Article

Rapid response to eating disorder treatment: A systematic review and meta-analysis

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Abstract

Objective: This review aimed to (a) examine the effects of rapid response on behavioral, cognitive, and weight-gain outcomes across the eating disorders, (b) determine whether diagnosis, treatment modality, the type of rapid response (changes in disordered eating cognitions or behaviors), or the type of behavioral outcome moderated this effect, and (c) identify factors that predict a rapid response. Method: Thirty-four articles met inclusion criteria from six databases. End of treatment and follow-up outcomes were divided into three categories: Behavioral (binge eating/purging), cognitive (EDE global scores), and weight gain. Average weighted effect sizes(r) were calculated. Results: Rapid response strongly predicted better end of treatment and follow-up cognitive and behavioral outcomes. Moderator analyses showed that the effect size for rapid response on behavioral outcomes was larger when studies included both binge eating and purging (as opposed to just binge eating) as a behavioral outcome. Diagnosis, treatment modality, and the type of rapid response experienced did not moderate the relationship between early response and outcome. The evidence for weight gain was mixed. None of the baseline variables analyzed (eating disorder psychopathology, demographics, BMI, and depression scores) predicted a rapid response. Discussion: As there is a solid evidence base supporting the prognostic importance of rapid response, the focus should shift toward identifying the within-treatment mechanisms that predict a rapid response so that the effectiveness of eating disorder treatment can be improved. There is a need for future research to use theories of eating disorders as a guide to assess within-treatment predictors of rapid response. © 2016 Wiley Periodicals, Inc.

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... Despite difficulties in accurately predicting outcome following psychological treatments, early symptom change (also known as rapid response) has emerged as a robust predictor across several psychiatric disorders, including eating disorders ( [1,2]; see [3] and [4] for reviews). Early changes in both behavioural symptoms and eating disorder (ED) psychopathology are associated with better outcomes following outpatient treatments based on cognitive behaviour therapy (CBT) [3,4]. ...
... Despite difficulties in accurately predicting outcome following psychological treatments, early symptom change (also known as rapid response) has emerged as a robust predictor across several psychiatric disorders, including eating disorders ( [1,2]; see [3] and [4] for reviews). Early changes in both behavioural symptoms and eating disorder (ED) psychopathology are associated with better outcomes following outpatient treatments based on cognitive behaviour therapy (CBT) [3,4]. Those who make early change are around twice as likely to achieve remission compared to those who do not [5], a finding demonstrated in intensive outpatient treatment [6], as well as brief [7] and standard [2,5,8] CBT for EDs. ...
... Although a comprehensive definition of remission was used, including both behavioural and cognitive symptoms, the timeframe was short and limited by self-report, thus not representing the "gold standard" of assessing outcome in such designs [47]. Overlaps in the measures used may have provided artefactual correlation towards the end of treatment, although findings regarding early change are in line with previous work [3]. The study was also limited by recruitment from one NHS Trust and provided GSH with ten sessions of support, more than some GSH studies [15], which may have influenced the findings. ...
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Purpose This study tests the value of a measure of eating disorder (ED) psychopathology in predicting outcome following guided self-help in a non-underweight sample with regular binge eating. It examines whether early reductions in ED psychopathology are associated with remission status at post-treatment. Methods Seventy-two adults with bulimia nervosa, binge-eating disorder, or an atypical form of these illnesses received up to ten sessions of cognitive behaviour therapy-based guided self-help. Using a session-by-session measure of eating pathology and associated reliable change indices, response was analysed using receiver operating characteristic analysis to predict outcomes at post-treatment. Results In this routine care setting, nearly one-quarter of the sample achieved remission following GSH, approximately two-thirds of whom showed early change in ED psychopathology. Early change prior to session 6 was accurate in predicting later remission. Individuals showing early change did not differ from others on baseline characteristics or rates of attrition. Conclusion Data suggest that a majority of those who respond to treatment will do so before the second half of treatment, information that could be used to ensure that evidence-based treatments are used as effectively as possible. Level of evidence Level III.
... The importance of early response in the field of eating disorders was initially highlighted by Vall and Wade (2015), who conducted a broad review of predictors of eating disorder treatment outcomes. Linardon, Brennan, and De la Piedad Garcia (2016) reached a similar overall conclusion in a meta-analysis based on similar but more targeted literature reviewed approximately a year later, though their overall effect sizes (behavioural outcomesr = 0.397; cognitive outcomesr = 0.288) were smaller than those of Vall and Wade (2015). However, while Vall and Wade (2015- Table 2) identified 12 relevant studies for their meta-analysis, the broad scope of their study meant that their search strategy was not specifically devised to be sensitive and specific to early response studies (i.e., their wider aim was to identify a much wider range of predictors of outcome). ...
... However, while Vall and Wade (2015- Table 2) identified 12 relevant studies for their meta-analysis, the broad scope of their study meant that their search strategy was not specifically devised to be sensitive and specific to early response studies (i.e., their wider aim was to identify a much wider range of predictors of outcome). Consequently, several of the 20 studies that were identified by Linardon et al. (2016 - Table 1) overlapped the period of time that Vall and Wade considered, but were not represented in the earlier review. A further meta-analysis (Nazar et al., 2017) has considered the role of early change in predicting subsequent diagnostic change, but identified fewer papers (N = 14) than Linardon et al. (2016), due to the more constrained eligibility criteria for inclusion (diagnostic outcomes). ...
... Consequently, several of the 20 studies that were identified by Linardon et al. (2016 - Table 1) overlapped the period of time that Vall and Wade considered, but were not represented in the earlier review. A further meta-analysis (Nazar et al., 2017) has considered the role of early change in predicting subsequent diagnostic change, but identified fewer papers (N = 14) than Linardon et al. (2016), due to the more constrained eligibility criteria for inclusion (diagnostic outcomes). Given that several years have elapsed since the previous analyses and several studies on the impact of early change in eating disorders have emerged since the Vall and Wade (2015) and Linardon et al. (2016) meta-analyses (e.g., Bell et al., 2017Hilbert et al., 2019;Matheson et al., 2020), it is important to revisit this topic to determine whether the impact of early change confirms the reduction in effect sizes between the Vall and Wade (2015) and Linardon et al. (2016) studies. ...
Article
Early response is a well-established predictor of positive outcomes at the end of psychological treatments for common mental disorders. There is some prior evidence that this conclusion also applies to eating disorders, including three meta-analyses, but no moderators of that relationship have been identified. However, a number of further papers have been published since, which might influence the size of the effect of early response or the potential role of moderating factors. This pre-registered systematic review presents a comprehensive examination of this literature. Three databases were searched (Scopus, PsycInfo, PubMed). In total, 33 eligible studies were included in a narrative synthesis, and 25 studies were included in random-effects meta-analysis. The majority (91%) of studies were rated as having low or moderate risk of bias. Approximately half of patients across clinical samples showed early response to psychological therapy, which was most often defined as reliable symptomatic improvement during the first four sessions. A significant and moderate association was found between early response and post-treatment outcomes (r = 0.41 [95% CI: 0.32-0.481], p < .0001). Significant evidence of heterogeneity (Q[28] = 136.42, p < .0001; I2 = 80.2%) was evident. The review was limited by the exclusion of grey literature and only 76% of studies provided sufficient statistical information for meta-analytic synthesis, although we found no significant evidence of publication bias, χ2(1) = 0.001, p = .97. Overall, evidence accumulated over twenty years establishes early response as the most robust predictor of treatment outcomes in the field of eating disorders. However, only half of patients show early change in this way. Further research is needed to determine whether there are patient or clinician characteristics that predict early response to psychological treatment for eating disorders.
... One well-studied pattern is rapid early treatment response, which predicts more favorable overall treatment outcome. A review and meta-analysis conducted by Linardon, Brennan, and de la Piedad Garcia (2016) indicated that larger early improvements in behavioral and cognitive ED symptoms were associated with significantly better end-of-treatment outcomes (Linardon et al., 2016). Notably, this review included studies with a range of rapid response definitions, including those contingent only upon reductions in binge eating and/or vomiting (e.g., 65% reduction in binge frequency by week) and others emphasizing self-report measures such as the Eating Disorder Examination-Questionnaire (EDE-Q). ...
... One well-studied pattern is rapid early treatment response, which predicts more favorable overall treatment outcome. A review and meta-analysis conducted by Linardon, Brennan, and de la Piedad Garcia (2016) indicated that larger early improvements in behavioral and cognitive ED symptoms were associated with significantly better end-of-treatment outcomes (Linardon et al., 2016). Notably, this review included studies with a range of rapid response definitions, including those contingent only upon reductions in binge eating and/or vomiting (e.g., 65% reduction in binge frequency by week) and others emphasizing self-report measures such as the Eating Disorder Examination-Questionnaire (EDE-Q). ...
... They were also more likely to endorse compensatory behaviors at admission and included fewer patients with anorexia nervosa-restricting type. This group most closely reflects the "rapid response" pattern characterized elsewhere in the literature, which is often observed among patients who engage in compensatory behaviors (Linardon et al., 2016;MacDonald, McFarlane, et al., 2017;MacDonald, Trottier, et al., 2017). In the residential setting, it is possible that patients who engaged in compensatory behaviors prior to admission were more prone to rapid symptom improvement due to the structured treatment setting; locked bathrooms and staff supervision typically preclude engagement in compensatory behaviors. ...
Article
Objective Eating disorder (ED) treatment outcomes are highly variable from beginning to end of treatment; however, little is known about differential trajectories during the course of treatment. This study sought to characterize heterogeneous patterns of ED treatment response during residential care. Method Participants were adolescent girls and adult women (N = 360) receiving residential ED treatment for anorexia nervosa, bulimia nervosa, binge‐eating disorder, other specified feeding or eating disorder, unspecified feeding or eating disorder, or avoidant/restrictive food intake disorder. Self‐report symptom assessments were completed at admission, discharge, and approximately weekly throughout the residential stay to assess curvilinear patterns of change. Latent growth mixture modeling was applied to identify subgroups of patients with similar treatment response trajectories. Results Three latent groups emerged, including gradual response (58.3%; steady improvements from admission to discharge), rapid response (23.9%; steep early improvements that were maintained through discharge), and low‐symptom static response (17.8%; nearly nonclinical self‐reported symptoms at admission that remained static through discharge). Groups differed on important clinical characteristics, such as body mass index, endorsement of compensatory behaviors, severity of global ED psychopathology at admission, and degree of symptom improvement by end of treatment. Discussion Patients follow heterogeneous response patterns in residential ED treatment, and these patterns are associated with differential treatment outcome. Future work should explore whether these trajectories are associated with differential outcomes at follow‐up and whether tailoring clinical intervention to a patient's trajectory type can improve treatment response.
... RR is typically defined as a clinically meaningful change in disorder-specific symptoms within the first half of treatment [12]. In two recent meta-analyses, RR was the strongest predictor of treatment success across diagnoses in several treatment settings [8,13]. However, RR has not yet been examined as a predictor of outcome in IOP settings. ...
... Given the large effect size in a recent meta-analysis of ED treatment outcome predictors [8] and consistent replication across samples from outpatient randomized controlled trials and higher levels of care [8,13], the current study aims to replicate RR findings in a transdiagnostic sample receiving evidence-based treatment in an IOP. Planned follow-up analyses will examine treatment factors that differentiate those who achieved RR and those who did not, should the primary hypothesis be supported. ...
... A lack of knowledge of precise mechanisms underlying RR or clinical profiles of clients who make RR are noted limitations in ED research [13] and have not previously been studied in intermediate level of care samples. In the current sample, there were no baseline differences between patients who did and did not make RR. ...
Article
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Objective There is a growing call to identify specific outcome predictors in real-world eating disorder (ED) treatment settings. Studies have implicated several ED treatment outcome predictors [rapid response (RR), weight suppression, illness duration, ED diagnosis, and psychiatric comorbidity] in inpatient settings or randomized controlled trials of individual outpatient therapy. However, research has not yet examined outcome predictors in intensive outpatient programs (IOP). The current study aimed to replicate findings from randomized controlled research trials and inpatient samples, identifying treatment outcome predictors in a transdiagnostic ED IOP sample.Method The current sample comprised 210 consecutive unique IOP patient admissions who received evidence-based ED treatment, M(SD)Duration = 15.82 (13.38) weeks. Weekly patient measures of ED symptoms and global functioning were obtained from patients’ medical charts.ResultsIn relative weight analysis, RR was the only significant predictor of ED symptoms post treatment, uniquely accounting for 45.6% of the predicted variance in ED symptoms. In contrast, baseline ED pathology was the strongest unique predictor of end-of-treatment global functioning, accounting for 15.89% of predicted variance. Baseline factors did not differentiate patients who made RR from those who did not.Conclusions Consistent with findings in more controlled treatment settings, RR remains a robust predictor of outcome for patients receiving IOP-level treatment for EDs. Future work should evaluate factors that mediate and moderate RR, incorporating these findings into ED treatment design and implementation.Level of evidenceLevel IV, uncontrolled intervention.
