ArticleLiterature Review

Predictors, Moderators, and Mediators of Treatment Outcome Following Manualised Cognitive-Behavioural Therapy for Eating Disorders: A Systematic Review

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Abstract

This systematic review synthesised the literature on predictors, moderators, and mediators of outcome following Fairburn's CBT for eating disorders. Sixty-five articles were included. The relationship between individual variables and outcome was synthesised separately across diagnoses and treatment format. Early change was found to be a consistent mediator of better outcomes across all eating disorders. Moderators were mostly tested in binge eating disorder, and most moderators did not affect cognitive-behavioural treatment outcome relative to other treatments. No consistent predictors emerged. Findings suggest that it is unclear how and for whom this treatment works. More research testing mediators and moderators is needed, and variables selected for analyses need to be empirically and theoretically driven. Future recommendations include the need for authors to (i) interpret the clinical and statistical significance of findings; (ii) use a consistent definition of outcome so that studies can be directly compared; and (iii) report null and statistically significant findings.

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... For instance, previous findings suggest that individuals with elevated depressive symptoms, greater shape and weight concern, more psychiatric comorbidities, lower selfesteem, and greater interpersonal difficulties have worse CBT or CBTgsh posttreatment outcomes (Vall & Wade, 2015). Importantly, a recent meta-analytic review revealed little consistency across studies of predictors and moderators of CBT outcomes (Linardon, de la Piedad Garcia, & Brennan, 2017), highlighting a need to further elucidate which factors yield reliable prognostic information regarding treatment outcome in BED, as well as for whom CBT might be more or less effective. ...
... Models reported in the present article utilized the full sample (N ϭ 112). However, given mixed findings from previous investigations of moderators of treatment outcome for BED (Linardon et al., 2017), additional follow-up analyses using randomly generated splithalved samples were conducted to examine consistency across effect size estimates. ...
... Despite evidence of group differences between ICAT-BED and CBTgsh (Peterson et al., 2019), the present findings suggest that both treatments are associated with positive effects on OBE abstinence rates, compared to abstinence rates associated with assessment-only and placebo control conditions from prior BED treatment trials at EOT (up to 25.6%) and 6-month FU (up to 8.7%; see Linardon et al., 2017 for meta-analytic review). However, the absence of significant predictor or moderator effects on OBE abstinence at both EOT and 6-month FU suggests that patient-therapy matching efforts may not influence abstinence rates among treatment-seeking individuals with BED. ...
Article
Objective: The current study examined predictors and moderators of two interventions for binge-eating disorder (BED). Method: Participants were 112 adults with BED (Mage = 39.7 ± 13.4 years; MBMI = 35.1 ± 13.4 kg/m²; 82% female; 91% Caucasian) randomly assigned to integrative cognitive-affective therapy for BED (ICAT-BED) or guided self-help cognitive-behavioral therapy (CBTgsh). Generalized linear models examined predictors and moderators of objective binge-eating episode (OBE) frequency and OBE abstinence at end-of-treatment (EOT) and 6-month follow-up (FU). Results: Lower levels of baseline dietary restraint and emotion regulation difficulties predicted greater reductions in OBE frequency at EOT and FU, respectively. At EOT, greater pretreatment self-control predicted greater reductions in OBE frequency in ICAT-BED than CBTgsh (ps < .05). In addition, low shape/weight overvaluation predicted greater reductions in OBE frequency in ICAT-BED than CBTgsh, whereas high shape/weight overvaluation predicted comparable reductions in OBE frequency across treatments at EOT (ps < .02). At EOT and FU, greater baseline actual-ideal self-discrepancy predicted significantly greater reductions in OBE frequency in ICAT-BED, than CBTgsh (ps < .02). No significant predictor or moderator effects were observed for models examining OBE abstinence. Conclusion: This study identified two general predictors and four moderators of BED treatment response. However, only one predictor (actual-ideal self-discrepancy) interacted with treatment type to differentially predict OBE frequencies at both EOT and FU. Altogether, findings suggest that ICAT-BED may confer specific and durable improvements in OBE frequencies among individuals with high actual-ideal self-discrepancy. Therefore, patients demonstrating these characteristics may be more likely to benefit from ICAT-BED. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
... There is evidence that greater pre-treatment bingeeating and/or purging severity (Cooper & Steele, 1995;Fairburn et al., 2004;Turnbull et al., 1997;Wilson et al., 1999), greater depressive symptoms (Agras et al., 2000;Cooper & Steele, 1995), and lower body mass index (BMI) (Agras et al., 2000;Fairburn et al., 2004) have been associated with lower end-treatment abstinence. However, these findings have not been consistent, with a systematic review of predictors of outcome of CBT for eating disorders, including BN, revealing no consistent pre-treatment predictors of outcome (Linardon et al., 2017). Moreover, previous studies have typically focussed on disorder-specific predictors, such as bingeeating/purging frequency or BMI, without consistently also examining psychological predictors of outcome. ...
... In sum, knowledge of predictors of outcome that may guide clinical care for BN is lacking, and additional studies contributing to this literature for future metaanalysis are needed (Linardon et al., 2017). We therefore examined predictors of outcome at end-treatment and 1-year follow-up using data from the aforementioned study comparing internetbased and face-to-face CBT for BN. ...
... However, considerable heterogeneity exists within the BN-specific literature. In a systematic review of predictors of outcome for CBT for BN, three studies reported that higher baseline severity predicted poorer behavioural outcomes, three studies reported no relationship, and one study reported that higher baseline symptoms predicted better behavioural outcomes (Linardon et al., 2017). Pending additional outcome data, future meta-analyses of outpatient trials of CBT for BN will further clarify the impact of illness severity on outcome within a BNspecific population. ...
Article
Objective: Cognitive-behavioural therapy (CBT) delivered face-to-face and via the internet reduces bulimia nervosa (BN) symptoms. However, our empirical understanding of factors affecting patient outcomes is limited. Method: Using data from a randomised, controlled trial comparing internet-based (CBT4BN, n = 78) with face-to-face (CBTF2F, n = 71) group CBT (97% female, M = 28 years), we examined general treatment (across conditions) and modality-specific predictors of end-treatment and 1-year outcomes (abstinence, binge-eating frequency, purging frequency). Results: Improved eating disorder-related quality of life (EDQOL) during treatment and follow-up predicted abstinence at end-treatment and 1-year assessments. Improved EDQOL, disordered eating cognitions, and anxiety symptoms predicted less frequent binge eating and purging. Previous CBT and being employed predicted more frequent binge eating and purging at both assessments. Higher self-transcendence and self-directedness predicted less frequent binge eating. More severe binge eating and purging at baseline and end-treatment predicted more frequent binge eating and purging at subsequent assessments. Improved EDQOL was more strongly associated with positive outcome in CBT4BN; improved depressive symptoms and health-related QOL predicted positive outcome in CBT4BN but not CBTF2F. Discussion: Symptom improvement and certain character traits predicted positive outcome, whereas more severe presentation and prior CBT experience predicted poorer outcome. Consideration of intreatment symptom improvement may facilitate care recommendations, particularly for internet-based modalities.
... In clinical practice, it may also contribute to illness chronicity, relapse, and costs [1]. A recent systematic review, evaluating predictors in following manualised CBT, BN, Binge Eating Disorder (BED) and mixed samples including normal weight eating disorders [2]. Similar results for sociodemographic aspects and eating disorder severity were found in a comprehensive review, but the authors noted that general psychopathology favours the non-sequence of treatment, and that binge-purging subtype of anorexia nervosa, two borderline personality disorder traits (high maturity fear and impulsivity) and two psychological traits (high maturity fear and impulsivity) are predictors for dropouts in eating disorders treatment [1]. ...
... However, late attrition is usually 75% or more of therapy sessions and has been applied in previous studies of the authors [8]. 2 Frequency of binge eating episodes was considered when the participant reported at least one episode per week during the last 3 months. 3 Purging was defined as any current use of self-induced vomiting, laxatives, and/or diuretics as a method of weight and/or shape control within the past 3 months. ...
... Some studies investigated the impact of illness duration and weight on outcomes in treatment, but not on prediction of treatment completion [2,3]. In the present study, adherence decreased over the course of therapy, and particularly after 33% of sessions. ...
Article
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Purpose Understanding the high rate of treatment attrition in trials of people with eating disorders is important as it can compromise the quality of the trials. In clinical practice, it may also contribute to illness chronicity, relapse, and costs. Thus, we investigated factors associated with treatment attrition to a new manualised psychotherapy HAPIFED compared to CBT-E, for individuals with Bulimia Nervosa or Binge Eating Disorder comorbid with overweight or obesity. Methods In total, 98 participants were recruited with 50 randomised to HAPIFED and 48 to the control intervention CBT-E, all administered in groups of up to 10 participants. An investigator external to the site conducted the random allocation, which was concealed from the statistician involved in the analysis, and known only to the therapists until the finalization of the 12-month follow-up after the end of active treatment. Three scenarios in the timeline treatment of a total of 30 sessions were assessed: 33% or 60% or 75% of presence. Logistic regression analysis was performed to find the correlates of attrition. Results None of the six variables - frequency of binge eating episodes, purging, eating disorder symptom severity, weight, illness duration and mental health-related quality of life - significantly predicted attrition at 33%, but longer illness duration predicted lower treatment attrition at both 60% and 75% presence of the interventions. Also for 75% presence, lower body weight predicted lower treatment attrition. Conclusions Lower attrition due to late treatment completion was associated with longer binge eating illness length and a lower body weight. More research is needed to recognize factors that may interfere with engagement in treatments aiming to avoid early dropout. Keywords binge eating disorder, bulimia nervosa, cognitive therapy, obesity, patient dropout Trial registration US National Institutes of Health clinical trial registration number NCT02464345, date of registration 1 June 2015.
... Comorbid PDs are generally thought to complicate the treatment of eating disorders and lead to a worse prognosis [3][4][5][6]. No moderation effects of personality disorders on treatment outcome were found in a systematic review for binge-eating disorder (BED), while comorbid personality disorders predicted a worse treatment response in bulimia nervosa (BN) [3]. ...
... Comorbid PDs are generally thought to complicate the treatment of eating disorders and lead to a worse prognosis [3][4][5][6]. No moderation effects of personality disorders on treatment outcome were found in a systematic review for binge-eating disorder (BED), while comorbid personality disorders predicted a worse treatment response in bulimia nervosa (BN) [3]. None of the included studies with AN examined personality disorders in general as a predictor, moderator, or mediator on treatment outcome [3]. ...
... No moderation effects of personality disorders on treatment outcome were found in a systematic review for binge-eating disorder (BED), while comorbid personality disorders predicted a worse treatment response in bulimia nervosa (BN) [3]. None of the included studies with AN examined personality disorders in general as a predictor, moderator, or mediator on treatment outcome [3]. In a mixed sample, patients with comorbid PD scored higher than patients without PD on EDI subscales Drive for Thinness, Body dissatisfaction, Ineffectiveness, perfectionism, interpersonal distrust, and interoceptive awareness at initial assessment and a 5year follow-up, but no significant Group x Time Interactions could be observed [4]. ...
