

analyses of the psychotherapy literature. In a meta-

meta-analysis of 17 previous meta-analyses in the

psychotherapy literature Luborsky and colleagues

(2002) found that when active treatments were

compared with each other the mean effect size was

small and non-significant (i.e. Cohen’s d¼ 0.20

uncorrected, and even lower d¼ 0.12 when corrected

for the researcher’s allegiance). The large and significant

effect sizes in the psychotherapy literature are to be

found when active treatments are compared to no

treatment or waiting list controls. In a review of the

literature Wampold (2007) surmises that these absolute

effects of psychotherapy lie in the region of d¼ 0.80 (i.e.

considerably large effects).

One factor that may go a long way to explaining the

considerable within-group variance in randomised

controlled trials in both the psychotherapy and eating

disorder literature is the therapist. Individual therapists

practising the same methods produce varying results

with different patients that cannot be explained on the

basis of patient background or severity (Luborsky,

McLellan, Diguer, Woody, & Seligman, 1997). What’s

more, Wampold and Serlin (2000) have found that

treatment effects can be systematically overestimated

when therapist effects are not taken into account. Even

in randomised trials where therapists are selected for

their technical skill and monitored for adherence to a

treatment manual, there will be a significant proportion

outcome variance that is attributable to therapists

within treatments. This therapist effect has been

estimated to be at least one order of magnitude greater

than any differences among treatments in randomised

trials (Kim, Wampold, & Bolt, 2006). More impor-

tantly, it appears that much of the variability among

therapists is due to differences in therapists’ ability to



form a working alliance with a variety of patients

(Baldwin, Wampold, & Imel, 2007).

Perhaps Cole Porter was right, ‘it’s not what you do,

it’s the way that you do it’. That’s what it’s all about.

Although there has as yet been relatively little systematic

research in the eating disorders field that has attempted

to disentangle how effective treatments work, there is a

growing body of evidence within psychotherapy

research generally that outcome is not so much

dependent on what psychological ingredients are

delivered but how they are delivered. This in turn

raises challenges for researchers. We need to knowmore

about what makes good therapists, and how therapists

contribute to outcome.

This brings us back to the research-practice divide,

and the question of sustainability within the eating

disorders field. There may be an inherent problem in

how eating disorder researchers and therapists view the

question of evidence. Scientists and proponents of ‘best

practice’ guidelines may tend to see evidence as simply a

question of weighing up the data on the efficacy of

specific techniques and implementing practice accord-

ingly, whereas clinicians may view evidence more in

terms of their own experience and what works for them

‘out there’. The result may be frustration on both parts.

Researchers feel frustrated over therapists who adopt

‘prejudice-based’ practice and refuse to integrate hard-

won scientific knowledge in treatment, while therapists

feel frustrated over rigid researchers who fail to grasp

the complexity of everyday clinical practice. If there is

no constructive dialogue between clinicians and

researchers then the gulf will widen, and sustainable

growth will be threatened.

Steps towards create greatersustainability

Despite the challenges, there is much that can be done

to affect adaptive evolution in the field of eating

disorders. Here I would like to propose six steps

towards greater sustainability that focus on closer

integration of scientific research and clinical practice.

Developing clinically relevant eating

disorder diagnosis

We stand on the verge of DSM-V. It will be essential

that the new system of eating disorder diagnosis is more

clinically relevant than at present. To this end it will be


essential that the new system reduces the number of

eating disorder patients who are relegated to EDNOS.

This could, for example, involve relinquishing the

amenorrhoea criterion for AN, and widening the

frequency criteria for BN. There should also be an

attempt to define what constitutes an ‘eating disorder’

per se, so eating disorders can be distinguished from

other psychiatric syndromes. Attention should also be

directed towards bringing the DSM and ICD systems

into better alignment.

Developing systematic quality

assurance

Quality assurance of specialist eating disorder care is in

increasing demand from public health officials,

practitioners and the patient community. There is a

need to know more about how treatment works in real-

life clinical settings, and the extent to which patients

attain empirically definable treatment goals. Today,

computer-based quality assurance is one possible way

of meeting demands for evaluating the real-life

effectiveness of eating disorder treatment, in a large-

scale, cost-effective and highly structured way. In

Sweden there is growing experience of the opportu-

nities and challenges involved in implementing such a

system (Birgegard, Bjorck & Clinton, in press). For

clinicians, computer-based quality assurance facilitates

systematic assessment of eating disorders and increases

the knowledge base for informed selection and evalua-

tion of services. For researchers, a rich database is

generated within a naturalistic setting, which allows

access to a large and clinically relevant sample of eating

disorder patients. Development of systematic quality

assurance alsomeans that differences between clinicians

and researchers come to the fore, and points of conflict

become more apparent. This poses challenges, but also

creates tangible opportunities for researchers and

clinicians to meet, discuss and solve these problems,

ultimately bringing them closer together.