... Rather than the length of treatment predicting outcome, the critical predictor is early change in eating disorder symptoms. Meta-analyses synthesising over 20 years of evidence have established that the change achieved in the first four to six sessions or weeks of treatment is the most robust predictor of treatment outcomes for people with eating disorders (Chang et al., 2021;Linardon et al., 2016;Vall & Wade 2015). This value of early change has been demonstrated for end of treatment and follow-up, among both children and adults, across eating disorder diagnoses, for inpatient, day patient and outpatient treatments, and for a range of eating disorder symptoms from weight gain to decrease in binge/purge frequency (Bell et al., 2017;Chang et al., 2021;Vall & Wade, 2015). ...
... Given the combined evidence outlined here (longer treatments may not improve outcomes [Linardon et al., 2016;Vall & Wade, 2015]; most change happens in the first eight to twelve sessions of treatment [Rose & Waller, 2017]; and early change is important in predicting outcomes [Bell et al., 2017;Chang et al., 2021;Rose & Waller, 2017]), alongside the imperative to use resources wisely, it is clearly important to evaluate the potential of shorter CBT-ED treatments. Indeed, NICE (2017) has recommended evaluating briefer treatments (<20 sessions) in order to determine whether a reduced number of sessions is as effective as longer treatment. ...
Article
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Objective: Treatment guidelines recommend that people with non-underweight eating disorders should receive up to 20 sessions of eating-disorder-focused cognitive behavioural therapy (CBT-ED). The present study reviewed ten studies of 10-session cognitive behavioural therapy for non-underweight patients (CBT-T). Method: We conducted a systematic review using four electronic databases and contacted researchers in the field for unpublished data. Random effects meta-analyses were conducted to pool within-group effect sizes. Results: From pre-treatment to post-treatment, medium to very large effect sizes were observed for eating disorder psychopathology, clinical impairment, depression, anxiety, and weekly frequencies of objective bingeing and vomiting. Furthermore, the effect of CBT-T appears to last after treatment with eating disorder psychopathology remaining below the norm for non-clinical females at follow-up. The dropout rate from CBT-T was 39%, and 65% of completers achieved a good outcome. Conclusions: While results should be interpreted as preliminary due to a number of limitations, the present study suggests that CBT-T is a promising treatment for people with non-underweight eating disorders, which can achieve a good outcome in half the time currently recommended in treatment guidelines. The present study, therefore, provides valuable justification for future randomised controlled trials directly comparing short and long forms of CBT�ED as well as examining who does best with which version.
... One unstudied predictor is early (or rapid) response. Early response has been defined as clinically meaningful improvement in symptoms within four weeks up to the first half of treatment (Linardon et al., 2016). First observed in CBT for depression, early response was strongly associated with better immediate and long-term treatment outcomes (Ilardi and Craighead, 1994;Tang et al., 2005). ...
... First observed in CBT for depression, early response was strongly associated with better immediate and long-term treatment outcomes (Ilardi and Craighead, 1994;Tang et al., 2005). The predictive utility of early response has been replicated for depression (Lewis et al., 2012;Lutz et al., 2009;Persons and Thomas, 2019), anxiety disorders (Beard and Delgadillo, 2019;Bradford et al., 2011), eating disorders (Linardon et al., 2016;Thompson-Brenner et al., 2015), obsessive-compulsive disorder (da Conceição Costa et al., 2013), and general outpatient problems (Nordberg et al., 2014;Rubel et al., 2015). Early stages of treatment appear critical to many patients' achieving and sustaining psychological treatment gains. ...
Article
Individuals with body dysmorphic disorder (BDD) suffer from distressing or impairing preoccupations with perceived imperfections in their appearance. This often-chronic condition is associated with significant functional impairment and elevated rates of psychiatric comorbidity and morbidity, including depression, substance use disorders, and suicidality. Cognitive behavioral therapy (CBT) for BDD has been shown to be efficacious. However, this intervention is long (up to 24 weeks) relative to many manualized approaches for other related conditions, there is a significant shortage of clinicians trained in CBT for BDD, and some patients drop out of treatment and/or do not respond. Thus, there is great interest in understanding and predicting who is most likely to respond, to better allocate clinical resources. This secondary data analysis of participants enrolled in prior uncontrolled and controlled studies of CBT for BDD explored whether early response to CBT, operationalized as percentage change in symptom severity within the first four weeks and the first 12 weeks of this 24-week treatment, predicts clinical outcomes for patients with BDD (n = 90). The findings indicated that minimal early symptom change was not indicative of eventual non-response. This suggests that patients and clinicians should not be discouraged by limited early improvement but should instead continue with a full course of treatment before reevaluating progress and alternative interventions. Overall, the results support the view that treatment success is more likely if a longer CBT protocol is followed. More work is needed to understand mechanisms of change and thus match optimal interventions to patient characteristics.
... Future research should aim to clarify individuals' perceptions of their ED behaviors as "normal" in an attempt to clarify these differential motivations to change compensatory behaviors. In sum, the lower precontemplation for BE and purging may suggest that individuals are more readily willing to change ED behaviors for which the personal incentive in doing so is greater, implicating the potential utility of targeting these behaviors early in treatment in favor of subsequent positive outcomes (Linardon et al., 2016). ...
... As might be expected, individuals with ANr reported the least aggregated contemplation to change. Given the importance of early behavior change in treatment (Linardon et al., 2016) and the well-documented tendency for individuals with AN to be less responsive to ED treatment (e.g., Strober, 2004), the use of publicly available decisional balance scales (e.g., Serpell et al., 2004) to weigh the benefits and consequences of change and navigate their ambivalence about change related to ED behaviors may be beneficial for individuals who have not yet engaged in treatment. Such a resource may be especially valuable given our finding that higher contemplation predicted lower pre-contemplation for fasting and driven exercise; that is, consistent with the TTM, once individuals begin considering the benefits of behavior change, their reluctance to recognize a problem decreases. ...
Article
We examined the naturalistic relations between motivation to change and change in four specific eating disorder (ED) beha- viors—binge eating (BE), purging, fasting, and driven exercise— in a community-based sample of individuals with EDs over two consecutive 6-week periods. We conducted cross-lagged general- ized estimating equations using the transtheoretical model’s four stages of change to predict changes in the ED behaviors 6 weeks later. Individuals reported lower pre-contemplation for behaviors typically associated with more distress (e.g., BE, purging) than they did for behaviors associated with less distress (e.g., fasting and driven exercise). Action predicted decreases in BE and pur- ging frequencies but not fasting or driven exercise frequencies. Naturalistic relations between ED behavior severity/frequency and motivation to change these features can be detected over 6-week intervals; that is, attempts at change in individuals’ natural environments can be successful over relatively brief periods of time, especially when individuals experience the motivation to change these features. The process of motivation to change ED behaviors is not linear, and our study highlights the movement between stages of change among individuals with EDs. Future research is needed to examine how much of the observed changes are sustained.
... A recent systematic review and meta-analysis identified early improvement in eating disorder symptoms as the most robust predictor of treatment outcome at both the end of treatment and at follow-up [28]. Early response with regards to weight gain has also been established as a marker of AN treatment in two recent systematic reviews and meta-analyses [29,30]. Early improvement in depression has been found to positively predict outcomes for patients with depressive disorders [31,32]. ...
... In the present study, early weight gain and reduction in eating disorder symptoms were not associated with a lower chance of re-hospitalization, as reported in previous investigations [28][29][30]. This discrepancy may be due to differences in definitions of outcome, in the length of follow-up, in population (adult vs. adolescent), in treatment setting (outpatient vs. inpatient), and in treatment modality. ...
Article
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Purpose: The aim of this study was to investigate the predictive value of early changes in depression levels during inpatient treatment of adolescent anorexia nervosa (AN). Methods: Fifty-six adolescents (88% girls) aged 10-18 years (M = 15.35, SD = 2.23) diagnosed with AN were assessed at admission and 1 month following admission to an inpatient setting. Depression levels and eating disorder symptoms were reported at both assessments. Re-hospitalization within 12 months of discharge was documented using official national records. Results: Whereas depression levels at baseline were found equivalent between subsequently re-hospitalized and non-re-hospitalized patients, at 1 month after admission patients who were later re-hospitalized had higher levels of depression compared to those who were not re-hospitalized. These differences remained significant after controlling for weight gain and anti-depressant medication intake. We additionally found that the proportion of boys in the non-re-hospitalized group was substantially larger than their proportion in the re-hospitalized group. Conclusions: Our results suggest that depression at the point of hospital admission may not be a reliable predictor of treatment outcomes, and highlight the risk of relapse in AN patients whose depression levels do not alleviate after a month of inpatient treatment. Clinicians should consider providing more adjusted and intensive attention to such patients in their efforts to facilitate remission. Level of evidence iii: Well-designed cohort study.
... Differences in how populations present and respond to treatment is understudied in the ED field (Cooper et al., 2016;Linardon, Brennan, & de la Piedad Garcia, 2016). Given the significant health disparities seen in SGMs (e.g., , which our findings have underscored, it is crucial to build upon recent data showing that EDs are especially prevalent among this population (Diemer et al., 2015;Kamody et al., 2019). ...
Article
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Eating disorders (EDs) occur at higher rates among sexual/gender minorities (SGMs). We currently know little about the risk factor profile of SGMs entering ED specialty care. Objective: To (a) compare history of abuse-related risk in SGMs to cisgender heterosexuals (CHs) when entering treatment, (b) determine if SGMs enter and exit treatment with more severe ED symptoms than CHs, and (c) determine if SGMs have different rates of improvement in ED symptoms during treatment compared to CHs. Method: We analyzed data from 2,818 individuals treated at a large, US-based, ED center, 471 (17%) of whom identified as SGM. Objective 1 was tested using logistic regression and Objectives 2 and 3 used mixed-effects models. Results: SGMs had higher prevalence of sexual abuse (OR = 2.10, 95% CI = 1.71, 2.58), other trauma (e.g., verbal/physical/emotional abuse; OR = 2.07, 95% CI = 1.68, 2.54), and bullying (OR = 2.13, 95% CI = 1.73, 2.62) histories. SGMs had higher global EDE-Q scores than CHs at admission (γ = 0.42, SE = 0.08, p < .001) but improved faster early in treatment (γ = 0.316, SE = 0.12, p = .008). By discharge, EDE-Q scores did not differ between SGMs and CHs. Discussion: Our main hypothesis of greater abuse histories among SGMs was supported and could be one explanation of their more severe ED symptoms at treatment admission compared to CHs. In addition, elevated symptom severity in SGMs at admission coincides with greater delay between ED onset and treatment initiation among SGMs-possibly a consequence of difficulties with ED recognition in SGMs by healthcare providers. We recommend increased training for providers on identifying EDs in SGMs to reduce barriers to early intervention.
... signment randomized trial (SMART) design (Nahum-Shani et al., 2012) to evaluate a proposed treatment model for patients with BED with coexisting obesity. The proposed adaptive treatment aims to benefit from reliable findings from RCTs showing that rapid response to treatments for eating disorders has robust prognostic significance (Linardon, Brennan, & de la Piedad Garcia, 2016). A series of studies found that rapid response to treatment, defined empirically (using receiver operating characteristic [ROC] curves) as 65% to 70% reductions in binge eating after 1 month of treatment predicted favorable outcomes for diverse treatments for BED Grilo, Masheb, & Wilson, 2006;Grilo, White, Masheb, & Gueorguieva, 2015;Grilo et al., 2012;. ...
Article
This randomized controlled trial (RCT) tested effectiveness of adaptive SMART stepped-care treatment to "standard" behavioral weight loss (BWL [standard]) for patients with binge-eating disorder (BED) and obesity. One hundred ninety-one patients were randomly assigned to 6 months of BWL (standard; n = 39) or stepped care (n = 152). Within stepped care, patients started with BWL for 1 month; treatment responders continued BWL, whereas nonresponders switched to cognitive-behavioral therapy (CBT), and patients receiving stepped care were additionally randomized to weight-loss medication or placebo (double-blind) for the remaining 5 months. Independent assessments were performed reliably at baseline, throughout treatment, and posttreatment. Intent-to-treat (ITT) analyses of remission rates (zero binges/month) revealed that BWL (standard) and stepped care did not differ (74.4% vs. 66.5%); within stepped care, remission rates ranged 40.0% to 83.3%, with medication significantly superior to placebo (overall) and among nonresponders switched to CBT. Mixed-models analyses of binge-eating frequency revealed significant time effects, but BWL (standard) and stepped care did not differ; within stepped care, medication was significantly superior to placebo and among nonresponders switched to CBT. Mixed models revealed significant weight loss, but BWL (standard; 5.1% weight-loss) and stepped care (5.8% weight-loss) did not differ; within stepped care (range = 0.4% to 8.8% weight-loss), medication was significantly superior to placebo and among both responders continued on BWL and nonresponders switched to CBT. In summary, BWL (standard) and adaptive stepped-care treatments produced robust improvements in binge eating and weight loss in patients with BED/obesity. Within adaptive stepped care, weight-loss medication enhanced outcomes for BED/obesity. Implications for clinical practice and future adaptive designs are offered. (PsycINFO Database Record
... It is possible that treatments for SAD may benefit from operating in a stepped-care model, where individuals who may not be showing rapid response to treatment are provided with higher levels of care (e.g., individual sessions, more intensive and/or alternate treatments). Within eating disorders treatment, it has been suggested that the research on rapid response be presented as part of the assessment and/or introduction to treatment as a means of increasing motivation for and prioritiziation of treatment (Linardon et al. 2016). Similarly, it may be helpful to assess initial motivation for treatment and ability to engage with treatment components prior to starting treatment to increase the likelihood of positive outcomes. ...