Article
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Background Data on patients with anorexia nervosa (AN) and comorbid Borderline personality disorder (AN+BPD) are scarce. Therefore, we investigated (1) whether patients with AN and AN+BPD differ in characteristics related to admission to, discharge from, and course of specialized inpatient eating disorder treatment and (2) how comorbid BPD affects treatment outcome. Method One-thousand one-hundred and sixty inpatients with AN (97.2% female, 5.9% with comorbid BPD; mean age = 26.15, SD = 9.41) were administered the Brief Symptom Inventory (BSI), the Eating Disorder Inventory 2 (EDI-2), and the Global Assessment of Functioning (GAF) at admission and discharge. Data were extracted by a retrospective chart review of naturalistic treatment data. Age, sex, weekly weight gain, length of stay, and discharge characteristics were compared with independent t -tests and χ ² -tests. Changes in outcome variables, including body mass index (BMI), were analyzed with longitudinal multilevel mixed-effects models. Results No differences in age or sex were found between patients with AN and AN+BPD, but groups differed in previous inpatient treatments, BMI at admission, and frequency of at least one additional comorbidity with higher values for AN+BPD. Higher levels of disorder-specific and general psychopathology at admission were found for AN+BPD. Patients with AN showed statistically significant improvement in all examined variables, patients with AN+BPD improved in all variables except EDI-2 body dissatisfaction. Strongest improvements in patients with AN+BPD occurred in BMI (Cohen’s d = 1.08), EDI-2 total score (Cohen’s d = 0.99), EDI-2 interpersonal distrust ( d = 0.84). Significant Group x Time Interactions were observed for BSI GSI, GAF, and EDI-2 body dissatisfaction, indicating a reduced benefit from inpatient treatment in AN+BPD. At discharge, no differences were found in weekly weight gain, BMI, length of stay, or discharge characteristics (e.g., ability to work, reason for discharge), however, patients with AN+BPD were more frequently treated with medication. Conclusions Patients with AN+BPD differ from patients with AN in that they show higher general and specific eating disorder psychopathology and only partially improve under specialized inpatient treatment. In particular, aspects of emotion regulation and core AN symptoms like body dissatisfaction and perfectionism need to be even more targeted in comorbid patients.
... In clinical practice, it may also contribute to illness chronicity, relapse, and costs [1]. A recent systematic review, evaluating predictors in following manualised CBT, BN, Binge Eating Disorder (BED) and mixed samples including normal weight eating disorders [2]. Similar results for sociodemographic aspects and eating disorder severity were found in a comprehensive review, but the authors noted that general psychopathology favours the non-sequence of treatment, and that binge-purging subtype of anorexia nervosa, two borderline personality disorder traits (high maturity fear and impulsivity) and two psychological traits (high maturity fear and impulsivity) are predictors for dropouts in eating disorders treatment [1]. ...
... However, late attrition is usually 75% or more of therapy sessions and has been applied in previous studies of the authors [8]. 2 Frequency of binge eating episodes was considered when the participant reported at least one episode per week during the last 3 months. 3 Purging was defined as any current use of self-induced vomiting, laxatives, and/or diuretics as a method of weight and/or shape control within the past 3 months. ...
... Some studies investigated the impact of illness duration and weight on outcomes in treatment, but not on prediction of treatment completion [2,3]. In the present study, adherence decreased over the course of therapy, and particularly after 33% of sessions. ...
Article
Full-text available
Purpose: Understanding the high rate of treatment adherence in trials of people with eating disorders is important as it can compromise the quality of the trials. In clinical practice, it may also contribute to illness chronicity, relapse, and costs. Thus, we investigated factors associated with adherence to a new treatment HAPIFED, which integrates cognitive behavioural therapy having extended sessions with body weight loss therapy compared to cognitive behavioural therapy with extended sessions alone, for individuals with Bulimia Nervosa or Binge Eating Disorder or other eating disorders comorbid with overweight or obesity. Methods: In total, 98 participants having bulimia nervosa, binge eating disorder and other specified and unspecified eating disorders were recruited with 50 randomised to HAPIFED and 48 to the control intervention CBT-E, all administered in groups of up to 10 participants. An investigator external to the site conducted the random allocation, which was concealed from the statistician involved in the analysis, and known only to the therapists until the finalization of the 12-month follow-up after the end of active treatment. Three scenarios in the timeline treatment of a total of 30 sessions were assessed: 33% or 60% or 75% of presence. Mixed-effects logistic regression analysis was performed to find the correlates of adherence after adjusting for clustering by number of group participants. To account for heterogeneity by types of eating disorders in the sample, the latter variable was considered as a control factor in the models. A subgroup analysis was performed for those with binge eating disorder as this was the largest (N = 66) eating disorder group. Results: None of the six variables-frequency of binge eating episodes, purging, eating disorder symptom severity, weight, illness duration and mental health-related quality of life-significantly predicted adherence at 33%, but longer illness duration predicted higher treatment adherence at both 60% and 75% presence of the interventions. Also for 75% presence, higher body weight predicted lower treatment adherence. For the subgroup analysis, those having higher illness duration had significantly higher odds of treatment adherence for 60% and 75% of the sessions. Conclusions: Higher adherence due to late treatment completion was associated with longer binge eating illness length and a lower body weight. More research is needed to recognize factors that may interfere with engagement in treatments aiming to avoid early dropout.
... This systematic review and meta-analysis explore whether there is a direct contribution of duration to treatment outcome for both anorexia nervosa and bulimia nervosa, regardless of SEED status. We contribute new information to the field, building on recent meta-analyses or reviews of predictors of treatment outcome (Gregertsen, Mandy, Kanakam, Armstrong, & Serpell, 2019;Linardon, de la Piedad Garcia, & Brennan, 2017;Vall & Wade, 2015). The first of these (Vall & Wade, 2015) reviewed publications related to both anorexia nervosa and bulimia nervosa and included seven studies relating to either duration or age of onset, thus confounding these two variables. ...
... A small but statistically significant effect at end of treatment was determined, r = 0.19, 95% confidence interval (CI): 0.10, 0.28. The second (Linardon et al., 2017) provided a systematic review but no metaanalytic data related to bulimia nervosa. The third (Gregertsen et al., 2019) only reported two studies examining duration as a predictor of outcome in anorexia nervosa, showing a negligible effect, r = 0.15, 95% CI: −0.03, 0.26. ...
... (anorexia OR Eating Disorder* OR disordered eat* OR binge eat OR bulimia) and (treatment OR therapy OR psychotherapy) and (response OR outcome) and (predictor OR predict). We searched from 2015 onwards in order to add studies already identified in the Vall and Wade (2015) meta-analysis, using search terms based on that of Linardon et al. (2017) and Gregertsen et al. (2019). The secondary search strategy involved hand searching of all relevant articles identified in the primary electronic search. ...
Article
Objective: This systematic review and meta-analysis examine the contribution of duration to treatment outcome for eating disorders. Method: Studies (n = 31) were identified that examined associations (r) between duration and 45 different outcomes. We were unable to extract r for seven studies (9 outcomes) and extracted r for 36 outcomes across 24 studies (2,349 participants). Indicators of treatment outcome were heterogeneous and thus a series of different meta-analyses, aimed at increasing homogeneity, were conducted. Results: First, we examined the average effect size for one primary eating disorder related outcome from each of the 24 studies. There was no association between duration and treatment outcome (r = .05, 95% CI: -.03:.13), with high heterogeneity. Second, we conducted three sub-group analyses to explore possible sources of heterogeneity (diagnosis: anorexia nervosa versus bulimia nervosa; nature of the outcome: binary versus continuous; or type of outcome: binary indicator of recovery, eating disorder psychopathology, weight gain). There was no significant moderation or associations between duration and outcome (ranging from .02-.08), with low to medium heterogeneity. Third, two stand-alone analyses examined outcomes related to weight gain (n = 8) and eating disorder psychopathology (n = 5), with nonsignificant rs of .23/-.06, respectively. High levels of heterogeneity were present. Discussion: Duration did not influence treatment outcome across any of our meta-analyses. Increasing homogeneity and power will allow more stable estimates of the impact of duration on outcome to be calculated; to this end, future treatment studies should include outcome related to weight gain (anorexia nervosa) and improvements in eating disorder psychopathology.
... For instance, previous findings suggest that individuals with elevated depressive symptoms, greater shape and weight concern, more psychiatric comorbidities, lower selfesteem, and greater interpersonal difficulties have worse CBT or CBTgsh posttreatment outcomes (Vall & Wade, 2015). Importantly, a recent meta-analytic review revealed little consistency across studies of predictors and moderators of CBT outcomes (Linardon, de la Piedad Garcia, & Brennan, 2017), highlighting a need to further elucidate which factors yield reliable prognostic information regarding treatment outcome in BED, as well as for whom CBT might be more or less effective. ...
... Models reported in the present article utilized the full sample (N ϭ 112). However, given mixed findings from previous investigations of moderators of treatment outcome for BED (Linardon et al., 2017), additional follow-up analyses using randomly generated splithalved samples were conducted to examine consistency across effect size estimates. ...
... Despite evidence of group differences between ICAT-BED and CBTgsh (Peterson et al., 2019), the present findings suggest that both treatments are associated with positive effects on OBE abstinence rates, compared to abstinence rates associated with assessment-only and placebo control conditions from prior BED treatment trials at EOT (up to 25.6%) and 6-month FU (up to 8.7%; see Linardon et al., 2017 for meta-analytic review). However, the absence of significant predictor or moderator effects on OBE abstinence at both EOT and 6-month FU suggests that patient-therapy matching efforts may not influence abstinence rates among treatment-seeking individuals with BED. ...
Article
In this report, we examined baseline affective response to binge eating as a predictor of binge-eating disorder (BED) treatment outcome. Baseline affective response was defined as (a) each individual’s average net change (i.e., area under the curve [AUC]) of positive affect (PA) or negative affect (NA) before and after binge-eating episodes and (b) slope of PA or NA after binge eating across 7 days of ecological momentary assessment. Adults with BED completed integrative cognitive-affective therapy (ICAT-BED) or cognitive behavioral therapy-guided self-help (CBT-gsh). Individuals with greater net increases in PA (AUC) after binge eating at baseline exhibited better treatment response in ICAT-BED at end of treatment and follow-up. NA affective response was significant only at end of treatment; individuals with less rapid postbinge improvements in NA (slope) did better in ICAT-BED, whereas individuals with lower net improvements in NA (AUC) did better in CBT-gsh. Affective response to binge eating may be a marker of BED treatment response.
... This prevalent clinical eating disorder co-occurs with eating disorder and general psychopathology, obesity (BMI ≥ 30.0 kg/m 2 ), and psychosocial impairment. Cognitive-behavioral therapy (CBT) is the most well-established therapy for BED, with similar efficacy in face-to-face and CBT structured self-help treatment formats [2,3], but pretreatment predictors of treatment outcomes have proven elusive [4]. Using a network approach to psychopathology, this study uniquely sought to elucidate the network structure, its change, and the predictive value in CBT for BED. ...
... As opposed to the prediction of network theory, assuming that an efficacious treatment should lead to a decrease in network connectivity and its self-sustaining character [4], CBT for BED resulted in a higher connectivity of the psychopathology network, which is consistent with some [8,9] but not all studies [10] on diverse mental disorders including depression. In mixed eating disorders, Smith et al. [17] did not find a change in network connectivity, presumably related to the lower homogeneity of their sample and treatment approaches. ...
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Introduction: Network approaches to psychopathology posit that mental disorders emerge from interrelated symptoms, and thus connectivity among symptoms are assumed to negatively predict the treatment response and decrease with efficacious treatment. Objective: This study uniquely sought to elucidate the network structure, its change, and its predictive value in cognitive-behavioral therapy (CBT) for binge-eating disorder (BED). Methods: In a multicenter randomized trial of face-to-face and Internet-based guided self-help CBT, 178 individuals with full syndrome and subsyndromal BED, eating disorder and general psychopathology, and body mass index (BMI) were subjected to Gaussian Graphical Network and Exploratory Graph Analyses before and after treatment and at 6-month follow-up. Results: At pretreatment, 3 network communities of: eating disorder psychopathology; general psychopathology; and restraint and BMI were identified, with the latter community included in the first thereafter. Eating disorder-related impairment and self-esteem were the most central symptoms, while BMI and binge eating had the lowest centrality. Network connectivity significantly increased from pre- to posttreatment, with the greatest increases in strength centrality found in binge eating and shape concern, but it did not predict remission from binge eating. Conclusions: With decreasing symptom severity, CBT resulted in a greater integration and connectivity of the psychopathology network in BED, suggesting an increased patient understanding of relations between binge eating and other symptoms. Network connectivity was not a negative prognostic indicator of treatment outcome. These results indicate a need for further research on the predictive value of network variables in the explanation of therapeutic change for patients with BED.