Expanding the scope of treatment

research

Randomised controlled trials have added enormously

to our knowledge of eating disorder treatment. Such

work will continue to be important, but it is now time

to expand the scope of treatment research. We need to

know more about how treatment works in everyday



practice. It will be important to explore questions

relating to the contribution of general and specific

factors, investigate how the therapeutic alliance can be

strengthened in work with eating disorder patients, and

how expectations may influence response to treatment

and outcome. Definitions of recovery should be

explored and expanded in order to encompass a richer

array of relevant variables. Statistically, there needs to

be greater attention paid to studying interaction effects,

so we can better understand the clinically relevant

question of what works for whom.

Expanding the definition of evidence

Using randomised controlled trials is one important

form of evidence, but it is not the only important form

of evidence. A greater rapprochement between clin-

icians and researchers will be aided by increased use and

discussion of results obtained by other types of research.

Attention should be directed towards qualitative

research, systematic cases studies, as well as naturalistic

and longitudinal work. Discussing and appraising these

different forms of evidence will contribute to a more

clinically relevant and holistic picture of what works in

the treatment of eating disorders and how it works.

Promoting therapist development

The therapist could be considered the lost variable of

treatment research. More attention needs to be directed

at understanding the how therapists actually work in

everyday clinical settings, and helping them to learn

new ways of better using their strengths and improving

on their weaknesses. This will involve attention to new

questions on the part of researchers, as well as increased

openness on the part of clinicians. Promoting the

development of individual therapists will need to go

beyond the use of treatment manuals, and focus more

on how treatment is conducted in real-life settings. To

this end, developments in the use of systematic quality

assurance can have an important role to play by

providing clinicians with relevant feedback on their

own work.

Stimulating diversity and discourse

In biological systems diversity forms the basis for

evolutionary adaptation in a changing environment.

Within the field of eating disorders we need to


encourage diversity of treatment approaches and

research strategies. Promoting diversity can help us

to understand the emerging complexity of eating

disorders, and make it easier to develop effective

treatment strategies. But in order for diversity to be

effective we will also need to stimulate discourse and the

exchange of ideas, between practitioners and research-

ers as a whole, and between groupings of practitioners

and researchers with differing theoretical orientations.

Discourse will help us to find common ground and

delineate points of difference. It will stimulate treat-

ment development and help us to achieve more widely

held standards of evidence for better understanding

eating disorders and evaluating treatment. This could

be done by organising workshops and panels at

conferences focusing on greater collaboration and

exchange of ideas by clinicians and researchers,

stimulatingmore longitudinal and naturalistic research,

greater involvement of clinicians in research and

researchers in treatment, as well as organising discus-

sions of clinical and research problems from a trans-

theoretical perspective where therapists and researchers

of differing orientations take on common problems.

Summary and conclusions

Pausing to reflect on the evolution of the field of eating

disorders there is cause for concern. We are currently at

a crossroads and facing important challenges of

sustainability. These challenges include problems with

the current diagnostic classification of eating disorders

and the tangible divide between scientific research and

clinical practice. If not addressed, there is a danger that

the field of eating disorders will fail to evolve adaptively,

with the risk of increased stagnation and reduced

relevance. To meet these challenges we need to work

together towards a more holistic ecology of eating

disorders based on a dynamic and productive

interaction of theory, research and practice. The

present paper proposes six steps towards increased

sustainability based on developing clinically relevant

diagnosis, systematic quality assurance, expanding the

scope of treatment research and the definition of

evidence, promoting therapist development, as well as

stimulating diversity and discourse within the field.

If we rise to the occasion and face these challenges,

then we will be better equipped to meet the evolving

needs of clinicians, researchers, and most importantly

patients.



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Documents

Towards an ecology of eating disorders: Creating sustainability through the integration of scientific research and clinical practice