Article
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Cognitive behavioural therapy (CBT) for Social Anxiety Disorder (SAD) is an effective intervention for SAD, however, many individuals with SAD remain symptomatic at the end of CBT. Therefore, it is important to understand variables that influence patients’ responses to treatment. The present study investigated temporal changes in SAD symptoms as related to fear of negative evaluation (FNE) in a clinical sample of individuals with SAD who completed CBT. Participants with SAD (N = 175) completed self-report measures of SAD symptoms and FNE weekly across 12 weeks of group CBT. We used latent difference score dynamic modelling to explore the relationship between SAD symptom scores and FNE during CBT. Reductions in FNE were associated with subsequent reductions in SAD symptoms for individuals who showed a rapid response to treatment. The coupling of FNE and subsequent reductions in SAD symptoms was not seen in individuals not showing a rapid response. This study provides further support for the phenomenon of rapid response in CBT for SAD and suggests that mechanisms of change may be different for rapid responders as compared to non-rapid responders. The results of the current study may have implications for understanding the mechanisms underlying treatment response during CBT for SAD and for whom particular mechanisms are relevant.
... In many psychotherapies, rapid symptom reduction predicts final treatment response [26]. The preliminary results of IPT-BNm showed a more rapid response [25] compared to earlier studies of IPT-BN by Agras [8]. ...
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Background: Interpersonal psychotherapy (IPT) can be effective for both Bulimia Nervosa (BN) and co-occurring depression. While changes in symptoms of Eating disorder (ED) and depression have been found to correlate, it is unclear how they interact during treatment and in which order the symptoms decrease. Methods: Thirty-one patients with BN and depressive symptoms received IPT using the manual IPT-BNm in a naturalistic design. The outcome was measured with the Eating Disorder Examination Questionnaire (EDE-Q) and the Montgomery Åsberg Depression Rating Scale (MADRS-S). Symptom improvement at each session was measured with Repeated Evaluation of Eating Disorder Symptoms (REDS) and the Patient Health Questionnaire-9 (PHQ-9). Results: Significant improvements with large effect sizes were found on both ED symptoms and depression. The rates of change were linear for both BN and depression. A strong correlation between reduction of depressive symptoms and ED symptoms was found. Depressive symptom reduction at one session predicted improvement of ED symptoms at the next session. Conclusions: IPT-BNm had an effect on both BN and co-occurring depressive symptoms. The analyses indicated that reduction in depressive symptoms preceded reduction in bulimic symptoms.
... One way of optimising treatment efficacy is to augment current interventions in the early phases of treatment. This is based on evidence that rapid symptomatic improvement during the first few weeks of treatment is associated with favourable clinical outcomes at the end of treatment and/or follow-up in adolescents and adult patients (Linardon, Brennan and de la Piedad Garcia, 2016;Wales et al. 2016;Nazar et al. 2017). To date, there are no published reports on the efficacy of different treatment augmentation strategies in the early phase of adult anorexia nervosa treatment. ...
Article
Background Outpatient interventions for adult anorexia nervosa typically have a modest impact on weight and eating disorder symptomatology. This study examined whether adding a brief online intervention focused on enhancing motivation to change and the development of a recovery identity (RecoveryMANTRA) would improve outcomes in adults with anorexia nervosa. Methods Participants with anorexia nervosa ( n = 187) were recruited from 22 eating disorder outpatient services throughout the UK. They were randomised to receiving RecoveryMANTRA in addition to treatment as usual (TAU) ( n = 99; experimental group) or TAU only ( n = 88; control group). Outcomes were measured at end-of-intervention (6 weeks), 6 and 12 months. Results Adherence rates to RecoveryMANTRA were 83% for the online guidance sessions and 77% for the use of self-help materials (workbook and/or short video clips). Group differences in body mass index at 6 weeks (primary outcome) were not significant. Group differences in eating disorder symptoms, psychological wellbeing and work and social adjustment (at 6 weeks and at follow-up) were not significant, except for a trend-level greater reduction in anxiety at 6 weeks in the RecoveryMANTRA group ( p = 0.06). However, the RecoveryMANTRA group had significantly higher levels of confidence in own ability to change ( p = 0.02) and alliance with the therapist at the outpatient service ( p = 0.005) compared to the control group at 6 weeks. Conclusions Augmenting outpatient treatment for adult anorexia nervosa with a focus on recovery and motivation produced short-term reductions in anxiety and increased confidence to change and therapeutic alliance.
... Disturbances in the experience of the body are typically addressed within the psychological and behavioral elements of treatment. Empirically supported psychological interventions for individuals with AN include cognitive behavioral therapy (CBT), interpersonal therapy (IPT), and family-based treatment (FBT) for adolescents (Linardon et al., 2016;Lock & Le Grange, 2015;Watson & Bulik, 2013). In individuals with BN, the use of CBT, IPT, as well as Dialectic Behavioral Therapy (DBT), a mindfulness-based therapy focusing on emotion regulation and distress tolerance, has shown to be effective (Erford et al., 2013;McIntosh et al., 2011;Poulsen et al., 2014;Tanofsky-Kraff & Wilfley, 2010). ...
Article
Yoga and its relation to embodiment and disordered eating has only recently received research attention. Nevertheless, early research indicates that yoga is an effective tool in the prevention and treatment of eating disorders. It is assumed that yoga ameliorates eating disorder symptoms and facilitates a shift from negative towards positive body image and well-being by cultivating positive embodiment (i.e., the ability to feel a sense of connection between mind and body). In order to provide the context of the constructs of disordered eating, embodiment, and yoga, this article presents a brief overview and conceptualization of these constructs. The three major eating disorders and current treatment methods are described. Further, the philosophical roots and theoretical models of embodiment are delineated and their communal core features are outlined. Lastly, the origin, basic principles, and modern interpretations of yoga are discussed.
... Strengths include prospective measurement, and data from an intensive residential setting with high survey response and retention rates. Indeed, a recent meta-analysis of 34 treatment studies highlighted the prognostic value of rapid response, with early symptom change predicting improvement at endof-treatment and longitudinal follow-up (Linardon et al., 2016). Thus, our findings could be important for understanding the impact of SUD/BPD on ED treatment. ...
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Objective We examined whether eating disorder (ED) outcome trajectories during residential treatment differed for patients screening positive for comorbid borderline personality disorder (BPD) and/or substance use disorders (SUDs) than those who do not. Method We examined data from patients in a residential ED treatment program. Patients completed validated self‐report surveys to screen for SUDs and BPD on admission, and the ED Examination‐Questionnaire (EDE‐Q) on admission and every 2 weeks until discharge (N = 479 females). Results Fifty‐four percent screened positive for at least one co‐occurring condition. At admission, patients screening positive for SUD and/or BPD had significantly greater eating pathology than patients screening negative for both (t[477] = 8.23, p < .001). Patients screening positive for SUD (independent of BPD screening status) had a significantly faster rate of symptom improvement during the initial 4 weeks than patients screening positive for BPD only and those with no comorbidities. Discussion Screening positive for SUD and/or BPD was common in residential ED treatment, and associated with more severe ED symptoms. Screening positive for SUD was associated with faster ED symptom improvement than screening positive for BPD. These findings suggest that intensive ED treatment, even in the absence of intensive SUD treatment, may enhance patient outcomes for those with SUDs.
... One potential example of a process that might be a useful target for investigationis the early response to treatment, which has been found to be a robust marker of longer termoutcome (Nazar et al., 2017;Vall & Wade, 2015;Linardon, Brennan, & de la Piedad Garcia, 2016). However, the relative contributions of factors related to patient, to treatment or to other processes of early change are unknown. ...
Article
Aim The aim of this study was to use the innovative technique of Network Intervention Analysis (NIA) to examine the trajectory of symptom change associated with the use of a digital guided self‐help intervention (RecoveryMANTRA) to augment treatment as usual in adult anorexia nervosa. Methods Self‐reported eating disorder symptoms and mood (stress, anxiety and depression), work and social adjustment, motivation and treatment (Treatment as usual + RecoveryMANTRAand Treatment as usual) were included as nodes in the network and examined using NIA. Networks were computed at baseline (n = 88, 99), at end of treatment (6 weeks, n = 71, 75) and at 6‐ (n = 58, 63) and 12‐month (n = 52, 63) follow‐up. Results RecoveryMANTRA was associated with a direct effect on anxiety, shape concern and restraint at the end of the intervention. This effect was not maintained at follow‐up. There were no direct effects of RecoveryMANTRA on motivation, stress and depression. Conclusions These findings indicate that RecoveryMANTRA exerts a direct effect on eating disorder symptoms and anxiety. NIA is a promising method to evaluate trajectories of clinical change and direct and indirect effects of a therapeutic intervention compared to a control condition.
... CBT will last 12 weeks, and participants will complete computerized training (ICT or sham) on their home computers daily for the first 4 weeks of treatment (see Figure 1). We chose to deliver the ICT daily for 4 weeks in order to facilitate "rapid response," or a large decrease in disordered eating within the first 4 weeks, a known strong predictor of posttreatment response in BN and BED (Linardon, Brennan, & De la Piedad Garcia, 2016). We also chose 4 weeks because our pilot data demonstrated that gains in inhibitory control peak at approximately 4 weeks of training, and that compliance with daily training decreases after 4 weeks (Forman et al., 2019). ...
Article
Outcomes from cognitive behavioral therapy (CBT) for bulimia nervosa (BN) and binge‐eating disorder (BED) are suboptimal. One potential explanation is that CBT fails to adequately target inhibitory control (i.e., the ability to withhold an automatic response), which is a key maintenance factor for binge eating. Computerized inhibitory control training (ICT) is a promising method for improving inhibitory control but is relatively untested in BN/BED. The present study will evaluate a computer‐based ICT as an adjunct to CBT for BN/BED. Participants with BN (n = 30) or BED (n = 30) will be randomized to 12 weeks of either CBT + ICT or CBT + a sham training. Trainings will be completed daily for 4 weeks and weekly for 8 weeks. Primary aims include the following: (a) confirm target engagement (evaluate whether ICT improves inhibitory control), (b) test target validation (evaluate whether improvements in inhibitory control are associated with improvements in binge eating), and (c) evaluate the incremental efficacy of ICT on binge eating. Secondary aims include the following: (a) evaluate ICT feasibility and acceptability and (b) assess the moderating effects of approach tendencies on highly palatable food, dietary restraint, and diagnosis. Data will be used to shape a fully powered clinical trial designed to assess efficacy and dose–response effects of ICT for BN/BED.
... While, other authors have conceptualized this early treatment phase in a broader context of patients' re-moralization, generally characterized by an alleviation of hopelessness and the promotion of (subtle) optimistic expectations about the treatment and the development of the trust in the therapeutic relationship (e.g., Frank & Frank, 1991;Wampold & Imel, 2015). Research across a variety of disorders and orientations has found that early treatment response is predictive of posttreatment outcome (e.g., Delgadillo, McMillan, Lucock, Leach, Ali, & Gilbody, 2014;Linardon, Brennan, & de la Piedad, 2016;Lutz et al., 2014;Lutz, Stulz & Köck, 2009;Wucherpfennig, Rubel, Hofmann, & Lutz , 2017;Shalom et al., 2018;Nazar et al., 2017;Rubel, Lutz, & Schulte, 2015). Moreover, a recent meta-analysis found large effect size differences in posttreatment outcomes between patients who showed early treatment response and participants without early improvements (r = .40; ...
Article
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Objective: Even though the early alliance has been shown to robustly predict posttreatment outcomes, the question whether alliance leads to symptom reduction or symptom reduction leads to a better alliance remains unresolved. To better understand the relation between alliance and symptoms early in therapy, we meta-analyzed the lagged session-by-session within-patient effects of alliance and symptoms from Sessions 1 to 7. Method: We applied a 2-stage individual participant data meta-analytic approach. Based on the data sets of 17 primary studies from 9 countries that comprised 5,350 participants, we first calculated standardized session-by-session within-patient coefficients. Second, we meta-analyzed these coefficients by using random-effects models to calculate omnibus effects across the studies. Results: In line with previous meta-analyses, we found that early alliance predicted posttreatment outcome. We identified significant reciprocal within-patient effects between alliance and symptoms within the first 7 sessions. Cross-level interactions indicated that higher alliances and lower symptoms positively impacted the relation between alliance and symptoms in the subsequent session. Conclusion: The findings provide empirical evidence that in the early phase of therapy, symptoms and alliance were reciprocally related to one other, often resulting in a positive upward spiral of higher alliance/lower symptoms that predicted higher alliances/lower symptoms in the subsequent sessions. Two-stage individual participant data meta-analyses have the potential to move the field forward by generating and interlinking well-replicable process-based knowledge. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
... These ndings may indicate that the superior effect of CBT on the behavioral symptoms of EDs (e.g., dietary restriction, bingeing and purging) found in the present study may be conveyed through other mechanisms in the therapeutic process or be contingent on some patient factors. An important within-treatment factor predictive of good outcomes of therapy is early change in eating-disordered behavior and cognitions (47,48). Among patient factors, higher motivation for change, fewer depressive features, fewer comorbidities and better interpersonal functioning have previously been found to predict better treatment outcomes (46). ...