... Some limitations of these contributions should be noted. First, none of the aforementioned studies with ED samples examined overall personality functioning-or PD cluster-as a mediator or moderator of treatment outcome (Linardon et al., 2017), despite some preliminary findings showing the mediating role of personality in the relationship between patients' attachment styles and ED symptomatic presentation (Eggert et al., 2007;Münch et al., 2016). Furthermore, research into the role of personality traits or disorders and their link to EDs is necessarily complicated by the ongoing debate over whether PDs are best conceptualized categorically or dimensionally, with increasing support for the latter hypothesis (e.g., Widiger, 2007). ...
... Despite these limitations, the present findings suggest that personality functioning and disorders may predict baseline symptomatic expression and treatment outcome in EDs, and that a deeper understanding of patient-related moderators and mediators of outcome should be enhanced to improve treatment effectiveness (Linardon et al., 2017). Most ED treatment guidelines share the view that patients' individual differences, with respect to symptom severity, treatment history, and comorbid psychopathology, should be clearly acknowledged to guide the selection of adequate psychosocial interventions within a stepped-care therapeutic approach (NICE, 2004;American Psychiatric Association, 2006). ...
Article
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Features of personality disorders (PDs) have been found to explain meaningful variance in the onset, maintenance, and symptomatic presentation of eating disorders (EDs), and a co-occurent personality pathology is commonly associated with poorer response to ED treatment. The “pathoplasty model” of the relationship between personality and EDs implies that, once both conditions are established, they are likely to interact in ways that modify therapy outcome; however, to date, no studies have explored overall personality functioning, and especially PD clusters, as a mediator of treatment outcome. The present study aimed at conjointly exploring the associations between personality functioning and PDs, respectively, with pre-treatment ED symptomatic impairment and therapy outcome; and the mediating role of personality variables. At treatment onset, a sample of 107 women with ED problems were evaluated using both the Structured Clinical Interview for DSM-5 (SCID-5-CV) and the Shedler-Westen Assessment Procedure-200 (SWAP-200)—a clinician-rated procedure to dimensionally assess personality. Participants were also asked to complete self-report questionnaires on overall ED symptomatology, symptoms of binge eating and purging behaviors, and therapy outcome. The findings showed that, over and above the categorical ED diagnosis, the SWAP-200 healthy personality functioning score mediated the relationship between baseline ED symptom severity and therapy outcome, as well as the association between baseline bulimic symptoms and treatment outcome; furthermore, SWAP-200 Cluster B PD scores mediated the link between baseline binge eating and purging symptoms and therapy outcome, whereas scores in Clusters A and C showed no significant effects. The findings suggest that personality-based outcome research may improve treatment effectiveness in this difficult-to-treat population.
... Our predictor importance analyses yielded evidence that adds to the limited eating disorder literature (Linardon et al., 2017); most clearly, findings provide further empirical confirmation for Note. Weight bias = weight bias internalization, ER = emotion regulation, Food add crit = food addiction criteria, Dep dx = depressive disorder, Emo overeat = emotional overeating, Bx.ind = binge-eating disorder behavioral indicator, Dissatisfy = weight/shape dissatisfaction, Interpers prob = interpersonal problems, overvaluation = weight/shape overvaluation, Food tht supp = food thought suppression, EDE = Eating Disorder Examination, TFEQ = Three Factor Eating Questionnaire, Diet hist = diet history, AUD dx = alcohol use disorder, Food add cat = food addiction category, CR = cognitive rumination, Anx dx = anxiety disorder, Dep score = depression score, OBE = objective binge episode. ...
... Note 1 Given that logistic and linear regressions are not well suited for analyzing large numbers of predictors, we also completed logistic and linear regressions using only 10 predictors (selected conceptually or empirically based on their associations with BED treatment response; see Grilo et al., 2012a;Linardon et al., 2017). These reduced models yielded similar predictive performance as the models with all 42 predictors. ...
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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.
... The current study highlights the need to further understand the underlying mechanisms of both CBT and BED. Early symptom change was found to consistently mediate better treatment outcomes in CBT (Linardon, de la Piedad Garcia & Brennan, 2017) and, in one study, also in DBT-BED (Safer & Joyce, 2011). In CBT, reductions in weight concern (Dingemans et al., 2007) and dietary restraint (Linardon, de la Piedad ...
... Also, subgroups may profit more from one treatment than the other. However, most tested moderator variables did not affect cognitive-behavioral treatment outcome relative to other treatments while some produced conflicting findings (Linardon, de la Piedad Garcia & Brennan, 2017). To BED patients who report greater difficulties in areas that are central to CBT treatment models (i.e. ...
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Objective: To evaluate whether the results of a quasi-randomized study, comparing dialectical behavior therapy for binge-eating disorder (DBT-BED) and an intensive, outpatient cognitive behavior therapy (CBT+) in individuals with BED, would be replicated in a nonrandomized study with patients who more closely resemble everyday clinical practice. Method: Patients with (subthreshold) BED (N = 175) started one of two group treatments: DBT-BED (n = 42) or CBT+ (n = 133), at a community eating disorder service. Measures of eating disorder pathology, emotion regulation, and general psychopathology were examined at end of treatment (EOT) and at 6-month follow-up using generalized linear models with multiple imputation. Results: Both treatments lead to substantial decreases on primary and secondary measures. Statistically significant, medium-size differences between groups were limited to global eating disorder psychopathology (d = -.62; 95% CI = .231, .949) at EOT and depressive symptoms at follow-up (d = -.45; 95% CI = .149, 6.965), favoring CBT+. Dropout of treatment included 15.0% from CBT+ and 19.0% from DBT-BED (difference nonsignificant). Discussion: Decreases in global eating disorder psychopathology were achieved faster with CBT+. Overall, improvements in DBT-BED were comparable to those observed in CBT+. Findings of the original trial, favoring CBT+ on the number of OBE episodes, emotional dysregulation and self-esteem at EOT, and on eating disorder psychopathology and self-esteem at follow-up, were not replicated. With similar rates of treatment dropout and about half of the therapy time used in CBT+, DBT-BED can be considered a relevant treatment for BED in everyday clinical practice. Public significance: In this effectiveness study, dialectical behavior therapy (DBT) resulted in clinically relevant improvements in individuals with binge eating disorder. Changes were broadly comparable to those of cognitive behavior therapy (CBT), the current treatment of choice. Although CBT resulted in decreases in eating disorder psychopathology faster, there was a trend toward relapse in CBT at 6-month follow-up. Therefore, the less costly DBT-program can be considered a relevant treatment in clinical practice.
... Such knowledge might provide clinicians with guidance as to which intervention might fit which patient. For patients with an ED, early symptom change predict favorable outcome [30,41], while symptom severity predicts worse outcome and dropout [41]. However, since outcome definitions vary between studies the predictors will vary as well [8]. ...
... A global score can be computed, ranging from 0 to 54. The global score can be used to suggest severity level of depression: no depression (0-12), mild depression (13)(14)(15)(16)(17)(18)(19), moderate depression (20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34) or severe depression (> 34) [38]. Cronbach's alpha for MADRS-S in the present study was 0.88. ...
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Background It is important to target body image in individuals with an eating disorder (ED). Acceptance and commitment therapy (ACT) has been trialed in a few studies for individuals with an ED. Although ACT outcomes in ED patients hold promise, studies of predictors are scarce. The aim of the present study was to explore differences in ED symptom outcome at two-year follow-up in subgroups of participants attending either treatment as usual (TAU), or a group intervention based on ACT targeting body image. Additionally, we aimed to compare subjective recovery experiences between groups. Methods The study took place at a specialized ED outpatient clinic, and included patients diagnosed with an ED that had received prior treatment and achieved a somewhat regular eating pattern. Study participants were randomly assigned to continue TAU or to participate in a group intervention based on ACT for body image issues. Only participants that completed the assigned intervention and had completed follow up assessment by two-years were included. The total sample consisted of 77 women. Results In general, ACT participants showed more favorable outcomes compared to TAU, and results were more pronounced in younger participants with shorter prior treatment duration and lower baseline depression ratings. Participants with restrictive ED psychopathology had three times higher ED symptom score change if participating in ACT in comparison to TAU. Conclusions An ACT group intervention targeting body image after initial ED treatment may further enhance treatment effects. There is a need for further investigation of patient characteristics that might predict response to body image treatment, particularly regarding ED subtypes and depression ratings.
... In their review of mediators and moderators of CBT for eating disorders, Linardon et al. (2017b) found that early change, that is, improvement in eating disorder symptoms early in treatment, and reductions in dietary restraint consistently mediated outcomes across disorders, but other findings were inconsistent. Similarly, in their meta-analysis of predictors, moderators, and mediators of treatment outcomes across eating disorder diagnoses and treatment types, Vall and Wade found that early symptom reduction was the strongest predictor of treatment outcome at both the end of treatment and at follow-up. ...
Chapter
There are many types of psychotherapy used to treat binge eating in bulimia nervosa (BN) and binge-eating disorder (BED). Some of the most common psychotherapies include cognitive behavioral therapy (CBT), interpersonal psychotherapy (IPT), behavioral weight-loss treatment (BWL), third-wave therapies (e.g., dialectical behavior therapy, DBT), and family-based therapy (FBT). This chapter was designed to review the empirical evidence for each of these interventions to treat binge eating in both BN and BED. The chapter highlights the most well-supported psychotherapies and briefly discusses promising psychotherapies that are emerging in the field. Given the vast differences in binge eating treatment for adults and youth, the chapter discusses each population separately to provide the most comprehensive overview of the literature. The chapter also discusses the efficacy of these psychotherapies to address comorbidities that are often associated with binge-eating-related disorders (e.g., depression) and reviews future directions of the field.
... Practicing awareness and congruent action is a foundational principle of cognitive behavioral therapy (Fenn & Byrne, 2013). In practice, cognitive behavioral therapy frequently coupled with pharmacological intervention are the most prevalent forms of therapy for problematic or disordered eating (Linardon et al., 2017). Yet it can be argued that focusing on behavioral modification and stages of change takes time, and while it is demonstrably effective in some cases, it remains inconsistent with lasting results in others (Costin, 2007). ...
Article
Health care professionals agree that there are countless individuals with problematic eating habits that detract from health and well-being but do not directly meet the criteria for diagnosis of disorder. Previous research identifies that problematic eating patterns are notoriously challenging to address and that positive changes in behavior are difficult to maintain. This qualitative study contributes to the literature identifying potential mechanisms for transformative and lasting change for individuals exhibiting problematic eating patterns. Utilizing heuristic methodology, the lived experience of spontaneous transformation as a mechanism of change in the development of, and recovery from, problematic eating habits was illuminated and explored by the primary researcher, SS, and six female coresearchers. The data for this study were obtained through in-depth, informal conversational interviews. Heuristic analysis of the data revealed six core themes relevant to the experience of the phenomenon of spontaneous transformation and the recovery from problematic eating habits: (a) early messaging in environment of origin, (b) moments of suffering as gateways to change, (c) perceived loss of control, (d) implicit awareness resulting in transformation, (e) physical expressions of expansion and constriction, (f) and the necessity for a new definition of recovery. The findings of this study point toward the experience of spontaneous transformation as a mechanism for enhanced self-awareness and potential for generating transformational change in patterns of problematic eating.
... Moreover, the criteria applied to measure the severity of AN (e.g., Body Mass Index), bulimia nervosa (number of inappropriate compensatory behaviors) and binge eating disorder (frequency of episodes of binge eating) do not predict course and outcome of these syndromes and do not provide reliable clinical information over the long-run. Therefore, it is not surprising that these severity criteria are only occasionally used in the literature [13][14][15][16][17][18]. ...
Article
The available treatments of Eating Disorders (EDs) mirror an excessive focus on symptoms to be eliminated rather than on the acknowledgment of what is relevant from the patient’s perspective. This Editorial offers a critical review of the limitations of the DSM-5-oriented approaches, as well as of their extreme consequences, namely ocularcentrism, nosographism, and paternalistic moralism. To overcome these limitations, it is suggested to get back to Psychopathology as the basic science of psychiatric practice whose aim is to grasp the distinctly personal dimension of the patient’s experience and to connect understanding with care. With the help of Psychopathology, clinicians engaged in the treatment of ED patients will better make sense of what it is like to suffer from these disorders and be encouraged to suspend their judgment and take patient’s perspective in the light of their troubled existence which is rich in meanings and not merely in abnormal beliefs and trivial anomalous behavior. According to these principles, treatment is a journey shared with the patient, which allows her/him to feel recognized and accepted in terms of her/his individuality.
... 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.
... Although research suggests that early change during treatment consistently predicts better outcomes (Linardon, de la Piedad Garcia, & Brennan, 2017), this research did not examine whether change in the hypothesized mediators was maintained or was related to longer-term outcomes. ...
Article
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Objective: Understanding the mechanisms of action of psychological treatments is a key first step in refining and developing more effective treatments. The present study examined hypothesized mediators of change of enhanced cognitive behavior therapy (CBT-E) and interpersonal psychotherapy for eating disorders (IPT-ED). Method: A series of mediation studies were embedded in a randomized controlled trial (RCT) comparing 20 weeks of CBT-E and IPT-ED in a transdiagnostic, non-underweight sample of patients with eating disorders (N = 130) consecutively referred to the service. Three hypothesized mediators of change in CBT-E (regular eating, weighing frequency, and shape checking) and the key hypothesized mediator of IPT-ED (interpersonal problem severity) were studied. Results: The data supported regular eating as being a mediator of the effect of CBT-E on binge-eating frequency. The findings were inconclusive regarding the role of the other putative mediators of the effects of CBT-E; and were similarly inconclusive for interpersonal problem severity as a mediator of the effect of IPT-ED. Discussion: This research highlights the potential benefits of embedding mediation studies within RCTs to better understand how treatments work. The findings supported the role of regular eating in reducing patients' binge-eating frequency. Other key hypothesized mediators of CBT-E and IPT-ED were not supported, although the data were not inconsistent with them. Key methodological issues to address in future work include the need to capture both behavioral and cognitive processes of change in CBT-E, and identifying key time points for change in IPT-ED.
... [22] The results showed that EAT-8 had a negative correlation with self-compassion [47,48] and self-esteem. [49,50] Self-compassion can be seen as an emotional strategy in which negative emotions are viewed consciously and creates a sense of shared human experience in the individual. Individuals with high self-compassion are less likely to judge themselves negatively, and they are mindful about negative experiences. ...
Article
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BACKGROUND: Disordered eating attitude may lead to full-blown eating disorders. Recent longitudinal studies show that disordered eating attitudes either remain stable or even increase from childhood to adulthood. The current study was done to determine the psychometric properties of the Eating Attitudes Test-8 (EAT-8) and introduce the suitable measure for researchers and therapist in the field of clinical psychology and psychiatrist. MATERIALS AND METHODS: The Persian version of the EAT-8 was produced through forward translation, reconciliation, and back translation. A sample of 302 students were selected through convenience sampling method and completed a set of questionnaires, including the EAT-8, Eating Attitudes Test-16 (EAT-16), Eating Beliefs Questionnaire-18 (EBQ-18), self-esteem scale, and self-compassion scale short-form. The construct validity of the EAT-8 was assessed using confirmatory factor analysis and divergent and convergent validity. Internal consistency and test–retest reliability (2 weeks' interval) were conducted to evaluate the reliability. Data analysis was conducted using SPSS (version 22) software and LISREL (version 8.8). RESULTS: EAT-8 was found to be valid and reliable measures, with good internal consistency and good test–retest reliability among students. In terms of convergent validity, EAT-8 showed a significant positive correlation with self-report measures of EAT-16 and EBQ-18. EAT-8 showed a negative correlation with self-compassion and self-esteem, thus demonstrated a good divergent validity. The results of this study also provide support for the one-factor model of the EAT-8. CONCLUSION: The EAT-8 showed good validity and reliability and could be useful in assessing disordered eating in Iranian population. The EAT-8 shows notable promise as a measure for use in disordered eating research and clinical settings.
... These unsatisfactory data regarding the long-term outcome of EDs might be the consequence of the paucity of evidence regarding the mediators of the efficacy of treatment interventions on EDs psychopathology, both in terms of body uneasiness and of overvaluation of body shape/ weight [23,24]. ...
Article
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Purpose Recent studies demonstrated that the embodiment disorder represents a core feature of eating disorders (EDs). The aim of this study was to evaluate the role of its variation as a possible mediator of the efficacy of enhanced cognitive behavioural therapy (CBT-E) on classic ED symptomatology, including body uneasiness. Methods 73 patients with anorexia nervosa and 68 with bulimia nervosa were treated with a multidisciplinary approach including CBT-E. Psychometric questionnaires were administered at baseline (T0) and after one (T1) and 2 years (T2) to evaluate general and ED-specific psychopathology, body uneasiness and the embodiment disorder. Data regarding diagnostic crossover and remission were also collected. Results Longitudinal analysis showed an improvement of all psychopathological dimensions at T1, which remained stable at T2 ( p < 0.05). Remission rate at T2 was 44.7%, and diagnostic crossover occurred in 17.0% of patients. Higher levels of embodiment disorder predicted increased diagnostic instability (OR: 1.80 [1.01–3.20], p = 0.045). The amelioration of the embodiment disorder mediated the decrease in both ED-specific psychopathology (indirect effect: 0.67 [0.46–0.92]) and body uneasiness (indirect effect: 0.43 [0.28–0.59]). Conclusion For the first time, these findings highlighted the role of the embodiment disorder as a maintaining factor of ED symptomatology, supporting the importance of integrating CBT-E with a phenomenological model of EDs. Level of evidence Level IV, longitudinal observational study (case series).
... The only consistent univariate predictor of treatment outcome in eating disorders is early change in treatment (Linardon, de la Piedad Garcia, & Brennan, 2017), with an effect size of 0.51 at end of treatment (Vall & Wade, 2015). Early changes in weight have been particularly indicated as a predictor of outcome in the treatment of anorexia nervosa (AN) in both adolescents (e.g., Van Huysse, Smith, Mammel, Prohaska, & Rienecke, 2020) and adults. ...
Article
Objective To better understand those patients with anorexia nervosa who do not show early response to treatment and are likely to have poorer outcome. Method From an existing data set of 187 patients with anorexia nervosa across 22 eating disorder outpatient services in the United Kingdom, participants who had started treatment and had at least one body mass index (BMI) observation in the first 6 weeks of treatment were eligible for these secondary analyses (N = 65), a latent class analysis of BMI change over the first 6 weeks of treatment. Fifty‐six patients showed no early change in BMI. We used logistic regression to examine predictors of good outcome in the 40 participants who had 12‐month follow‐up data. Predictors included global EDE‐Q, negative affect (Depression, Anxiety, and Stress Scales) and functional impairment (Work and Social Adjustment Scale). Results Good outcome was achieved by 23% of patients and remission by 15%. Good outcome was predicted by greater functional impairment at baseline. Discussion Further work that can identify sub‐groups of patients with anorexia nervosa who do not achieve good outcome after treatment will inform the development of targeted engagement approaches.
... From an empirical perspective, the need for reducing the complexity of the psychotherapeutic system into few coarse-grained macro-parameters is justified by the continuously increasing number of identified singleand multiple-outcome predictors (de Felice et al., 2019a). In a recent systematic review on the outcome of cognitive-behavioral therapy for eating disorders, for instance, Linardon et al. (2017) found 6 mediators, 13 moderators, and 20 predictors while considering only patient characteristics (i.e., excluding any relational or therapist-related variables); also, no other forms of therapies or diagnoses were included in the review. ...
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Statistical mechanics is the field of physics focusing on the prediction of the behavior of a given system by means of statistical properties of ensembles of its microscopic elements. The authors examined the possibility of applying such an approach to psychotherapy research with the aim of investigating (a) the possibility of predicting good and poor outcomes of psychotherapy on the sole basis of the correlation pattern among their descriptors and (b) the analogies and differences between the processes of good-and poor-outcome cases. This work extends the results reported in a previous paper and is based on higher-order statistics stemming from a complex network approach. Four good-outcome and four poor-outcome brief psychotherapies were recorded, and transcripts of the sessions were coded according to Mergenthaler's Therapeutic Cycle Model (TCM), i.e., in terms of abstract language, positive emotional language, and negative emotional language. The relative frequencies of the three vocabularies in each word-block of 150 words were investigated and compared in order to understand similarities and peculiarities between poor-outcome and good-outcome cases. Network analyses were performed by means of a cluster analysis over the sequence of TCM categories. The network analyses revealed that the linguistic patterns of the four good-outcome and four poor-outcome cases were grounded on a very similar dynamic process substantially dependent on the relative frequency of the states in which the transition started and ended ("random-walk-like behavior", adjusted R 2 = 0.729, p < 0.001). Furthermore, the psychotherapy processes revealed statistically significant changes in the relative occurrence of visited states between the beginning and the end of therapy, thus pointing to the non-stationarity of the analyzed processes. The present study showed not only how to quantitatively describe psychotherapy as a network, but also found out the main principles on which its evolution is based. The mind, from a linguistic perspective, seems to work-through psychotherapy sessions by passing from the most adjacent states and the most occurring ones. This finding can represent a fertile ground to rethink pivotal clinical concepts such as the timing of an interpretation or a comment, the clinical issue to address within a given session, and the general task of a psychotherapist: from someone who delivers a given technique toward a consultant promoting the flexibility of the clinical field and, thus, of the patient's mind.
... [39][40][41] To explaining the result, individual with eating disorders may have some personal vulnerability such as emotional-sensitive reactivity and experience of invalid response, which cause them to apply dysfunctional emotional strategy like rumination and thought suppression in response to negative affect. The results showed that EBQ-18 and subscales had a negative and significant correlation with self-compassion, [42,43] self-esteem, [44,45] and eating self-efficacy. [46,47] To explaining the result, self-efficacy is a significant factor which enable the individual to manage emotions and stressful situation successfully. ...