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Background: Cognitive behavior therapy (CBT) and psychodynamic-interpersonal therapies (PIT) are the most used outpatient treatments for eating disorders. Knowledge about the outcomes of these therapies in terms of remission is limited. Also, there is a lack of knowledge about how different therapeutic changes and patient characteristic affects outcomes. Method: Reports on the effects of CBT and PIT for eating disorders were searched. Rates of remission and changes in eating disorder specific and general psychopathology were computed and meta-analytically synthesized. Regression models were made to predict summary event rates by patient characteristics and changes in specific and general psychopathology. Results: Only CBT produced remission rates (34.2%) significantly different from waitlist conditions, and only CBT led to significantly greater change in specific psychopathology than waitlist/nutritional counseling conditions. However, CBT and PIT were equally effective in changing general psychopathology. For CBT, change in specific psychopathology predicted remission only when controlling for differences between diagnostic categories. Change in general psychopathology predicted remission only for PIT. The presence of comorbid personality disorder decreased the effect of CBT. Conclusions: A group of patients with eating disorders may require therapy aimed at strengthening deficits in self functions not easily ameliorable by cognitive behavioral techniques alone. However, although effective in changing specific and general psychopathology, PIT is not effective in producing behavioral change. Further research should be aimed at identifying treatment interventions that effectuate both behavioral change and strengthening self-functions to substitute eating-disordered behavior to meet psychological needs in the long-term.
... La importancia clínica de realizar un tamizaje de los trastornos alimentarios y de la ingestión de alimentos radica en que, muchas veces, los mismos no son detectados a tiempo, sino cuando los pacientes tienen ya disfunciones a nivel físico y mental por su causa. Un diagnóstico oportuno y precoz mejora el pronóstico, puesto que permite establecer a tiempo un tratamiento adecuado (17) . ...
... As with other disorders [61], early change has been proposed to be key to longer-term treatment outcome. There have been several meta-analyses demonstrating that early change is a key predictor (possibly the key predictor) of treatment outcome across eating disorders [62 && , 63,64]. Although these reviews have not been specific to CBT-ED, the papers that they review indicate very clearly that early change is critical in the outcome of eating disorders when using CBT-ED [62 && ]. ...
Article
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Purpose of review: This review summarizes recent developments in cognitive-behavioural therapy for eating disorders (CBT-ED). More specifically, the past five years were covered, with the latest UK and Dutch guidelines for eating disorders as a starting benchmark, and with special consideration of the past 18 months. Recent findings: The new research can be divided into findings that have: (1) reinforced our existing understanding of CBT-ED's models and impact; (2) advanced our understanding and the utility of CBT-ED, including its application for the 'new' disorder Avoidant/Restrictive Food Intake Disorder (ARFID); (3) suggested new directions, which require further exploration in clinical and research terms. These include learning from the circumstances of the COVID-19 pandemic. Summary: CBT-ED has developed substantially in the past 5 years, with consolidation of its existing evidence base, further support for real-life implementation, extension of methods used, and the development of new approaches for working with younger people - particularly in the form of treatments for ARFID. Over the past 18 months, even more promising changes in delivery occurred in response to the COVID19 pandemic, showing that we can adapt our methods in order to work effectively via remote means. Challenges remain regarding poor outcomes for anorexia nervosa.
... Previous research, not necessarily pertaining to PHP settings as mentioned above, has identified numerous baseline variables that predict outcomes and mediators that help explain favorable treatment response, including: higher body mass index (BMI), fewer binge/purge episodes, increased motivation to recover, lower shape/weight concern, fewer comorbidities, and better interpersonal functioning (Vall and Wade, 2015;Linardon et al., 2016). Several studies have also evaluated whether age is a predictor of outcome, with inconsistent results. ...
Article
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Partial hospitalization programming (PHP) is a treatment option available for individuals with eating disorders (ED) who have made insufficient progress in outpatient settings or are behaviorally or medically unstable. Research demonstrates that this level of care yields efficacy for the majority of patients. However, not all patients achieve recovery in PHP and later admit to a higher level of care (HLOC) including residential treatment or inpatient hospitalization. Although PHP is an increasingly common treatment choice for ED, research concerning outcome predictors in outpatient, stepped levels of care remains limited. Thus, the current study sought to identify the predictors of patients first admitted to PHP that later enter residential or inpatient treatment. Participants were 788 patients (after exclusions) enrolled in adolescent or adult partial hospitalization programs in a specialized ED clinic. When compared to patients who maintained treatment in PHP, a significantly greater proportion of patients who discharged to a HLOC had previously received ED residential treatment. Moreover, patients who discharged to a HLOC were diagnosed with a comorbid anxiety disorder and reported greater anxious and depressive symptomatology. A logistic regression model predicting discharge from PHP to a HLOC was significant, and lower body mass index (BMI) was a significant predictor of necessitating a HLOC. Supplemental programming in partial hospitalization settings might benefit individuals with previous ED residential treatment experience, higher levels of anxiety and depression, and lower BMIs. Specialized intervention for these cases is both practically and economically advantageous, as it might reduce the risk of rehospitalization and at-risk patients needing to step up to a HLOC.
... 4 On the other hand, patients who achieve an early reduction of symptoms are more likely to also achieve remission, 5,6 and rapid response to treatment is associated with better outcomes. 7 Not receiving adequate treatment (or any kind of treatment at all) can cause chronification and far-reaching consequences for both the patient and the health care system. ...
Article
Background Eating disorders are causing severe consequences for those affected as well as a high burden for their carers. Although there is a substantial need for psychological assistance, different factors are hindering access to support. Internet-based interventions can help to overcome these barriers. To date, there is only little knowledge on attitudes of potential users, facilitators (e.g. psychologists) and decision makers (e.g. health insurances) regarding these interventions. Methods We conducted focus groups with potential users (N = 30) and semi-structured interviews with potential decision makers (N = 4). Potential facilitators (N = 41) participated in an online survey. Stakeholders’ experiences, attitudes, and their needs regarding Internet-based interventions for eating disorder patients and carers were assessed. Furthermore, hindering and fostering factors related to reach, adoption, implementation and maintenance were analyzed. Results About two-thirds of the participating facilitators have heard or read about Internet-based interventions in general. In contrast, the other stakeholders mentioned to have no or little experience with such interventions. Factors like anonymity, availability and cost-effectiveness were seen as major advantages. Also disadvantages, e.g. lack of personal contact, limitations by disease severity and concerns on data safety, were mentioned. Stakeholders stated the need for interventions which are usable, evidence-based, tailored and provide personal support. Conclusion Stakeholders considered Internet-based programmes to have more advantages than disadvantages. Effort should be put in providing systematic education to address prejudices. When offering an online intervention, stakeholders’ needs, as well as a continuous evaluation and adaptation, have to be taken into account.
... Some patients may experience significant ambivalence towards the prospect of change due to the ego-syntonic nature of the eating-disordered symptoms [54,55] In patients where the sense of self is pervasively impaired (i.e., where there is significant lack of self-cohesion, and doubt in self-worth and self-efficacy), or the self is wholly dependent upon the over-evaluation of shape and weight [19], the working alliance to change behavioral aspects of the disorders in therapy may be lacking [56]. Because early change in eating-disordered behavior and cognitions [57,58] is an important predictor of a favorable outcome of CBT, this could imply that some patients would at baseline be less likely to benefit from treatment than others. ...
Article
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Background: Cognitive behavior therapy (CBT) and psychodynamic-interpersonal therapies (PIT) are two widely used and conceptually different outpatient treatments for eating disorders (EDs). To better understand how these treatments works, for whom, and under what circumstances, there is a need for knowledge about how outcomes are affected by diagnosis, comorbidity, changes in psychopathology, and study design. Method: Reports on the effects of CBT and PIT for eating disorders were searched. Rates of remission and changes in ED specific- and general psychopathology were computed. Regression models were made to predict event rates by changes in specific- and general psychopathology, as well as ED diagnosis and study design. Results: The remission rate of CBT for binge eating disorder was 50%, significantly higher than the effect for other diagnostic groups (anorexia = 33%, bulimia: 28%, mixed samples 30%). The number of studies found for PIT was limited. All effect sizes differed from zero (binge eating disorder = 27%, anorexia = 24%, bulimia = 18%, mixed samples = 15%), but the precision of the estimates was low, with some lower-bound confidence intervals close to zero. For CBT, change in ED specific psychopathology predicted remission only when controlling for ED diagnosis, while change in general psychopathology did not predict remission at all. The predictive value of change in psychopathology for PIT, and the potential impact of comorbid personality disorders could not be analyzed due to a lack of studies. There was no difference in effects between randomized controlled trials and observational studies. Conclusions: CBT showed consistent remission rates for all EDs but left a substantial number of patients not in remission. Extant evidence suggest that PIT is not consistently effective in achieving remission for patients with EDs, although this finding is uncertain due to a small number of eligible studies. A group of patients with eating disorders may, however, require therapy aimed at strengthening deficits in self functions not easily ameliorable by cognitive behavioral techniques alone. Further research should be aimed at identifying treatment interventions that helps patients change behavior, while strengthening self-functions to substitute eating-disordered behavior in the long-term.
... La importancia clínica de realizar un tamizaje de los trastornos alimentarios y de la ingestión de alimentos radica en que, muchas veces, los mismos no son detectados a tiempo, sino cuando los pacientes tienen ya disfunciones a nivel físico y mental por su causa. Un diagnóstico oportuno y precoz mejora el pronóstico, puesto que permite establecer a tiempo un tratamiento adecuado (17) . ...
Article
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Introducción: los trastornos alimentarios y de la ingestión de alimentos están asociados con importantes efectos físicos y morbilidad psicosocial, así como con un impacto negativo en la calidad de vida de las personas. Objetivo: determinar la proporción de pacientes con riesgo de padecer algún trastorno alimentario y de la ingestión de alimentos en población general paraguaya. Metodología: estudio observacional, descriptivo de asociación cruzada, de corte transversal y temporalmente prospectivo. Una encuesta en línea fue difundida a nivel nacional a través de redes sociales (Facebook, Twitter, Instagram) y aplicaciones de mensajería (Whatsapp, Telegram). Se recabaron datos sociodemográficos y los participantes respondieron la Eating Disorder Examination Questionnaire (S-EDE-Q), en búsqueda de trastornos alimentarios. Se utilizó estadística descriptiva para todas las variables. Para buscar asociaciones se utilizaron la prueba t de Student y ANOVA, según sea apropiado. Para cuantificar los riesgos se utilizó Odds ratio. Resultados: participaron 375 personas, de las cuales el 70,9 % era del sexo femenino, con edad media de 31 ± 9 años. Se obtuvo una media de 2,09 ± 1,5 puntos en la Eating Disorder Examination Questionnaire (S-EDE-Q) y se encontró que 51 participantes tenían indicios de padecer algún tipo de trastorno alimentario. Conclusión: el 13,6 % de los participantes de esta investigación tiene indicios de padecer algún tipo de trastorno alimentario, las mujeres tienen 2,4 veces más chances de padecer un trastorno y existen una serie de factores que están asociados a un mayor riesgo en el desarrollo de algún tipo de trastorno alimentario.
... La importancia clínica de realizar un tamizaje de los trastornos alimentarios y de la ingestión de alimentos radica en que, muchas veces, los mismos no son detectados a tiempo, sino cuando los pacientes tienen ya disfunciones a nivel físico y mental por su causa. Un diagnóstico oportuno y precoz mejora el pronóstico, puesto que permite establecer a tiempo un tratamiento adecuado (17) . ...