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Background: Metacognitive beliefs play an essential role in the maintenance of binge eating behavior. Examining the psychometric properties of tools in societies with different cultures than western societies can help with examining the external validity of those tools. This research aimed at standardization and validation of the Eating Beliefs Questionnaire (EBQ-18) in Iran. Materials and methods: Persian version of the EBQ-18 was produced through forward translation, reconciliation, and back translation. A total of 302 non-WEIRD nonclinical students were selected through convenience sampling method and completed a set of questionnaires, including the EBQ-18, Eating Attitude Test-16 (EAT-16), Difficulties in Emotion Regulation Scale-16 (DERS-16), Weight Efficacy Lifestyle Questionnaire-Short Form (SF), self-esteem scale, and self-compassion scale (SCS) short-form. The construct validity of the EBQ-18 was assessed using confirmatory factor analysis and divergent and convergent validity. Internal consistency and test-retest reliability (2 weeks' interval) were used to evaluate the reliability. Data analysis was performed using LISREL (version 8.8) and SSPS (version 22) softwares. Results: EBQ-18 and subscales were found to be valid and reliable measures, with high test-retest reliability and good internal consistency in the nonclinical sample. Cronbrash's Alpha coefficient, for the whole of scale, negative beliefs scale, Permissive Beliefs scale, and Positive Beliefs scale were gained. 96.,89.,90, and. 94 respectively. Intraclass correlations coefficient, for the whole of scale, negative beliefs scale, Permissive Beliefs scale, and Positive Beliefs scale were gained. 84.,78.,75, and. 87, respectively. In terms of convergent validity, EBQ-18 and subscales showed a significant positive correlation with selfreport measures of EAT-16 and DERS-16 (P < 0.01). EBQ-18 and subscales showed a negative correlation with self-compassion, self-esteem, and eating self-efficacy, thus demonstrated divergent validity with these constructs (P < 0.01). The results showed that three factors of negative beliefs, positive beliefs, and permissive beliefs had the goodness of fit indices (root mean square error of approximation = 0.08, normed fit index = 0.97, nonnormed fit index = 0.98, comparative fit index = 0.98, and standardized root mean square residual = 0.04). The results of this study support the EBQ-18 three-factor model. Conclusion: These findings indicate that the EBQ-18 is a reliable measure of eating beliefs in the Iranian population. In addition, the study supplements the literature on the cross-cultural validity of this measure.
... 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.
... Second, our study design provides possible insights towards understanding how online CBT programmes work. As it stands, the mechanisms of change during traditional CBT for eating disorders are largely unknown because most existing studies have failed to investigate the isolated effects of specific techniques that form part of the multi-modular programme (Linardon, de la Piedad Garcia, & Brennan, 2016). Present findings may suggest that digital CBT could 'work' at least in part via three core techniques emphasised in this intervention, namely self-monitoring, the prescription of regular eating patterns, or forbidden food exposure. ...
Article
Background Existing internet-based prevention and treatment programmes for binge eating are composed of multiple distinct modules that are designed to target a broad range of risk or maintaining factors. Such multi-modular programmes (1) may be unnecessarily long for those who do not require a full course of intervention and (2) make it difficult to distinguish those techniques that are effective from those that are redundant. Since dietary restraint is a well-replicated risk and maintaining factor for binge eating, we developed an internet- and app-based intervention composed solely of cognitive-behavioural techniques designed to modify dietary restraint as a mechanism to target binge eating. We tested the efficacy of this combined selective and indicated prevention programme in 403 participants, most of whom were highly symptomatic (90% reported binge eating once per week). Method Participants were randomly assigned to the internet intervention ( n = 201) or an informational control group ( n = 202). The primary outcome was objective binge-eating frequency. Secondary outcomes were indices of dietary restraint, shape, weight, and eating concerns, subjective binge eating, disinhibition, and psychological distress. Analyses were intention-to-treat. Results Intervention participants reported greater reductions in objective binge-eating episodes compared to the control group at post-test (small effect size). Significant effects were also observed on each of the secondary outcomes (small to large effect sizes). Improvements were sustained at 8 week follow-up. Conclusions Highly focused digital interventions that target one central risk/maintaining factor may be sufficient to induce meaningful change in core eating disorder symptoms.
... From an empirical perspective, the need for reducing the complexity of the psychotherapeutic system into few coarse-grained macro-parameters is justified by the continuously increasing number of identified singleand multiple-outcome predictors (de Felice et al., 2019a). In a recent systematic review on the outcome of cognitive-behavioral therapy for eating disorders, for instance, Linardon et al. (2017) found 6 mediators, 13 moderators, and 20 predictors while considering only patient characteristics (i.e., excluding any relational or therapist-related variables); also, no other forms of therapies or diagnoses were included in the review. ...
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Table of Contents -Editorial: The Patient’s Change: Understanding the Complexity of the Dynamics of Change and Its Precursors in Psychotherapy Giulio de Felice, Melissa M. De Smet, Reitske Meganck and Guenter Schiepek -The Role of Entrapment in Crisis-Focused Psychotherapy Delivered in Psychiatric Emergency Settings: A Comparative Study Dana Tzur Bitan, Adi Otmazgin, Mirit Shani Sela and Aviv Segev -Love, Work, and Striving for the Self in Balance: Anaclitic and Introjective Patients’ Experiences of Change in Psychoanalysis Andrzej Werbart, Annelie Bergstedt and Sonja Levander -The Action of Verbal and Non-verbal Communication in the Therapeutic Alliance Construction: A Mixed Methods Approach to Assess the Initial Interactions With Depressed Patients Luca Del Giacco, M. Teresa Anguera and Silvia Salcuni -Roles of Trait Mindfulness in Behavioral Activation Mechanism for Patients With Major Depressive Disorder Koki Takagaki, Masaya Ito, Yoshitake Takebayashi, Shun Nakajima and Masaru Horikoshi -What Differentiates Poor- and Good-Outcome Psychotherapy? A Statistical-Mechanics-Inspired Approach to Psychotherapy Research, Part Two: Network Analyses Giulio de Felice, Alessandro Giuliani, Omar C. G. Gelo, Erhard Mergenthaler, Melissa M. De Smet, Reitske Meganck, Giulia Paoloni, Silvia Andreassi, Guenter K. Schiepek, Andrea Scozzari and Franco F. Orsucci -A Mixed Methods Framework for Psychoanalytic Group Therapy: From Qualitative Records to a Quantitative Approach Using T-Pattern, Lag Sequential, and Polar Coordinate Analyses Eulàlia Arias-Pujol and M. Teresa Anguera -A Phase Transition of the Unconscious: Automated Text Analysis of Dreams in Psychoanalytic Psychotherapy Alessandro Gennaro, Sylvia Kipp, Kathrin Viol, Giulio de Felice, Silvia Andreassi, Wolfgang Aichhorn, Sergio Salvatore and Günter Schiepek -Convergent Validation of Methods for the Identification of Psychotherapeutic Phase Transitions in Time Series of Empirical and Model Systems Günter Schiepek, Helmut Schöller, Giulio de Felice, Sune Vork Steffensen, Marie Skaalum Bloch, Clemens Fartacek, Wolfgang Aichhorn and Kathrin Viol -Long-Term Effects of Home-Based Family Therapy for Non-responding Adolescents With Psychiatric Disorders. A 3-Year Follow-Up Egon Bachler, Benjamin Aas, Herbert Bachler, Kathrin Viol, Helmut Johannes Schöller, Marius Nickel and Günter Schiepek
... [42,43] To explaining the result, individual with eating disorders may have some personal vulnerability such as emotional-sensitive reactivity and experience of invalid response, which cause them to apply dysfunctional emotional strategy like rumination and thought suppression in response to negative affect. The results showed that EAT-16 and subscales had a negative correlation with self-compassion, [44,45] self-esteem, [46,47] and eating self-efficacy. [48][49][50] To explaining the result, self-efficacy is a significant factor which enables the individual to managing emotions and stressful situation successfully. ...
Article
Background: Screening for eating disorders via reliable instruments is of high importance for clinical and preventive purposes. Examining the psychometric properties of tools in societies with differing dynamics can help with their external validity. This research specifically aimed at standardization and validation of the eating attitude test (EAT-16) in Iran. Methods: The Persian version of the EAT-16 was produced through forward translation, reconciliation, and back translation. The current research design was descriptive cross-sectional (factor analysis). A total of 302 nonclinical students were selected through the convenience sampling method and completed a set of questionnaires. The questionnaires included, the EAT-16, eating beliefs questionnaire-18 (EBQ-18), difficulties in emotion regulation scale-16 (DERS-16), weight efficacy lifestyle questionnaire-short form, self-esteem scale, and self-compassion scale short-form. The construct validity of the EAT-16 was assessed using confirmatory factor analysis and divergent and convergent validity. Internal consistency and test-retest reliability (2 weeks' interval) were used to evaluate the reliability. Data analysis was conducted using LISREL (version 8.8) and SSPS (version 22) software. Results: EAT-16 and subscales were found to be valid and reliable, with good internal consistency and good, test-retest reliability in a non-clinical sample. In terms of convergent validity, EAT-16 and subscales showed a positive correlation with the selfreport measures of EBQ-18 and DERS-16. EAT-16 and subscales showed a negative correlation with self-compassion, self-esteem and eating self-efficacy., Therefore, it demonstrated divergent validity with these constructs. The results of this study support the EAT-16 four-factor model. Conclusions: The EAT-16 showed good validity and reliability and could be useful in assessing eating disorders in Iranian populations. The EAT-16 is an efficient instrument that is suitable for screening purposes in the nonclinical samples.
... However, it is possible that the high relapse and chronicity rate can be attributed to the less clear efficacy on a more profound psychopathological core. Very few empirical studies reported evidence regarding the mediators of the efficacy of treatment interventions on EDs psychopathology [143,144]. CBT-E is first and foremost aimed at interrupting abnormal behaviours, such as starvation, binge-eating and body checking, through the disputing of the distorted beliefs related to body shape and weight. Therefore, it seems that the research is also biased on an optical-coenaesthetic disproportion in its choice of treatment target and treatment mediators [145]. ...
Article
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Cognitive, psychodynamic, and phenomenological scholars converged their attention on abnormal bodily phenomena as the core psychopathological feature of eating disorders (EDs). While cognitive approaches focus their attention on a need for “objective” (i.e., observable, measurable) variables (including behaviours and distorted cognitions), the phenomenological exploration typically targets descriptions of persons’ lived experience. According to a new emerging phenomenological perspective, the classic behavioural and cognitive symptoms of EDs should be considered as epiphenomena of a deeper core represented by a disorder of the embodiment. The cognitive–behavioural model is the most studied and, up till now, clinically efficacious treatment for EDs. However, as any coherent and scientifically grounded model, it presents some limitations in its application. Numerous patients report a chronic course, do not respond to treatment and develop a personality structure based on pathological eating behaviours, since “being anorexic” becomes a new identity for the person. Furthermore, the etiopathogenetic trajectory of EDs influences the treatment response: for example, patients reporting childhood abuse or maltreatment respond differently to cognitive-behavioural therapy. To obtain a deeper comprehension of these disorders, it seems important to shift attention from abnormal eating behaviours to more complex and subtle psycho(patho)logical features, especially experiential ones. This characterisation represents the unavoidable premise for the identification of new therapeutic targets and consequently for an improvement of the outcome of these severe disorders. Thus, the present review aims to provide an integrated view of cognitive, psychodynamic, and phenomenological perspectives on EDs, suggesting new therapeutic targets and intervention strategies based on this integrated model. Level of Evidence: Level V. Level of evidence Level V: Opinions of authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.
... Non-specific predictors, moderators, and mediators of ED outcome have been of increasing interest, with several recently published reviews [55,56], but none has comprehensively examined these associations specifically in FBT. Mechanisms of action are processes that occur within treatment that lead to therapeutic change and include treatment mediators [57]. ...
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Purpose This scoping review presents an up-to-date synthesis of the current evidence base for non-specific predictors, moderators, and mediators of family-based treatment (FBT) for adolescent anorexia and bulimia nervosa. Methods We identify ways in which end-of-treatment outcomes have been shown to differ based upon baseline clinical features and person-specific factors and explore psychological mechanisms that may explain differences in treatment response. We draw from this evidence base to outline recommendations for clinical practice, as well as directions for future clinical eating disorder research. Results Noted findings from review include that early response in weight gain and parental criticism may be particularly influential in treatment for anorexia nervosa. Further, for adolescents with either anorexia or bulimia nervosa, eating-related obsessionality may be a key intervention target to improve outcomes. Conclusion In addition to highlighting a need for attention to specific patient- and caregiver-level factors that impact treatment response, recommendations for research and clinical practice include testing whether certain targeted treatments (e.g., exposure-based approaches) may be suitable within the context of FBT for eating disorders. Level of evidence Level I: Evidence obtained from: at least one properly designed randomized controlled trials; experimental studies.