Article
Full-text available
Introducción: los trastornos alimentarios y de la ingestión de alimentos están asociados con importantes efectos físicos y morbilidad psicosocial, así como con un impacto negativo en la calidad de vida de las personas. Objetivo: determinar la proporción de pacientes con riesgo de padecer algún trastorno alimentario y de la ingestión de alimentos en población general paraguaya. Metodología: estudio observacional, descriptivo de asociación cruzada, de corte transversal y temporalmente prospectivo. Una encuesta en línea fue difundida a nivel nacional a través de redes sociales (Facebook, Twitter, Instagram) y aplicaciones de mensajería (Whatsapp, Telegram). Se recabaron datos sociodemográficos y los participantes respondieron la Eating Disorder Examination Questionnaire (S-EDE-Q), en búsqueda de trastornos alimentarios. Se utilizó estadística descriptiva para todas las variables. Para buscar asociaciones se utilizaron la prueba t de Student y ANOVA, según sea apropiado. Para cuantificar los riesgos se utilizó Odds ratio. Resultados: participaron 375 personas, de las cuales el 70,9 % era del sexo femenino, con edad media de 31 ± 9 años. Se obtuvo una media de 2,09 ± 1,5 puntos en la Eating Disorder Examination Questionnaire (S-EDE-Q) y se encontró que 51 participantes tenían indicios de padecer algún tipo de trastorno alimentario. Conclusión: el 13,6 % de los participantes de esta investigación tiene indicios de padecer algún tipo de trastorno alimentario, las mujeres tienen 2,4 veces más chances de padecer un trastorno y existen una serie de factores que están asociados a un mayor riesgo en el desarrollo de algún tipo de trastorno alimentario.
... Gradual Response was identified as the reference class. Three predictors were selected, informed primarily by prior research on early rapid response as a predictor of outcome (Linardon, Brennan, & de la Piedad Garcia, 2016;MacDonald, Trottier, McFarlane, & Olmsted, 2015): baseline severity on the PMED (T 0 ), percent change between T 0 and T 1 , and slope of change from T 0 to T 1 . The logistic model was also run with all 80 SVM features to ensure that observed differences in model performance were not solely attributable to differences in predictors included. ...
Article
Objective Patterns of response to eating disorder (ED) treatment are heterogeneous. Advance knowledge of a patient's expected course may inform precision medicine for ED treatment. This study explored the feasibility of applying machine learning to generate personalized predictions of symptom trajectories among patients receiving treatment for EDs, and compared model performance to a simpler logistic regression prediction model. Method Participants were adolescent girls and adult women (N = 333) presenting for residential ED treatment. Self‐report progress assessments were completed at admission, discharge, and weekly throughout treatment. Latent growth mixture modeling previously identified three latent treatment response trajectories (Rapid Response, Gradual Response, and Low‐Symptom Static Response) and assigned a trajectory type to each patient. Machine learning models (support vector, k‐nearest neighbors) and logistic regression were applied to these data to predict a patient's response trajectory using data from the first 2 weeks of treatment. Results The best‐performing machine learning model (evaluated via area under the receiver operating characteristics curve [AUC]) was the radial‐kernel support vector machine (AUCRADIAL = 0.94). However, the more computationally‐intensive machine learning models did not improve predictive power beyond that achieved by logistic regression (AUCLOGIT = 0.93). Logistic regression significantly improved upon chance prediction (MAUC[NULL] = 0.50, SD = .01; p <.001). Discussion Prediction of ED treatment response trajectories is feasible and achieves excellent performance, however, machine learning added little benefit. We discuss the need to explore how advance knowledge of expected trajectories may be used to plan treatment and deliver individualized interventions to maximize treatment effects.
... Research has also tested treatment parameters (Thompson-Brenner et al., 2013) and processes such as rapid response to treatment (⩾65% reduction in binge-eating episodes within the first month of treatment; Grilo, White, Masheb, & Gueorguieva, 2015). To date, however, no reliable predictors of BED outcome (other than rapid response) have been identified (Linardon, Brennan, & de la Piedad Garcia, 2016;Vall & Wade, 2015). One potential reason for the limited ability to predict treatment outcomesa problem across many fields, not just eating disorderscould be due to reliance on traditional statistical techniques, such as linear/logistic regression. ...
Article
Background While effective treatments exist for binge-eating disorder (BED), prediction of treatment outcomes has proven difficult, and few reliable predictors have been identified. Machine learning is a promising method for improving the accuracy of difficult-to-predict outcomes. We compared the accuracy of traditional and machine-learning approaches for predicting BED treatment outcomes. Methods Participants were 191 adults with BED in a randomized controlled trial testing 6-month behavioral and stepped-care treatments. Outcomes, determined by independent assessors, were binge-eating (% reduction, abstinence), eating-disorder psychopathology, and weight loss (% loss, ⩾5% loss). Predictors included treatment condition, demographic information, and baseline clinical characteristics. Traditional models were logistic/linear regressions. Machine-learning models were elastic net regressions and random forests. Predictive accuracy was indicated by the area under receiver operator characteristic curve (AUC), root mean square error (RMSE), and R ² . Confidence intervals were used to compare accuracy across models. Results Across outcomes, AUC ranged from very poor to fair (0.49–0.73) for logistic regressions, elastic nets, and random forests, with few significant differences across model types. RMSE was significantly lower for elastic nets and random forests v. linear regressions but R ² values were low (0.01–0.23). Conclusions Different analytic approaches revealed some predictors of key treatment outcomes, but accuracy was limited. Machine-learning models with unbiased resampling methods provided a minimal advantage over traditional models in predictive accuracy for treatment outcomes.
Article
Objective Early response, as indicated by early weight gain, in family‐based treatment (FBT) for adolescent anorexia nervosa (AN) predicts remission at end of treatment. However, little is known about what factors contribute to early response. Further, no previous studies have examined early response to separated forms of FBT. Method Data from a randomised clinical trial of conjoint FBT and separated FBT (parent‐focused treatment, PFT) were analysed to examine the timing and amount of early weight gain that predicted remission and identify factors associated with early response. Results Weight gain of at least 2.80 kg in FBT (N = 55) and 2.28 kg in PFT (N = 51), by Session 5, were the best predictors of remission at end of treatment. Early response in FBT was predicted by greater paternal therapeutic alliance and lower paternal criticism. Early response in PFT was predicted by less severe eating‐disorder symptoms and negative affect at baseline, lower maternal criticism, and greater adolescent therapeutic alliance. Conclusions The results confirm that early weight gain is an important prognostic indicator in both conjoint FBT and PFT and suggest that addressing negative emotion, parental criticism, and therapeutic alliance early in treatment could improve remission rates.
Article
Objective: Early decrease in symptoms is a consistent predictor of good treatment outcome across all eating disorders. The current study explored the predictive value of novel early change variables in a transdiagnostic, non-underweight sample receiving 10-session cognitive behavioural therapy. Method: Participants who reported bingeing and/or purging in the week preceding baseline assessment (N = 62) were included in analyses. Early change variables were calculated for novel (body image flexibility, body image avoidance, body checking, and fear of compassion) and established predictors (behavioural symptoms and therapeutic alliance). Outcomes were global eating disorder psychopathology and clinical impairment at posttreatment and three-month follow-up. Intent-to-treat analyses were conducted using linear regression, adjusting for baseline values of the relevant outcome and early change in behavioural symptoms. Results: Early improvement in body image flexibility was the most consistent predictor of good outcome. Early change in body image avoidance and the fear of expressing and receiving compassion to/from others were significant predictors in some analyses. Discussion: Novel early change variables were significant predictors of eating disorder outcomes in this exploratory study. Model testing is required to understand the exact mechanisms by which these variables impact on outcomes, and whether there is potential benefit of modifying existing protocols. Anzctr trial number: ACTRN12615001098527.
Article
The Inflexible Eating Questionnaire (IEQ) is a recently developed measure that assesses an individual's inflexible adherence to rigid eating rules, along with the tendency to respectively feel empowered or distressed when such rules are or are not followed. At present, evidence supporting the unidimensional structure and psychometric properties of the IEQ is limited to one specific sample of Portuguese adults. Establishing whether the IEQ is a valid and reliable measure in a different sample and by an independent research team is needed. We sought to examine the factor structure and psychometric properties of the IEQ in large sample (n = 1000) of Australian female adults. A unidimensional structure was replicated and evidence of internal consistency (α = .89) was found. IEQ scores were significantly and moderately correlated with various eating restraint measures and intuitive eating, providing evidence of convergent validity. IEQ scores also predicted incremental variance in global eating disorder symptomatology and psychosocial impairment after controlling for intuitive eating, flexible control, and rigid dietary control. Present findings offer further support for the validity and reliability of the IEQ in a non-clinical sample of women. A brief measure that assesses the inflexible adherence to eating rules may be valuable for validating current models of eating disorder psychopathology. Furthermore, incorporating the IEQ into the assessment of future randomized trials of eating disorder prevention or treatment programs may be beneficial for elucidating these interventions mechanisms of change.
Article
Objective This virtual issue of the International Journal of Eating Disorders highlights recently published research that aligns with the broad themes of the 2019 International Conference on Eating Disorders (ICED), held in New York, NY, USA. Methods and results We selected articles that were published between 2017 and 2019 that complement the content of the keynote and plenary sessions. We also curated additional articles from early career scholars, given that an important component of the annual ICED is to foster the development and training of the next generation of eating‐disorder clinicians and researchers. Discussion We hope that this virtual issue will spark more in‐depth discussion and reflection on the topics, questions, and critical advances in the field of eating disorders that were presented at the 2019 ICED.
Article
Background Empirically validated digital interventions for recurrent binge eating typically target numerous hypothesized change mechanisms via the delivery of different modules, skills, and techniques. Emerging evidence suggests that interventions designed to target and isolate one key change mechanism may also produce meaningful change in core symptoms. Although both ‘broad’ and ‘focused’ digital programs have demonstrated efficacy, no study has performed a direct, head-to-head comparison of the two approaches. We addressed this through a randomized non-inferiority trial. Method Participants with recurrent binge eating were randomly assigned to a broad ( n = 199) or focused digital intervention ( n = 199), or a waitlist ( n = 202). The broad program targeted dietary restraint, mood intolerance, and body image disturbances, while the focused program exclusively targeted dietary restraint. Primary outcomes were eating disorder psychopathology and binge eating frequency. Results In intention-to-treat analyses, both intervention groups reported greater improvements in primary and secondary outcomes than the waitlist, which were sustained at an 8-week follow-up. The focused intervention was not inferior to the broad intervention on all but one outcome, but was associated with higher rates of attrition and non-compliance. Conclusion Focused digital interventions that are designed to target one key change mechanism may produce comparable symptom improvements to broader digital interventions, but appear to be associated with lower engagement.
Article
This study evaluated the effects of two treatments for adolescent bulimia nervosa (BN), family‐based treatment (FBT‐BN), and cognitive behavioral therapy (CBT‐A), on both attitudinal and behavioural outcomes at end‐of‐treatment. These associations were examined specifically relative to motivation for change in obsessive–compulsive (OC) features of eating disorder (ED) symptoms. Adolescents (N = 110) were randomly assigned to FBT‐BN or CBT‐A and completed assessments of eating pathology and OC‐ED behaviour. Across both treatments, greater motivation for change in OC‐ED behaviour was associated with improved attitudinal features of ED at end‐of‐treatment. Motivation for change did not demonstrate a direct or interaction effect on BN behavioural outcomes. Results suggest that adolescents with BN who are more motivated to change OC‐ED behaviours at the start of treatment, FBT‐BN or CBT‐A, are more likely to demonstrate improvements in cognitions, but not behaviours associated with EDs, at treatment conclusion.
Chapter
The term “eating disorders” (EDs) broadly refers to psychiatric disorders marked by maladaptive eating patterns and attitudes about eating, body shape, and body weight. The four ED diagnoses described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) include anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), and “other specified feeding or eating disorder” (OSFED; American Psychiatric Association, 2013).
Article
Objective Increasing evidence suggests that mindfulness‐ and acceptance‐based psychotherapies (MABTs) for bulimia nervosa (BN) and binge eating disorder (BED) may be efficacious; however, little is known about their active treatment components or for whom they may be most effective. Methods We systematically identified clinical trials testing MABTs for BN or BED through PsychINFO and Google Scholar. Publications were categorized according to analyses of mechanisms of action and moderators of treatment outcome. Results Thirty‐nine publications met inclusion criteria. Twenty‐seven included analyses of therapeutic mechanisms, and five examined moderators of treatment outcome. Changes were largely consistent with hypothesized mechanisms of MABTs, but substandard mediation analyses, inconsistent measurement tools, and infrequent use of mid‐treatment assessment points limited our ability to make strong inferences. Discussion Analyses of mechanisms of action and moderators of outcome in MABTs for BN and BED appear promising, but the use of more sophisticated statistical analyses and adequate replication is necessary.
Article
PurposeUp to 44% of individuals with bulimia nervosa (BN) experience worsening of symptoms after cognitive behavior therapy (CBT). Identifying risk for post-treatment worsening of symptoms using latent trajectories of change in eating disorder (ED) symptoms during treatment could allow for personalization of treatment to improve long-term outcomesMethods Participants (N = 56) with BN-spectrum EDs received 16 sessions of CBT and completed digital self-monitoring of eating episodes and ED behaviors. The Eating Disorder Examination was used to measured ED symptoms at post-treatment and 3-month follow-up. Latent growth mixture modeling of digital self-monitoring data identified latent growth classes. Kruskal–Wallis H tests examined effect of trajectory of change in ED symptoms on post-treatment to follow-up symptom change.ResultsMulti-class models of change in binge eating, compensatory behaviors, and regular eating improved fit over one-class models. Individuals with high frequency-rapid response in binge eating (H(1) = 10.68, p =0 .001, η2 = 0.24) had greater recurrence of compensatory behaviors compared to individuals with low frequency-static response. Individuals with static change in regular eating exhibited greater recurrence of binge eating than individuals with moderate response (H(1) = 8.99, p = 0.003, η2 = 0.20).Conclusion Trajectories of change in ED symptoms predict post-treatment worsening of symptoms. Personalized treatment approaches should be evaluated among individuals at risk of poor long-term outcomes.Level of evidenceIV, evidence obtained from multiple time series.Trial registrationClinicalTrials.gov registration number NCT03673540, registration date: September 17, 2018.