... Even with more empirically supported treatments available however, it is important to recognize that clear superiority of one form of treatment over another is rarely found in head-to-head trials (e.g., Crow, 2003;Kristeller et al., 2014;Stice et al., 2019;Wonderlich et al., 2014). Accordingly, research efforts have turned to a more intentional focus on mechanisms and moderators to help guide decisions about treatment targets and for whom certain modalities may be better suited (e.g., Barney et al., 2019;Linardon et al., 2017). To be sure, funding agencies have shown that identification of treatment process variables is useful at the earliest stages of research, such as pilot and acceptability/feasibility testing. ...
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To enhance access to evidence-based treatment it is increasingly important to evaluate scalable virtual programs that support the needs of those struggling with disordered eating. This study described a scientifically grounded, trauma-informed framework known as Body Trust,® and aimed to pilot test the preliminary effectiveness and mechanisms of change in a Body Trust® program to improve disordered eating. Using quality outcomes data, we examined 70 mostly white (87%) female-identifying (97%) individuals enrolled in a 6-module online program based in the Body Trust® framework (Mage = 45.5 ±10.9; MBMI = 33.7 ±8.0). Putative mediators included traumatic stress, internalized weight stigma, and body shame. Outcomes were objective and subjective binge episodes, overvaluation of weight and shape, and eating concerns. Generalized estimating equations were applied to determine pre-to-post changes. We applied Montoya's MEMORE macro, the joint-significance test, and calculated 95% Monte Carlo confidence intervals to assess mediation. Significant pre-to-post improvements with medium to large effect sizes were detected for all outcomes and mediators (ps<.008). All hypothesized mechanisms supported mediation. Using the Body Trust® framework shows early promise for alleviating disordered eating symptoms through targeting traumatic stress, body shame, and internalized weight stigma. Given the program's use of mindfulness techniques, future research should test target mechanisms like interoception.
Article
Research findings strongly suggest that cognitive behavioral therapy for the eating disorders (CBT-ED) is more effective than other treatments for bulimia nervosa (BN) and for binge eating disorder (BED), although interpersonal psychotherapy appears to be equally effective for BED. Evidence for the effectiveness of CBT-ED for the persistent (adult) form of anorexia nervosa (AN) is insufficient at present and is essentially absent for AN in adolescents except for some evidence from uncontrolled trials. This article begins with an overview of the early studies in the development of CBT-ED that showed a similar effectiveness of other symptom-focused psychotherapies—a finding that was neglected at the time. Later developments are then considered, including comparisons of CBT-ED with other psychotherapies, efforts to develop Internet-based training and treatment, and electronic applications for treatment. Finally, implications of the findings for future short- and long-term research and for clinical practice are considered.
Article
Objective CBT-T is a relatively new, brief cognitive behavioral therapy eating disorder treatment for non-underweight patients. This study evaluates CBT-T independently from the team that developed the protocol, and examines the relationship between eating disorder duration and CBT-T effectiveness. Method A case series design was used, comprising N = 40 adults with bulimia or atypical anorexia type eating disorders. CBT-T was delivered by CBT therapists in a specialist outpatient service. Mixed model analysis examined the interactions between eating disorder duration and change to eating disorder psychopathology and secondary impairment from pre-post treatment. Abstinence, good outcome, and remission rates were also provided. Results Intervention effect sizes were large. Treatment completers reported abstinence from binge eating and purging over the final 28-days, and 7-days of treatment at 30.1%, and 73.1%, respectively; 76.9% reported good outcome; and 23.1% reported remission. No relationship between eating disorder duration and treatment effectiveness was found. Discussion These findings build on existing evidence supporting provision of CBT-T in routine clinical practice, for patients with eating disorders of any duration. Replication, extension, and RCT will strengthen comparability with other evidence-based approaches.
Article
Introduction: Specific characteristics of sleep (e.g., duration, quality, and fatigue) are positively associated with (ED) behaviors, specifically binge eating (BE) potentially through decreased self-regulation and increased appetite. However, prior work has been largely cross-sectional and has not examined temporal relationships between sleep characteristics and next-day ED behaviors. Thus, the present study examined daily relationships between sleep and ED behaviors among individuals with binge-spectrum EDs. Method: Participants (N = 96) completed 7 daily ecological momentary assessment (EMA) surveys over 7-14 days; morning surveys assessed sleep characteristics and 6 randomly timed surveys each day captured ED behaviors. Analyses examined within-subject and between-subject effects of sleep quality, duration, and fatigue on BE, compensatory purging behaviors, and maladaptive exercise. Results: Within-subject sleep quality was significantly negatively associated with engagement in maladaptive exercise later that day. Additionally, between-subject sleep duration was significantly negatively associated with engagement in compensatory purging behaviors. Discussion: Within- and between-subjects associations between sleep quality and duration and compensatory behavior engagement indicate that sleep plays an important role in ED behaviors. Future research should incorporate sensor-based measurement of sleep and examine how specific facets of sleep impact BE and treatment response. Level of evidence: Level II: Evidence obtained from controlled trial without randomization.
Article
Objective: Effective treatments exist for binge-eating disorder (BED), although roughly 50% of patients fail to attain binge-eating abstinence. Evidence on how to refine treatments is lacking. Conceptualizing BED as arising from a network of symptom-to-symptom interactions allows for the identification of the most strongly connected symptoms, which could inform intervention targets. This study assessed how BED symptom centrality changed with behaviorally based weight-loss treatments (BBWLTs). Methods: Participants were 191 adult patients (71% female, 79% White) with BED with comorbid obesity participating in a randomized controlled trial testing 6-month BBWLTs for BED. Independent assessments of BED symptoms were performed at pretreatment, posttreatment, and 12 months after treatment. Strength centrality indicated how strongly and frequently symptoms were associated with each other in the network. Significant changes in centrality between timepoints were determined using permutation tests. Results: At pretreatment, overvaluation of shape/weight and preoccupation with shape/weight and food/eating had the highest strength centrality. At posttreatment and 12-month follow-up, dissatisfaction with shape/weight had the highest centrality, which significantly increased from pretreatment. Conclusions: The relations among symptoms of BED are not static and change over time with treatment. BBWLTs do not appear to reduce connectivity of overvaluation of shape/weight (the most central BED symptom prior to treatment), but instead increase connectivity of dissatisfaction with shape/weight with other symptoms following treatment. The observed network structure of symptoms following BBWLTs resembles network analyses of people without eating disorders. Findings highlight the importance of understanding how treatments impact symptom relationships, not just symptom intensities. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
Article
Despite growing interest in the possible link between positive body image and eating disorder (ED) symptoms, little is known about what role this adaptive construct plays in ED treatment. This study investigated whether: (1) interventions principally designed to target ED psychopathology also lead to improvements in positive body image indices (i.e., body appreciation, functionality appreciation, and body image flexibility); (2) changes in ED symptoms correlate with changes in positive body image, both concurrently and prospectively; and (3) baseline positive body image levels moderate the degree of symptom improvement. Secondary analyses from a randomized controlled trial on digital interventions for EDs (n=600) were conducted. Intervention participants reported greater increases in the three positive body image constructs than the control group (ds=0.15-0.41). Greater pre-post reductions in ED psychopathology and binge eating were associated with greater pre-post improvements in positive body image indices. However, earlier reductions in ED psychopathology and binge eating did not predict later improvements in positive body image at follow-up. None of the positive body image constructs at baseline moderated degree of symptom change. Standard ED interventions can cultivate a more positive body image, although this is not explained by earlier symptom reduction. Understanding the mechanisms through which ED interventions enhance positive body image is needed.
Chapter
Self-help interventions (SHIs) represent established psychological treatments for binge-eating disorder (BED) and bulimia nervosa (BN) with demonstrated short- and long-term efficacy. Implemented via self-help books, the internet, or smartphone applications, SHIs are highly accessible and may thus be suited to overcome patient- and provider-related barriers in traditional face-to-face psychological treatments. SHIs can be offered with or without professional guidance, with some evidence on more favorable outcomes with higher degrees of guidance. Key limitations of SHIs include low acceptability and participation, depicted through insufficient treatment engagement and completion as well as patient adherence, and should, therefore, be further investigated and enhanced. Predictors of outcome, including treatment-specific moderators and mediators, are largely unclear. The individual tailoring of interventions and their components to individual patients is part of the high potential of technology-based SHIs, although these remain underutilized and understudied. Cost-effectiveness compared to minimal treatment was suggested for SHIs and might be increased using complex models of care including SHIs. In sum, more research is needed to understand and further establish SHIs as psychological approaches to the treatment of BED and BN.
Article
Objective: Hedonic hunger (i.e., the motivation to consume palatable foods in the absence of an energy deficit) has been associated with the onset and maintenance of loss of control (LOC) eating. However, it remains underexplored as a mechanism of action in outpatient cognitive behavioral therapy (CBT) for bulimia nervosa (BN). In the present study, we hypothesized that reductions in hedonic hunger would significantly mediate reductions in overall eating pathology and LOC episodes in two samples (N 1 = 28, N 2 = 23) of 20 and 16 sessions, respectively. Method: Participants completed the Eating Disorder Examination (EDE) and Power of Food Scale (PFS) at pre‐ and post‐treatment. Results: In both samples, EDE Global scores, LOC episodes, and PFS Total scores significantly improved over the course of treatment. In Sample 1, significant indirect effects of PFS Total scores on EDE Global scores and LOC episodes were observed. In Sample 2, the indirect effect of PFS Total scores was significant on EDE Global scores and nonsignificant on LOC episodes though it followed a similar pattern of change. Discussion: Results suggest that reductions in hedonic hunger are associated with better outcomes in CBT for BN. Replication and further research is needed to elucidate the treatment components driving these reductions.
Article
Cognitive behaviour therapy-enhanced (CBT-E) is an effective treatment for non-underweight patients with eating disorders. Its efficacy and effectiveness is investigated mostly among transdiagnostic samples and remains unknown for binge eating disorder. The aim of the present study was to assess several treatment outcome predictors and to compare effectiveness of CBT-E among adult out-patients with bulimia nervosa ( n =370), binge eating disorder ( n =113), and those with a restrictive food pattern diagnosed with other specified feeding and eating disorders ( n =139). Effectiveness of CBT-E was assessed in routine clinical practice in a specialised eating disorders centre. Eating disorder pathology was measured with the EDEQ pre- and post-treatment, and at 20 weeks follow-up. Linear mixed model analyses with fixed effect were performed to compare treatment outcome among the eating disorder groups. Several predictors of treatment completion and outcome were examined with a regression analysis. No predictors for drop-out were found, except the diagnosis of bulimia nervosa. Eating disorder pathology decreased among all groups with effect sizes between 1.43 and 1.70 on the EDE-Q total score. There were no differences in remission rates between the three groups at end of treatment or at follow-up. Eating disorder severity at baseline affected treatment response. The results can be generalised to other specialised treatment centres. No subgroup of patients differentially benefited from CBT-E supporting the transdiagnostic perspective for the treatment of eating disorders. Longer-term follow-up data are necessary to measure persistence of treatment benefits. Key learning aims (1) What is the effectiveness of CBT-E among patients suffering from binge eating disorder? (2) Does any subgroup of patients suffering from an eating disorder differentially benefit from CBT-E? (3) What factors predict treatment response?
Article
Objective A substantial proportion of patients with binge-eating disorder (BED) do not derive sufficient benefits from available evidence-based psychological interventions. We examined depression scores as predictors and moderators of response to cognitive-behavioral therapy (CBT) and behavioral weight-loss (BWL) for BED. We explored associations between changes in depression scores and changes in treatment outcomes. Method Ninety adults with BED with obesity were randomized to CBT or BWL (6 months) and were evaluated independently throughout treatment, at posttreatment, and 12-month follow-up after treatments (18 months post-randomization). Pre-treatment depression scores, early changes in depression, and changes in depression from pre- to post-treatment were tested as predictors/moderators of outcomes (binge-eating frequency and eating-disorder psychopathology). Results Baseline depression scores did not predict nor moderate outcomes at post-treatment or 12-month follow-up. Changes in depression scores (both early and throughout treatment) were not associated significantly with changes in binge-eating frequency or eating-disorder psychopathology at post-treatment or 12-month follow-up. Discussion Findings suggest depression scores do not predict nor moderate acute- or longer-term outcomes in patients with BED receiving CBT or BWL. Findings reinforce need to improve treatments for BED overall, although they provide confidence that patients with elevated depression scores derive benefits from existing CBT and BWL interventions.
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Background: Individuals with bulimia nervosa (BN) experience persistent episodes of binge eating and inappropriate compensatory behavior associated with impaired physical and mental health. Despite the existence of effective treatments, many individuals with BN remain untreated, leading to a high burden and an increased risk of chronicity. Web-based interventions may help facilitate access to evidence-based treatments for BN by reducing barriers to the health care system. Methods: The present study will investigate the effectiveness of a web-based self-help intervention for BN in a two-armed, randomized controlled trial. Individuals diagnosed with BN (N = 152) will be randomly assigned to either (1) an intervention group receiving a 12-week web-based intervention or (2) a waitlist control group with delayed access to the intervention. Further assessments will be scheduled 6 (mid-treatment) and 12 (post-treatment) weeks after baseline. Changes in the number of binge eating episodes and compensatory behaviors will be examined as primary outcomes. Secondary outcomes include global eating pathology, functional impairments, well-being, comorbid psychopathology, self-esteem, and emotion regulation abilities. Discussion: Adding web-based interventions into routine care is a promising approach to overcome the existing treatment gap for patients with BN. Therefore, the current study will test the effectiveness of a web-based intervention for BN under standard clinical care settings. Trial registration: ClinicalTrials.gov, Identifier: NCT04876196 (registered on May 6th, 2021).
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.
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Objective: The network theory of mental disorders conceptualizes eating disorders (EDs) as networks of interacting symptoms. Network analysis studies in EDs mostly have examined transdiagnostic and/or mixed age samples. The aim of our study was to investigate similarities and differences of networks in adolescents and adults with anorexia nervosa (AN) or bulimia nervosa (BN). Method: Participants were 2,535 patients (n = 991 adults with AN, n = 821 adolescents with AN, n = 473 adults with BN, and n = 250 adolescents with BN) who completed the Eating Disorder Inventory-2. Twenty-seven items were selected. Cross-sectional networks were estimated via Joint Graphical Lasso. Core symptoms were identified using strength centrality. Spearman correlations and network comparison tests (NCTs) were used to compare groups. Results: Across diagnoses and ages, feeling ineffective, desire to be thinner, worries that feelings will get out of control, guilt after overeating as well as doing things perfectly emerged as most central symptoms. There were moderate to high correlations between symptom profiles (0.62-0.97, mean: 0.78) as well as high correlations between network structures (0.83-0.93, mean: 0.87) and network strengths (0.73-0.95, mean: 0.85). Global strength significantly differed in two of the six NCTs, and 2.5-10% of edges differed between networks. Discussion: Considerable similarities in network structures and strengths across diagnoses and ages speak in favor of the transdiagnostic approach to EDs. Besides drive for thinness, ineffectiveness, emotion regulation difficulties, and perfectionism might be the most consistent factors in ED networks. These symptoms as well as their symptom connections should be especially focused in treatment regardless of age and diagnosis.
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
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
Objective Socio-economic-status (SES) has rarely been reported or investigated in eating disorders (EDs) research. This Research Forum considers, from various perspectives, how SES may impact on evaluating evidence-based treatments for EDs. Method We first reviewed previous literature that informs how SES impacts prevalence of EDs, help-seeking, and treatment outcome. We then present findings from a case series effectiveness study of an early intervention program in low SES areas for EDs and discuss implications about the impact of SES on the effectiveness of evidence-based interventions. Finally, we examine barriers to conducting rigorous evaluations in this population and discuss directions for future treatment outcome research. Results Evidence suggests a higher level of disordered eating but less help seeking in lower SES groups. In our case series, 96 participants started treatment and completed a mean of 13.85 sessions, 84 (87.5%) completed a mean of 6.40 sessional measures on ED cognitions and behaviors, but only 31% completed more extensive pre-treatment and post-treatment measures. The completer effect size decrease for the global Eating Disorder Examination-Questionnaire score was 2.05 (95% CI: 1.43, 2.68) commensurate with other effectiveness studies in mixed SES groups. The high rates of missing data related to more extensive assessment present a barrier to evaluating evidence-based treatments in this population. Discussion Evidence from the present study revealed individuals from low SES can achieve similar treatment outcomes to other populations when receiving evidence-based ED treatment. Future studies should investigate a range of approaches to maximizing data collection, including use of shorter sessional measures.
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Background: Acceptance and Commitment Therapy (ACT) resulted to be efficacious in promoting the core process of Psychological Flexibility, a key ability related to physical and psychological health outcomes. Despite evidence-based ACT protocols were applied successfully in different contexts, including the promotion of long-standing behavioral change, the impact of the single processes in the psychological flexibility model remains unclear. The aim of the present study is to evaluate the efficacy of a Focused-ACT intervention for the maintenance of a healthy lifestyle, by separating and evaluating the impact of single core processes targeted into a modular intervention on the maintenance of healthy lifestyle. Methods: An individually randomized group treatment trial will be conducted. 150 adult obese patients who are attending a four-week medically-based multidisciplinary rehabilitation of weight loss will be randomly allocated into three groups: Module Engage, Module Openness, and Module Awareness. At the beginning (Time 0) and at the end of the intervention (Time 1), at six months (Time2) and one year (Time 3) follow-up weight and height will be recorder and participants will complete the Psychological General Well Being Inventory(PGWBI), the Outcome Questionnaire-45.2 (OQ-45.2), the Brief Values Inventory (BVI), the Committed Action Questionnaire (CAQ), the Italian-Cognitive Fusion Questionnaire (I-CFQ), the Acceptance and Action Questionnaire (AAQ II) and the Five Facet Mindfulness Questionnaire (FFMQ). Repeated measures 3 (conditions) x 4 (times) will be assessed to examine differences between three groups within four times on both general outcomes measure of weight, BMI, PGWBI and OQ-45.2, and FACT processes targeted during the interventions. Discussion: By providing additional evidence supporting the relevance of modular transdiagnostic interventions in clinical practice and the use of Process-Based Therapy, this study will contribute to clarify which mechanisms are involved in a generalizable lifestyle behavioral change intervention. Trial registration ClinicalTrials.gov Registration number: NCT04474509 Date: July, 4 2020 https://clinicaltrials.gov/ct2/show/NCT04474509
Article
Zusammenfassung Die Binge-Eating-Störung (BES), als eigenständige Essstörung erstmals im Diagnostischen und Statistischen Manual psychischer Störungen DSM-5 definiert, ist durch wiederkehrende Essanfälle ohne gewichtskompensatorische Verhaltensweisen gekennzeichnet. Die breitere Definition in der avisierten International Classification of Diseases ICD-11 wird zu Veränderungen in Präsentation und Prävalenz dieser Störung führen. Die BES tritt vor dem Hintergrund einer komplexen, multifaktoriellen Ätiologie auf und geht mit einer erhöhten Essstörungs- und allgemeinen Psychopathologie, psychischen und körperlichen Komorbidität einschließlich Adipositas und verringertem Funktionsniveau einher. Trotz dieser Beeinträchtigungen wird die BES häufig weder diagnostiziert noch behandelt. Evidenzbasierte Therapien für die BES umfassen die Psychotherapie, wobei die Kognitive Verhaltenstherapie das etablierteste Verfahren darstellt, und die strukturierte Selbsthilfebehandlung. Andere Therapien wie die Pharmakotherapie, behaviorale Gewichtsreduktionstherapie und Kombinationstherapien erhielten in den aktuellen evidenzbasierten S3-Essstörungsleitlinien einen geringeren Empfehlungsgrad für spezielle Indikationen.
Article
Cognitive behaviour therapy for eating disorders (CBT-ED) outperforms other treatments for non-underweight eating disorders in adults, but we have limited ability to match CBT-ED to individual profiles. We examined if we could identify who benefits most from two forms of 10-session CBT-ED; one emphasizing early behaviour change with substantial content on improving body image (CBT-T), and the other including motivational work and no content on body image using chapters from self-help books (CBTm). Participants were 98 consecutive referrals to the Flinders University Services for Eating Disorders. Fourteen clinical psychology postgraduates delivered the treatment under expert supervision. Outcome measures were completed on five occasions: baseline, 4-, 10-, 14- and 22-weeks post-randomisation. Our primary outcome was global eating psychopathology. Moderators included motivation (readiness and confidence to change) and body avoidance and body checking. Intent-to-treat analyses showed no difference between the groups with a significant main effect of time associated with large effect size improvements, commensurate with longer forms of CBT-ED. Participants with lower readiness to change in CBTm had significantly greater decreases in disordered eating over follow-up compared to those with low motivation in CBT-T. People with lower readiness to change might benefit from the incorporation of motivational work in CBT-ED.
Article
Objective Cognitive-behavioral therapy (CBT)—therapist-led (CBTth) and guided-self-help (CBTgsh)—has efficacy for binge-eating disorder (BED) but many patients do not benefit sufficiently. We examined predictors and moderators for these two CBT methods. Method Data were aggregated from randomized controlled trials (RCTs) testing psychosocial treatments for BED in the U.S. Predictors and moderators of outcomes (treatment completion and binge-eating remission) were examined in N = 457 participants who received either CBTgsh (N = 164) or CBTth (N = 293). Results Analyses, adjusting for demographic/clinical variables, indicated CBTth was significantly superior to CBTgsh for treatment completion (odds ratio [OR] = 20.0) and remission (OR = 14.6). For remission, analyses revealed significant predictors (age, treatment length, Weight Concern), a moderator (weight concern [OR = 5.13]), and a significant interaction between CBT-type and treatment length (OR = 2.66). For CBTgsh, longer treatment was associated with less remission, whereas for CBTth, longer treatment was associated with greater remission. For CBTgsh, 44.1% with low weight concern versus 56.3% with high weight concern achieved remission whereas for CBTth, 43.5% with high weight concern and 61.0% with low weight concern achieved remission. Discussion Analyses of aggregated RCT BED data, adjusting for demographic/clinical characteristics, indicated superiority (large effect-sizes) in treatment outcomes of CBTth over CBTgsh and that Weight Concern moderated outcomes.
Article
Although evidence demonstrated efficacy of cognitive-behavioral therapy (CBT) in adolescents with binge-eating disorder (BED), treatment response is heterogeneous. This study uniquely examined baseline predictors of symptom trajectories in N=73 adolescents (12-20y) with an age-adapted diagnosis of BED (i.e., based on objective and subjective binge-eating episodes). Based on evidence from adult BED, dietary restraint, overvaluation of weight/shape, and depressive symptoms were used to predict changes in abstinence from binge eating and eating disorder psychopathology after 4 months of individual, face-to-face CBT using growth models. Longitudinal trajectories of abstinence from objective and subjective binge eating and global eating disorder psychopathology assessed via the Eating Disorder Examination were modeled for five time points (pre- and posttreatment, 6-, 12-, and 24-month follow-up). Beyond significant positive effects for time, no significant predictors for abstinence from binge eating emerged. In addition to significant decreases in eating disorder psychopathology over time, higher pretreatment dietary restraint and overvaluation of weight/shape significantly predicted greater decreases in eating disorder psychopathology over time. Consistent with research in adult BED, adolescents with higher than lower eating disorder-specific psychopathology especially benefit from CBT indicating that restrained eating and overvaluation of weight/shape may be BED-specific prognostic characteristic across developmental stages. Future predictor studies with an additional focus on potential age-specific predictors, such as family factors, and within-treatment processes may be critical in further evaluating treatment-related symptom trajectories in adolescent BED.