Article
Objective: We previously demonstrated that early improvements in access to emotion regulation strategies during the first 4 weeks of intensive cognitive behavior therapy (CBT)-based eating disorder (ED) treatment predicted a range of post-treatment outcomes. This follow-up article examines whether early improvements in access to emotion regulation strategies continue to predict good treatment outcomes at 6 months post-treatment. Method: Participants were 76 patients with bulimia nervosa or purging disorder who participated in the original study and the 6-month follow-up assessment. Hierarchical regression models were used to examine whether early improvements in emotion regulation strategies predicted 6-month follow-up outcomes. Results: After controlling relevant covariates and rapid and substantial behavior change, greater early improvements in access to emotion regulation strategies during the first 4 weeks of intensive treatment predicted lower overall ED psychopathology and ED-related functional impairment 6 months after treatment. They did not predict abstinence from binge, vomit, and laxative use behaviors during the follow-up period. Discussion: Individuals who learn early in treatment that they can use skills to more effectively regulate emotions have better treatment outcomes on some variables 6 months after treatment. Teaching emotion regulation skills in the first phase of CBT for ED may be beneficial, particularly for individuals with baseline difficulties.
Article
Objective: The aim of this study was to determine whether posttraumatic stress disorder (PTSD) predicts non-completion of CBT-based day hospital treatment for bulimia nervosa (BN) and other specified feeding and eating disorder (OSFED). Method: Participants were 151 day hospital patients with BN or OSFED. Participants were assessed at pretreatment via interview and self-report measures. Cox regression was used to model the rate and timing of treatment termination; pretreatment binge and vomit frequencies, eating disorder-related clinical impairment, depression, and ED psychopathology were entered as covariates. Results: Participants who screened positive for PTSD (n = 64) had more severe ED psychopathology, ED-related impairment, negative schemas, and depression relative to those who did not screen positive. Cox regression indicated that PTSD significantly predicted premature termination and was associated with a 2.32 times greater risk. Individuals with BN or OSFED and co-occurring PTSD were particularly likely to terminate in the early phase of treatment compared with later in treatment. Conclusion: PTSD appears to affect some individuals' ability to complete intensive ED treatment. Future research should examine whether PTSD predicts premature termination from less intensive ED treatments, as well as in other intensive treatment settings, and whether PTSD predicts poorer outcomes from ED treatment.
Article
Objective: To critically appraise papers reporting on moderators and mediators of recommended psychological treatments for anorexia nervosa (AN) and bulimia nervosa (BN) in adolescents. Method: A systematic search of databases was conducted including PsycINFO, Embase, MEDLINE, AMED, CINAHL, and the Cochrane Library. Studies were included where a randomized controlled trial (RCT) compared therapies for AN or BN and reported on moderators or mediators of treatment effect. Twenty-one eligible papers were included, all based on data from eight RCTs. Results: Family therapies were dominant in the literature. Individual or separated treatment appeared superior for families with more difficult relationships, whereas conjoint family treatment appeared to be superior where good family relationships were reported. Where there was greater eating disorder psychopathology in AN, including eating disorder-related obsessions and compulsions, the response was better to a family approach than to individual therapies. There was some evidence that a family treatment was superior for those engaging in purging behaviors in BN. Measures of family relationships, parental self-efficacy, and early change emerged as possible mediators; however, the quality of evidence was mixed and the findings, in some cases, arguably circular. Moderator and mediator analyses were underpowered in all studies, with multiple, and post-hoc, analyses being run, and a broad range of outcome measures used. Discussion: This review recommends that emerging findings are explored further in adequately powered trials of the different recommended therapies, with a move toward focusing on effect sizes. A consensus on acceptable definitions of outcome, including remission and recovery, would benefit future research.
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Menschen mit der Diagnose einer Binge-Eating-Störung (BES) leiden unter regelmäßig auftretenden Essanfällen. Charakteristisch für einen Essanfall ist, dass die Betroffenen in einem begrenzten Zeitraum (z. B. innerhalb von zwei Stunden) eine erheblich größere Nahrungsmenge zu sich nehmen als die meisten Menschen unter vergleichbaren Umständen (American Psychiatric Association, APA 2013). Um zu entscheiden, ob es sich in einem konkreten Fall um einen Essanfall handelt oder nicht, wird empfohlen, den Kontext heranzuziehen, innerhalb dessen gegessen wird. So essen die meisten Menschen beispielsweise bei einem festlichen Büffet in der Regel deutlich mehr als bei üblichen Mahlzeiten. Demnach kann die gegessene Nahrungsmenge nach den DSM-5-Kriterien in einem Kontext als objektiv große Nahrungsmenge zu werten sein (z. B. bei einer gewöhnlichen Mahlzeit), während dies in einem anderen Kontext nicht gilt (z. B. bei einem festlichen Büffet).
Article
Background Impulsivity may be a process underlying binge-eating disorder (BED) psychopathology and its treatment. This study examined change in impulsivity during cognitive-behavioral therapy (CBT) and/or pharmacological treatment for BED and associations with treatment outcomes. Methods In total, 108 patients with BED ( N FEMALE = 84) in a randomized placebo-controlled clinical trial evaluating the efficacy of CBT and/or fluoxetine were assessed before treatment, monthly throughout treatment, at post-treatment (16 weeks), and at 12-month follow-up after completing treatment. Patients completed established measures of impulsivity, eating-disorder psychopathology, and depression, and were measured for height and weight [to calculate body mass index (BMI)] during repeated assessments by trained/monitored doctoral research-clinicians. Mixed-effects models using all available data examined changes in impulsivity and the association of rapid and overall changes in impulsivity on treatment outcomes. Exploratory analyses examined whether baseline impulsivity predicted/moderated outcomes. Results Impulsivity declined significantly throughout treatment and follow-up across treatment groups. Rapid change in impulsivity and overall change in impulsivity during treatment were significantly associated with reductions in eating-disorder psychopathology, depression scores, and BMI during treatment and at post-treatment. Overall change in impulsivity during treatment was associated with subsequent reductions in depression scores at 12-month follow-up. Baseline impulsivity did not moderate/predict eating-disorder outcomes or BMI but did predict change in depression scores. Conclusions Rapid and overall reductions in impulsivity during treatment were associated with improvements in specific eating-disorder psychopathology and associated general outcomes. These effects were found for both CBT and pharmacological treatment for BED. Change in impulsivity may be an important process prospectively related to treatment outcome.
Article
Obesity is often associated with mental comorbidity in adults, likely impacting on weight loss success and can indicate treatment that is not covered by the standard program of multimodal behavioral weight loss (BWL) treatment. Using the example of binge-eating disorder (BED) as a frequent comorbid condition, this article discusses current research on the etiology and interventions in cases of comorbidity in order to derive implications for research and treatment. Cognitive-behavioral therapy (CBT), the best established form of treatment for adults with BED, was more efficacious than BWL treatment in improving binge-eating symptomatology, while tending to show lower weight loss effects and only in the short term. Therefore, further development of interventions should focus on gradual adaptations of CBT for improving weight loss in patients with obesity and BED. These interventions could be adapted from BWL treatment and aim at a slight weight loss. Parallel or sequential combinations of these treatments have not consistently demonstrated improved treatment effects. Interventions based on the results of current research on the comorbidity of both disorders could be included on an individual basis in order to enhance the efficacy for eating disorder symptomatology and body weight. New digital treatment modalities could support the transfer into daily life and boost the long-term sustainability of therapeutic gains. These modifications regarding adaptive CBT for adults with obesity and BED should be based on an individual treatment rationale and require confirmation by further experimental treatment research.
Article
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La psicoterapia es un recurso efectivo y eficaz, pero no lo es para todas las personas. Uno de los problemas clínicos con el que nos encontramos en este campo es la terminación prematura por parte del paciente sin acuerdo con el psicoterapeuta. El problema mencionado deriva en dos problemas, uno conceptual y otro operacional, existiendo distintas definiciones del término como así diferentes maneras de medirlo. El objetivo general de este trabajo es realizar una revisión no sistemática sobre el tema, teniendo como ejes las distintas maneras en que se ha definido el concepto, las diversas formas de medirla, los resultados de meta-análisis realizados sobre la temática y las variables que pueden modularla.
Article
Objective Rapid response to treatment, indicated by substantial decreases in eating‐disorder (ED) symptoms within the first 4–6 weeks of treatment, is the most reliable predictor of treatment outcomes for EDs. However, there is limited research evaluating short‐term longitudinal trajectories of ED symptoms during treatment. Thus, it is difficult to know which aspects of ED psychopathology are slow or fast to change. The purpose of this study was to elucidate three‐month trajectories of ED psychopathology during treatment and test whether ED diagnosis influenced the direction and rate of change. Method Participants were Recovery Record users seeking treatment for an ED (N = 4,568; 86.8% female). Participants completed the Eating Pathology Symptoms Inventory once per month for 3 months. Results Latent growth curve models indicated that ED diagnosis influenced the rate of ED behavior change. Anorexia nervosa was associated with faster reductions in cognitive restraint, excessive exercise, restricting, yet slower reductions in body dissatisfaction, and binge eating. Bulimia nervosa was associated with faster reductions in binge eating, cognitive restraint, excessive exercise, and purging. Binge‐eating disorder was associated with faster reductions in body dissatisfaction and binge eating, yet slower reductions in restricting. Conclusions Our results have implications for future research by providing initial information about the direction and rate of ED change over the course of treatment. If clinicians and researchers know which ED symptoms are slow to change, on average, across diagnostic groups, treatment protocols could be adjusted to target slow changing symptoms more quickly, and therefore improve ED treatment outcomes.
Article
The efficacy of individual CBT for eating disorders can be assessed by investigating the potential predictors, mediators, and moderators of treatment. The present review focused on personality since its crucial role has been emphasized both by research and practice. Sixteen studies were collected, and data were extracted through a highly operationalized coding system. Overall, personality disorders were the most investigated construct; however, their influence was somewhat contradictory. A more cogent result occurred for Borderline Personality Disorder (BPD) when considered as a moderator (not a predictor, nor a mediator). Patients with a more disturbed borderline personality benefited to a greater extent from treatments including booster modules on affects, interpersonal relationships, and mood intolerance, rather than symptoms exclusively. Nine additional personality dimensions, beyond BPD, were investigated sparsely, and results regarding them were barely indicative in this review. However, some of these dimensions (e.g., affective lability and stimulus‐seeking behaviors) could be traced back to BPD, thereby strengthening evidence of the role of borderline disorder as a moderator. Although research on the relationship between personality and eating disorders needs to be increased and methodologically improved, personality, taken as a whole, emerged as a promising variable for enhancing the efficacy of CBT.
Article
This study reports on feasibility and acceptability outcomes of a brief, adjunctive cognitive-behavior therapy (CBT) intervention focused on encouraging rapid behavior change in intensive eating disorder treatment (CBT-RR). Effectiveness outcomes of this study have been previously reported (MacDonald, McFarlane, Dionne, David, & Olmsted, 2017). CBT-RR was found to be feasible to implement and acceptable to patients, relative to the comparison condition (motivational interviewing [MI]). Rates of treatment retention were good in both conditions. CBT-RR participants reported higher goal-related alliance with the therapist compared to MI, whereas task-related and bond-related alliances with the therapist were similar between interventions. Both groups reported high levels of homework completion, and strong satisfaction with treatment. Following demonstration of feasibility and acceptability, the second part of this paper provides a detailed description of how we conceptualized and developed the CBT-RR intervention. A detailed description of the protocol components and session content is provided, with a fictional case vignette to illustrate use of the intervention. This section provides a clinical resource that may be helpful to clinicians interested in actively encouraging rapid behavior change with clients with eating disorders.
Article
Background: Although effective treatments exist for diagnostic and subthreshold-level eating disorders (EDs), a significant proportion of affected individuals do not receive help. Interventions translated for delivery through smartphone apps may be one solution towards reducing this treatment gap. However, evidence for the efficacy of smartphones apps for EDs is lacking. We developed a smartphone app based on the principles and techniques of transdiagnostic cognitive-behavioral therapy for EDs and evaluated it through a pre-registered randomized controlled trial. Methods: Symptomatic individuals (those who reported the presence of binge eating) were randomly assigned to the app (n = 197) or waiting list (n = 195). Of the total sample, 42 and 31% exhibited diagnostic-level bulimia nervosa and binge-eating disorder symptoms, respectively. Assessments took place at baseline, 4 weeks, and 8 weeks post-randomization. Analyses were intention-to-treat. The primary outcome was global levels of ED psychopathology. Secondary outcomes were other ED symptoms, impairment, and distress. Results: Intervention participants reported greater reductions in global ED psychopathology than the control group at post-test (d = -0.80). Significant effects were also observed for secondary outcomes (d's = -0.30 to -0.74), except compensatory behavior frequency. Symptom levels remained stable at follow-up. Participants were largely satisfied with the app, although the overall post-test attrition rate was 35%. Conclusion: Findings highlight the potential for this app to serve as a cost-effective and easily accessible intervention for those who cannot receive standard treatment. The capacity for apps to be flexibly integrated within current models of mental health care delivery may prove vital for addressing the unmet needs of people with EDs.
Article
Objective: This study aimed to examine longer-term effects of behavioral weight loss (BWL) and Stepped Care for binge-eating disorder and obesity through 12-month follow-up after completing treatments. Methods: A total of 191 patients with binge-eating disorder/obesity were randomized to 6 months of BWL (n = 39) or Stepped Care (n = 152). Within Stepped Care, patients began BWL (1 month), treatment responders continued BWL, nonresponders switched to cognitive behavioral therapy, and all were randomized (double-blind) to weight-loss medication or placebo (5 months). Patients were independently assessed throughout/after treatment and at 6- and 12-month follow-ups. Results: Intent-to-treat analyses of remission rates revealed that BWL and Stepped Care did not differ significantly at posttreatment (74.4% vs. 66.5%), 6-month follow-up (38.2% vs. 33.3%), or 12-month follow-up (44.7% vs. 41.0%). Mixed models of binge-eating frequency indicated significant reductions through posttreatment but no significant changes or differences between BWL and Stepped Care during follow-up. Mixed models revealed significant weight loss with no differences between BWL and Stepped Care (5.1% vs. 5.8%) at posttreatment and significant time effects (larger percent weight loss at 6-month than at 12-month follow-up) with no differences between BWL and Stepped Care (-5.1% vs. -5.2% and -3.4% vs. -5.0%, respectively). Conclusions: Binge-eating improvements and weight loss produced by BWL and adaptive Stepped Care did not differ significantly 12 months after completing treatments.
Article
Objective: The efficacy of cognitive‐behavioral therapy (CBT) for eating disorders is well‐established. The extent to which CBT tested in controlled research settings generalizes to real‐world circumstances is unknown. We conducted a meta‐analysis of nonrandomized studies of CBT for eating disorders, with three aims: (a) to estimate the prevalence of patients who achieve binge‐purge abstinence after CBT in routine practice; (b) to compare these estimates with those derived from two recent meta‐analyses of randomized controlled trials (RCTs) of CBT for bulimia nervosa (BN) and binge‐eating disorder (BED); (c) to examine whether the degree of clinical representativeness of studies was associated with effect sizes. Method: Twenty‐seven studies, mainly involving BN, were included. Pooled event rates were calculated using random effects models. Results: The percentage of treatment completers who achieved abstinence at post‐treatment was 42.1% (95% CI = 34.7–50.0). The intention‐to‐treat (ITT) estimate was lower (34.6% [95% CI = 29.3–40.4]). However, abstinence rates varied across diagnoses, such that the completer and ITT analysis abstinence estimates were larger for BED samples (completer = 50.2%, 95% CI = 29.4–70.9; ITT = 47.2%, 95% CI = 29.8–65.2) than for BN (completer = 37.4%, 95% CI = 29.1–46.5; ITT = 29.8%, 95% CI = 24.9–35.3) and atypical eating disorder samples (completer = 37.8%, 95% CI = 20.2–59.3; ITT = 28.8%, 95% CI = 18.2–42.4). No relationship between the degree of clinical representativeness and the effect size was observed, and our estimates were highly comparable to those observed in recent meta‐analyses of RCTs. Discussion: Findings suggest that CBT for eating disorder can be effectively delivered in real‐world settings. This study provides evidence for the generalizability of CBT from controlled research settings to routine clinical services.
Article
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Systematic reviews should build on a protocol that describes the rationale, hypothesis, and planned methods of the review; few reviews report whether a protocol exists. Detailed, well-described protocols can facilitate the understanding and appraisal of the review methods, as well as the detection of modifications to methods and selective reporting in completed reviews. We describe the development of a reporting guideline, the Preferred Reporting Items for Systematic reviews and Meta-Analyses for Protocols 2015 (PRISMA-P 2015). PRISMA-P consists of a 17-item checklist intended to facilitate the preparation and reporting of a robust protocol for the systematic review. Funders and those commissioning reviews might consider mandating the use of the checklist to facilitate the submission of relevant protocol information in funding applications. Similarly, peer reviewers and editors can use the guidance to gauge the completeness and transparency of a systematic review protocol submitted for publication in a journal or other medium.
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Anorexia nervosa is difficult to treat. It is important to identify patients at risk for failure early in the treatment process. Eighty-five consecutively admitted inpatients (DSM IV) were treated with an integrative approach including a treatment contract. Failure at discharge was defined as leaving with a BMI of less than 17.5 kg/m² or gaining \textless2 kg/m² in weight. Statistical analysis consisted of growth curve analysis, methods of regression with optimal scaling and ROC-curves. Twenty percent of patients were rated as 'failures'. Parameters of weight curves of week 3 and 4 predicted outcome at an effectiveness of p = 0.84. Thirty percent of the patients were classified as 'at-risk-of-failure' and 82.4
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The purpose of this study was to perform a receiver operator characteristics (ROC) analysis on a treatment sample from a randomized controlled treatment trial of participants with binge eating disorder (BED). An ROC analysis was completed with 179 adults in a 20-week treatment trial for BED to predict abstinence from binge eating at end of treatment. Percent reductions in binge eating episodes were examined following weeks 1 through 10 of treatment. The rate of percent decrease in binge eating episodes during treatment for BED was a significant predictor of clinical outcome at end of treatment. Participants who demonstrated a 15% reduction in binge eating episodes at week one were more likely to respond positively to treatment and achieve clinical remission. Findings from the current study suggest that a significant reduction in binge eating during the first week of treatment may be predictive of end of treatment remission in those with BED.
Article
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Little is known about how psychological treatments work. Research on treatment-induced mediators of change may be of help in identifying potential causal mechanisms through which they operate. Outcome-focused randomised controlled trials provide an excellent opportunity for such work. However, certain conceptual and practical difficulties arise when studying psychological treatments, most especially deciding how best to conceptualise the treatment concerned and how to accommodate the fact that most psychological treatments are implemented flexibly. In this paper, these difficulties are discussed, and strategies and procedures for overcoming them are described.
Article
Starting from the discovery of the sudden gain/critical session, a series of empirical studies were conducted on the mechanism of change in cognitive behavioral therapy for depression (CBT). The findings offer empirical support for the cognitive mediation hypothesis, especially for its core principle that CBT interventions lead to cognitive changes, and cognitive changes lead to much of the observed symptom improvements. The findings also highlight several aspects of the change process that have previously been neglected, like the idea that therapeutic progress tends to concentrate in a few critical sessions, that symptom improvement tends to concentrate in a few sudden gains, that therapeutic alliance and cognitive interventions interact in complex ways, and that different patients might recover through fundamentally different mechanisms.
Article
Many problems in randomized clinical trial design, execution, analysis, presentation and interpretation stem in part from an inadequate understanding of the roles of moderators and mediators of treatment outcome. As a result, 1) the results of clinical research are slow to have an impact on clinical decision making and thus to benefit patients; 2) it is difficult for clinicians or patients to apply randomized clinical trial results comparing two treatments (treatment versus control); 3) when such trials are conducted at various sites, the results often do not replicate; 4) when the results influence clinical decision making, the results clinicians obtain do not match what researchers report; and 5) the treatment effects comparing treatment and control conditions, particularly for psychiatric treatments, often seem trivial. In this review article, the author reviews and integrates the methodological literature concerning dealing with covariates in trials to emphasize their impact on clinical decision making. The goal of trials should ultimately be to establish who should get the treatment condition rather than the control condition (moderators) and to determine how to obtain the best outcomes with whatever is the preferred treatment (mediators). The author makes recommendations to clinicians as to which trials might best be ignored and which carefully considered, and urges clinical researchers to focus on studies best designed to reduce the burden of mental illness on patients.
Article
Reports an error in "Predicting meaningful outcomes to medication and self-help treatments for binge-eating disorder in primary care: The significance of early rapid response" by Carlos M. Grilo, Marney A. White, Robin M. Masheb and Ralitza Gueorguieva ( Journal of Consulting and Clinical Psychology , 2015[Apr], Vol 83[2], 387-394). The axis labels are missing on Figure 3. A corrected figure appears in the correction. (The following abstract of the original article appeared in record 2015-02674-001 .) Objective: We examined rapid response among obese patients with binge-eating disorder (BED) in a randomized clinical trial testing antiobesity medication and self-help cognitive–behavioral therapy (shCBT), alone and in combination, in primary-care settings. Method: One hundred four obese patients with BED were randomly assigned to 1 of 4 treatments: sibutramine, placebo, shCBT + sibutramine, or shCBT + placebo. Treatments were delivered by generalist primary-care physicians and the medications were given double-blind. Independent assessments were performed by trained and monitored doctoral research clinicians monthly throughout treatment, posttreatment (4 months), and at 6- and 12-month follow-ups (i.e., 16 months after randomization). Rapid response, defined as ≥65% reduction in binge eating by the fourth treatment week, was used to predict outcomes. Results: Rapid response characterized 47% of patients, was unrelated to demographic and baseline clinical characteristics, and was significantly associated, prospectively, with remission from binge eating at posttreatment (51% vs. 9% for nonrapid responders), 6-month (53% vs. 23.6%), and 12-month (46.9% vs. 23.6%) follow-ups. Mixed-effects model analyses revealed that rapid response was significantly associated with greater decreases in binge-eating or eating-disorder psychopathology, depression, and percent weight loss. Discussion: Our findings, based on a diverse obese patient group receiving medication and shCBT for BED in primary-care settings, indicate that patients who have a rapid response achieve good clinical outcomes through 12-month follow-ups after ending treatment. Rapid response represents a strong prognostic indicator of clinically meaningful outcomes, even in low-intensity medication and self-help interventions. Rapid response has important clinical implications for stepped-care treatment models for BED. Clinical Trial Registration: clinicaltrials.gov: NCT00537810
Article
Despite significant advances in the development of prevention and treatment interventions for eating disorders and disordered eating over the last decade, there still remains a pressing need to develop more effective interventions. In line with the 2008 Medical Research Council (MRC) evaluation framework from the United Kingdom for the development and evaluation of complex interventions to improve health, the development of sound theory is a necessary precursor to the development of effective interventions. The aim of the current review was to identify the existing models for disordered eating and to identify those models which have helped inform the development of interventions for disordered eating. In addition, we examine the variables that most commonly appear across these models, in terms of future implications for the development of interventions for disordered eating. While an extensive range of theoretical models for the development of disordered eating were identified (N = 54), only ten (18.5%) had progressed beyond mere description and to the development of interventions that have been evaluated. It is recommended that future work examines whether interventions in eating disorders increase in efficacy when developed in line with theoretical considerations, that initiation of new models gives way to further development of existing models, and that there be greater utilisation of intervention studies to inform the development of theory.
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Background: Despite the considerable efficacy of cognitive-behavioral therapy (CBT) for panic disorder (PD) and agoraphobia, a substantial minority of patients fail to improve for reasons that are poorly understood. Objective: The aim of this study was to identify consistent predictors and moderators of improvement in CBT for PD and agoraphobia. Data sources: A systematic review and meta-analysis of articles was conducted using PsycInfo and PubMed. Search terms included panic, agoraphobi*, cognitive behavio*, CBT, cognitive therapy, behavio* therapy, CT, BT, exposure, and cognitive restructuring. Study selection: Studies were limited to those employing semi-structured diagnostic interviews and examining change on panic- or agoraphobia-specific measures. Data extraction: The first author extracted data on study characteristics, prediction analyses, effect sizes, and indicators of study quality. Interrater reliability was confirmed. Synthesis: 52 papers met inclusion criteria. Agoraphobic avoidance was the most consistent predictor of decreased improvement, followed by low expectancy for change, high levels of functional impairment, and Cluster C personality pathology. Other variables were consistently unrelated to improvement in CBT, understudied, or inconsistently related to improvement. Limitations: Many studies were underpowered and failed to report effect sizes. Tests of moderation were rare. Conclusions: Apart from agoraphobic avoidance, few variables consistently predict improvement in CBT for PD and/or agoraphobia across studies.
Article
The present study explored the impact of early symptom change (cognitive and behavioural) and the early therapeutic alliance on treatment outcome in cognitive-behavioural therapy (CBT) for the eating disorders. Participants were 94 adults with diagnosed eating disorders who completed a course of CBT in an out-patient community eating disorders service in the UK. Patients completed a measure of eating disorder psychopathology at the start of treatment, following the 6th session and at the end of treatment. They also completed a measure of therapeutic alliance following the 6th session. Greater early reduction in dietary restraint and eating concerns, and smaller levels of change in shape concern, significantly predicted later reduction in global eating pathology. The early therapeutic alliance was strong across the three domains of tasks, goals and bond. Early symptom reduction was a stronger predictor of later reduction in eating pathology than early therapeutic alliance. The early therapeutic alliance did not mediate the relationship between early symptom reduction and later reduction in global eating pathology. Instead, greater early symptom reduction predicted a strong early therapeutic alliance. Early clinical change was the strongest predictor of treatment outcome and this also facilitated the development of a strong early alliance. Clinicians should be encouraged to deliver all aspects of evidence-based CBT, including behavioural change. The findings suggest that this will have a positive impact on both the early therapeutic alliance and later change in eating pathology. Copyright © 2015 Elsevier Ltd. All rights reserved.
Article
Understanding the factors that predict a favourable outcome following specialist treatment for an eating disorder may assist in improving treatment efficacy, and in developing novel interventions. This review and meta-analysis examined predictors of treatment outcome and drop-out. A literature search was conducted to identify research investigating predictors of outcome in individuals treated for an eating disorder. We organized predictors first by statistical type (simple, meditational, and moderational), and then by category. Average weighted mean effect sizes (r) were calculated for each category of predictor. The most robust predictor of outcome at both end of treatment (EoT) and follow-up was the meditational mechanism of greater symptom change early during treatment. Simple baseline predictors associated with better outcomes at both EoT and follow-up included higher BMI, fewer binge/purge behaviors, greater motivation to recover, lower depression, lower shape/weight concern, fewer comorbidities, better interpersonal functioning and fewer familial problems. Drop-out was predicted by more binge/purge behaviors and lower motivation to recover. For most predictors, there was large interstudy variability in effect sizes, and outcomes were operationalized in different ways. There were generally insufficient studies to allow analysis of predictors by eating disorder subtype or treatment type. To ensure that this area continues to develop with robust and clinically relevant findings, future studies should adopt a consistent definition of outcome and continue to examine complex multivariate predictor models. Growth in this area will allow for stronger conclusions to be drawn about the prediction of outcome for specific diagnoses and treatment types. © 2015 Wiley Periodicals, Inc.
Article
In this study of cognitive-behavioral therapy for depression, many patients experienced large symptom improvements in a single between sessions. These sudden gains' average magnitude was 11 Beck Depression Inventory points, accounting for 50% of these patients' total improvement. Patients who experienced sudden gains were: less depressed than the other patients at posttreatment, and they remained so IB months later. Substantial cognitive changes were observed in the therapy sessions preceding sudden gains, but few cognitive! changes were observed in control sessions, suggesting that cognitive change in the pregain sessions triggered the sudden gains, improved therapeutic alliances were also observed in the therapy sessions immediately after the sudden gains, as were additional cognitive changes, suggesting a three-stage model for these patients' recovery: preparation --> critical session/sudden gain --> upward spiral.
Article
Analysis of short- and long-term effects of rapid response across 3 different treatments for binge eating disorder (BED). In a randomized clinical study comparing interpersonal psychotherapy (IPT), cognitive-behavioral therapy guided self-help (CBTgsh), and behavioral weight loss (BWL) treatment in 205 adults meeting Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; APA, 1994) criteria for BED, the predictive value of rapid response, defined as ≥70% reduction in binge eating by Week 4, was determined for remission from binge eating and global eating disorder psychopathology at posttreatment, 6-, 12-, 18-, and 24-month follow-ups. Rapid responders in CBTgsh, but not in IPT or BWL, showed significantly greater rates of remission from binge eating than nonrapid responders, which was sustained over the long term. Rapid and nonrapid responders in IPT and rapid responders in CBTgsh showed a greater remission from binge eating than nonrapid responders in CBTgsh and BWL. Rapid responders in CBTgsh showed greater remission from binge eating than rapid responders in BWL. Although rapid responders in all treatments had lower global eating disorder psychopathology than nonrapid responders in the short term, rapid responders in CBTgsh and IPT were more improved than those in BWL and nonrapid responders in each treatment. Rapid responders in BWL did not differ from nonrapid responders in CBTgsh and IPT. Rapid response is a treatment-specific positive prognostic indicator of sustained remission from binge eating in CBTgsh. Regarding an evidence-based, stepped-care model, IPT, equally efficacious for rapid and nonrapid responders, could be investigated as a second-line treatment in case of nonrapid response to first-line CBTgsh. (PsycINFO Database Record (c) 2015 APA, all rights reserved).
Article
Rapid response (RR) to eating disorder treatment has been reliably identified as a predictor of post-treatment and sustained remission, but its definition has varied widely. Although signal detection methods have been used to empirically define RR thresholds in outpatient settings, RR to intensive treatment has not been investigated. This study investigated the optimal definition of RR to day hospital treatment for bulimia nervosa and purging disorder. Participants were 158 patients who completed ≥6 weeks of day hospital treatment. Receiver operating characteristic (ROC) analysis was used to create four definitions of RR that could differentiate between remission and nonremission at the end of treatment. Definitions were based on binge/vomit episode frequency or percent reduction from pre-treatment, during either the first four or first two weeks of treatment. All definitions were associated with higher remission rates in rapid compared to nonrapid responders. Only one definition (i.e., ≤3 episodes in the first four weeks of treatment) predicted sustained remission (versus relapse) at 6- and 12-month follow-up. These findings provide an empirically derived definition of RR to intensive eating disorder treatment, and provide further evidence that early change is an important prognostic indicator. Copyright © 2015 Elsevier Ltd. All rights reserved.
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Objective: We examined rapid response among obese patients with binge-eating disorder (BED) in a randomized clinical trial testing antiobesity medication and self-help cognitive-behavioral therapy (shCBT), alone and in combination, in primary-care settings. Method: One hundred four obese patients with BED were randomly assigned to 1 of 4 treatments: sibutramine, placebo, shCBT + sibutramine, or shCBT + placebo. Treatments were delivered by generalist primary-care physicians and the medications were given double-blind. Independent assessments were performed by trained and monitored doctoral research clinicians monthly throughout treatment, posttreatment (4 months), and at 6- and 12-month follow-ups (i.e., 16 months after randomization). Rapid response, defined as ≥65% reduction in binge eating by the fourth treatment week, was used to predict outcomes. Results: Rapid response characterized 47% of patients, was unrelated to demographic and baseline clinical characteristics, and was significantly associated, prospectively, with remission from binge eating at posttreatment (51% vs. 9% for nonrapid responders), 6-month (53% vs. 23.6%), and 12-month (46.9% vs. 23.6%) follow-ups. Mixed-effects model analyses revealed that rapid response was significantly associated with greater decreases in binge-eating or eating-disorder psychopathology, depression, and percent weight loss. Discussion: Our findings, based on a diverse obese patient group receiving medication and shCBT for BED in primary-care settings, indicate that patients who have a rapid response achieve good clinical outcomes through 12-month follow-ups after ending treatment. Rapid response represents a strong prognostic indicator of clinically meaningful outcomes, even in low-intensity medication and self-help interventions. Rapid response has important clinical implications for stepped-care treatment models for BED. Clinical trial registration: clinicaltrials.gov: NCT00537810 (PsycINFO Database Record
Article
Objective Relapse remains a significant concern in bulimia nervosa, with some patients relapsing within months of treatment completion. The purpose of the study was to identify predictors of relapse within the first 6 months following treatment.Method The 116 participants were bingeing and/or vomiting ≥ 8 times per month before day hospital (DH), and had ≤ 2 episodes per month in the last month of DH and the first month after DH. Rapid relapse was defined as ≥ 8 episodes per month for 3 months starting within 6 months.ResultsThe rate of rapid relapse was 27.6%. Patients who relapsed soon after DH had higher frequencies of bingeing and vomiting before treatment, engaged in less body avoidance before treatment and were more likely to be slow responders to treatment. Weight and shape concerns and body checking were not significant predictors.DiscussionMore frequent bulimic symptoms accompanied by less body avoidance may indicate an entrenchment in the illness which in turn augurs a labored and transient response to DH treatment that is difficult to sustain after intensive treatment ends. © 2014 Wiley Periodicals, Inc. (Int J Eat Disord 2014)
Article
I received the Early Career Award from Division 29 and the American Psychological Foundation in 2013. In this article, I briefly review some of my research areas, relevant issues, and future directions. Specifically, I focus on 3 core research areas: psychotherapy process-outcome, psychotherapy integration, and science-practice integration. Within each of these core areas, I also touch on important methodological issues. In addition, I argue that progress in the field will require the application of diverse research methods, spanning basic and applied areas, as well as interdisciplinary and interinstitutional collaboration. (PsycINFO Database Record (c) 2015 APA, all rights reserved).
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IntroductionIndividual studiesThe summary effectHeterogeneity of effect sizesSummary points
Article
Bulimia nervosa (BN) treatment studies consistently observe that substantial reductions in purging frequency after four weeks of treatment predict outcome. Although baseline levels of other variables have been compared to change in purging, measures of early change in other domains have not been examined. This study aimed to compare percentage change in purging, depression, and cognitive eating disorder (ED) symptoms for associations with BN remission post-treatment and at six months follow-up. Data from N = 43 patients with BN in a clinical trial comparing the broad and focused versions of enhanced cognitive behavior therapy (CBT-E; Fairburn, 2008) were utilized. Measures included self-reported purging frequency, Beck Depression Inventory (BDI) score, and a mean of items from the Eating Disorder Inventory Body Dissatisfaction and Drive for Thinness subscales. Results indicated that both percentage change in purging frequency and percentage change in BDI score at week four/session eight were significantly associated with remission at termination. The optimal cutoffs for purging change and BDI score change were 65% decrease and 25% decrease respectively. Only change in BDI score at week four significantly predicted remission at six-month follow-up. These data suggest that change in depressive symptoms may be as important as ED symptom change to predict outcome in some groups.
Article
This study examined the relationships between acceptance of the treatment rationale (ATR), homework compliance, and change during cognitive-behavioral therapy (CBT) for depression. By evaluating the associations between these variables over time it was possible to compare competing theories of change in CBT. Clients meeting criteria for major depression (N = 150) were assessed longitudinally for their reaction to the treatment rationale and homework compliance over the course of a 20-session treatment. The results suggest that both ATR and homework compliance make independent contributions to predicting within-treatment change and treatment outcome. There was no evidence that compliance mediates the effect of ATR on treatment outcome. These findings support a multiprocess model of change in CBT. Acceptance of the treatment rationale may facilitate involvement in treatment and nonspecific change processes, while compliance with homework assignments contributes to additional change. We discuss these findings in regard to alternative theories of change and the dissemination of CBT to real-world clinical settings.
Article
Determine whether early weight gain predicts full remission at end-of-treatment (EOT) and follow-up in two different treatments for adolescent anorexia nervosa (AN), and to track the rate of weight gain throughout treatment and follow-up. Participants were 121 adolescents with AN (mean age = 14.4 years, SD = 1.6), from a two-site (Chicago and Stanford) randomized controlled trial. Adolescents were randomly assigned to family-based treatment (FBT) (n = 61) or individual adolescent focused therapy (AFT) (n = 60). Treatment response was assessed using percent of expected body weight (EBW) and the global score on the Eating Disorder Examination (EDE). Full remission was defined as having achieved ≥95% EBW and within one standard deviation of the community norms of the EDE. Full remission was assessed at EOT as well as 12-month follow-up. Receiver operating characteristic analyses showed that the earliest predictor of remission at EOT was a gain of 5.8 pounds (2.65 kg) by session 3 in FBT (area under the curve (AUC) = 0.670; p = .043), and a gain of 7.1 pounds (3.20 kg) by session 4 in AFT (AUC = 0.754, p = .014). Early weight gain did not predict remission at follow-up for either treatment. A survival analysis showed that weight was marginally superior in FBT as opposed to AFT (Wald chi-square = 3.692, df = 1, p = .055). Adolescents with AN who receive either FBT or AFT, and show early weight gain, are likely to remit at EOT. However, FBT is superior to AFT in terms of weight gain throughout treatment and follow-up. (Int J Eat Disord 2013).
Article
The aims of this study were to investigate the number of sessions and time required for a clinical meaningful symptomatic change with a guided self-help treatment and to assess the predictive value of early response and other potential predictors of end-of-treatment clinical status. Participants were 42 patients with a diagnosis of bulimia nervosa or ED not otherwise specified. Survival analyses (Kaplan-Meier) were performed to estimate the median time required to attain a 51% reduction in bulimic symptoms. Logistic regression was used to assess predictors of symptom remission. Results showed that the median time to achieve a 51% reduction in binge and purge frequencies was 3.68 and 3.77, respectively. This change occurred at session 3 for 50% of the participants. Early response was the most significant predictor of binge eating remission. No pretreatment predictors of time to achieve early response were found. These results have implications for allocating treatment resources in a stepped-care intervention model. Copyright © 2013 John Wiley & Sons, Ltd and Eating Disorders Association.