Article
Eating disorders are severe mental illnesses characterized by the hallmark behaviors of binge eating, restriction, and purging. These disordered eating behaviors carry extreme impairment and medical complications, regardless of eating disorder diagnosis. Despite the importance of these disordered behaviors to every eating disorder diagnosis, our current models are not able to accurately predict behavior occurrence. The current study utilized machine learning to develop longitudinal predictive models of binge eating, purging, and restriction in an eating disorder sample (N = 60) using real-time intensive longitudinal data. Participants completed four daily assessments of eating disorder symptoms and emotions for 25 days on a smartphone (total data points per participant = 100). Using data, we were able to compute highly accurate prediction models for binge eating, restriction, and purging (.76-.96 accuracy). The ability to accurately predict the occurrence of binge eating, restriction, and purging has crucial implications for the development of preventative interventions for the eating disorders. Machine learning models may be able to accurately predict onset of problematic psychiatric behaviors leading to preventative interventions designed to disrupt engagement in such behaviors.
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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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Background The aim of the present study was to provide benchmark data on the duration of treatment required to restore body weight (to BMI ≥18.5 or a corresponding BMI centile) in adolescents and adults with anorexia nervosa treated with outpatient cognitive behaviour therapy. Methods Ninety-five participants (46 adolescents and 49 adults) were recruited from consecutive referrals to a specialist eating disorder clinic. Each was offered 40 sessions of enhanced cognitive behaviour therapy (CBT-E) over 40 weeks, the conventional length of this treatment. Results Twenty-nine (63.1%) of the adolescents and 32 (65.3%) of the adults completed all 40 sessions of treatment (P = 0.818). Significantly more adolescents reached the goal BMI than adults (65.3% vs. 36.5%; P = 0.003). The mean time required by the adolescents to restore body weight was about 15 weeks less than that for the adults (14.8 (SE = 1.7) weeks vs. 28.3 (SE = 2.0) weeks, log-rank = 21.5, P < 0.001). Conclusions The findings indicate that adolescent patients receiving CBT-E are able to regain weight more successfully than adults and at a faster rate. If these findings are replicated and extend to eating disorder psychopathology, then their treatment could be shorter than that of adults.
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Eating disorders may be viewed from a transdiagnostic perspective and there is evidence supporting a transdiagnostic form of cognitive behaviour therapy (CBT-E). The aim of the present study was to compare CBT-E with interpersonal psychotherapy (IPT), a leading alternative treatment for adults with an eating disorder. One hundred and thirty patients with any form of eating disorder (body mass index >17.5 to <40.0) were randomized to either CBT-E or IPT. Both treatments involved 20 sessions over 20 weeks followed by a 60-week closed follow-up period. Outcome was measured by independent blinded assessors. Twenty-nine participants (22.3%) did not complete treatment or were withdrawn. At post-treatment 65.5% of the CBT-E participants met criteria for remission compared with 33.3% of the IPT participants (p < 0.001). Over follow-up the proportion of participants meeting criteria for remission increased, particularly in the IPT condition, but the CBT-E remission rate remained higher (CBT-E 69.4%, IPT 49.0%; p = 0.028). The response to CBT-E was very similar to that observed in an earlier study. The findings indicate that CBT-E is potent treatment for the majority of outpatients with an eating disorder. IPT remains an alternative to CBT-E, but the response is less pronounced and slower to be expressed. ISRCTN 15562271. Copyright © 2015. Published by Elsevier Ltd.
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Readiness and motivation for change were examined in 32 women with broadly defined eating disorders who took part in a 10-week Cognitive Behavioral Therapy (CBT)-based group intervention. Readiness for change and eating disorder psychopathology were assessed before and after the intervention. The results revealed significant negative associations between degree of eating disorder symptoms and degree of readiness for change before the intervention started. In particular, higher levels of eating concern, shape concern, and body dissatisfaction were associated with lower motivation for change. No significant associations between degree of readiness for change before the intervention started and changes in eating disorder symptoms at the end of intervention were found. Readiness for change increased from the beginning to the end of the intervention, indicating that group CBT may be a cost-effective and time-efficient way of enhancing readiness and motivation for change in individuals with eating psychopathology.
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Objective: The authors compared psychoanalytic psychotherapy and cognitive-behavioral therapy (CBT) in the treatment of bulimia nervosa. Method: A randomized controlled trial was conducted in which 70 patients with bulimia nervosa received either 2 years of weekly psychoanalytic psychotherapy or 20 sessions of CBT over 5 months. The main outcome measure was the Eating Disorder Examination interview, which was administered blind to treatment condition at baseline, after 5 months, and after 2 years. The primary outcome analyses were conducted using logistic regression analysis. Results: Both treatments resulted in improvement, but a marked difference was observed between CBT and psychoanalytic psychotherapy. After 5 months, 42% of patients in CBT (N=36) and 6% of patients in psychoanalytic psychotherapy (N=34) had stopped binge eating and purging (odds ratio=13.40, 95% confidence interval [CI]=2.45-73.42; p<0.01). At 2 years, 44% in the CBT group and 15% in the psychoanalytic psychotherapy group had stopped binge eating and purging (odds ratio=4.34, 95% CI=1.33-14.21; p=0.02). By the end of both treatments, substantial improvements in eating disorder features and general psychopathology were observed, but in general these changes took place more rapidly in CBT. Conclusions: Despite the marked disparity in the number of treatment sessions and the duration of treatment, CBT was more effective in relieving binging and purging than psychoanalytic psychotherapy and was generally faster in alleviating eating disorder features and general psychopathology. The findings indicate the need to develop and test a more structured and symptom-focused version of psychoanalytic psychotherapy for bulimia nervosa.
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Cognitive behavioral therapy-based guided self-help (CBT-GSH) via the Internet has been shown to be effective in the treatment of bulimia nervosa (BN) and similar eating disorders (EDs), but it is rarely offered, and little is known about the effects, in clinical settings. The present study investigated the effects of a bibliotherapy-based CBT-GSH with Internet support in a clinical setting. Participants were 48 adult outpatients who were recruited without randomization from a specialized ED clinic, diagnosed with BN or similar eating disorder. Forty-eight patients in an intensive day patient program (DPP) were used as comparison group. The Eating Disorder Examination Questionnaire (EDE-Q) and the Eating Disorder Inventory 2 measured pre- and post treatment symptoms. Results showed that both groups attained significant improvements in core- as well as related ED symptoms in both instruments. As expected, treatment effects were larger in the more intensive DPP. Nonetheless, bibliotherapy CBT-GSH appears to be a cost-effective treatment that represents a new way to provide more CBT in clinical settings.
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Background: The purpose of this investigation was to compare a new psychotherapy for bulimia nervosa (BN), integrative cognitive-affective therapy (ICAT), with an established treatment, 'enhanced' cognitive-behavioral therapy (CBT-E). Method: Eighty adults with symptoms of BN were randomized to ICAT or CBT-E for 21 sessions over 19 weeks. Bulimic symptoms, measured by the Eating Disorder Examination (EDE), were assessed at baseline, at the end of treatment (EOT) and at the 4-month follow-up. Treatment outcome, measured by binge eating frequency, purging frequency, global eating disorder severity, emotion regulation, self-oriented cognition, depression, anxiety and self-esteem, was determined using generalized estimating equations (GEEs), logistic regression and a general linear model (intent-to-treat). Results: Both treatments were associated with significant improvement in bulimic symptoms and in all measures of outcome, and no statistically significant differences were observed between the two conditions at EOT or follow-up. Intent-to-treat abstinence rates for ICAT (37.5% at EOT, 32.5% at follow-up) and CBT-E (22.5% at both EOT and follow-up) were not significantly different. Conclusions: ICAT was associated with significant improvements in bulimic and associated symptoms that did not differ from those obtained with CBT-E. This initial randomized controlled trial of a new individual psychotherapy for BN suggests that targeting emotion and self-oriented cognition in the context of nutritional rehabilitation may be efficacious and worthy of further study.
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Objective: In light of prior inconsistent findings, this study revisits the relationship between weight suppression and treatment outcome in bulimia nervosa. Aside from differences in methodology, we propose that moderator effects may assist the field in interpreting previous inconsistency. In this study, we considered moderators that might place individuals at risk of broad cognitive and biobehavioral mechanisms implicated in weight (dys)regulation and binge eating, and that within the context of a history of weight suppression, might be associated with especially poor outcomes. Method: Participants were 117 female outpatients aged 16-54 years (M = 25.5) with bulimic disorders treated with enhanced cognitive behavioral therapy. Results: Logistic regression indicated that higher pretreatment weight suppression did not predict drop-out or poor treatment outcome (nonabstinence from binging and purging). Moderators of parental history of overweight, childhood body shape, pretreatment body mass index, and the difference between highest and lowest ever adult body weight were analyzed, but no moderator effects were apparent. Discussion: This study, along with other negative studies, calls into question the association between weight suppression and treatment outcome. We maintain that moderators may account for inconsistencies, but no candidates were identified in this study. Moderator models could assist us to refine conceptualizations of why some patients high in weight suppression may be vulnerable to poor treatment adherence and outcome and to establish clinical interventions that enhance prognosis.
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Different studies considered the mechanisms involved in the maintenance of binge eating in bulimia nervosa (BN) and binge eating disorder (BED), suggesting different pathways. The present 3-year follow-up study evaluated the relationships between psychopathological variables, and objective and subjective binge eating episodes in the two syndromes. Methods: 85 BN and 133 BED patients were studied. Objective and subjective binge eating, and psychopathological data were collected in a face-to-face interview, and by means of different self-reported questionnaires. The same assessment was repeated at baseline (T0), at the end of an individual cognitive-behavioral treatment (T1), and 3 years after the end of treatment (T2). At baseline, BN and BED patients showed different emotions associated with binge eating: anger/frustration for BN and depression for BED patients. Objective binge eating frequency reduction across time was associated with lower impulsivity and shape concern in BN patients, and with lower emotional eating and depressive symptoms in BED patients. Lower subjective binge eating frequency at baseline predicted recovery, in both BN and BED patients. Recovery was associated with lower impulsivity and body shape concern at baseline for BN patients, and lower depression and emotional eating for BED patients. Eating psychopathology, psychiatric comorbidity, impulsivity and emotional eating have a different pattern of association with objective and subjective binge eating in BN and BED patients, and they act as different moderators of treatment. A different target of intervention for these two syndromes might be taken into account, and subjective binge eating deserves an accurate assessment.
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Cognitive behavioral therapy (CBT) is the leading evidence-based treatment for bulimia nervosa. A new "enhanced" version of the treatment appears to be more potent and has the added advantage of being suitable for all eating disorders, including anorexia nervosa and eating disorder not otherwise specified. This article reviews the evidence supporting CBT in the treatment of eating disorders and provides an account of the "transdiagnostic" theory that underpins the enhanced form of the treatment. It ends with an outline of the treatment's main strategies and procedures.
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Despite proven efficacy of cognitive behavioral therapy (CBT) for treating eating disorders with binge eating as the core symptom, few patients receive CBT in clinical practice. Our blended efficacy-effectiveness study sought to evaluate whether a manual-based guided self-help form of CBT (CBT-GSH), delivered in 8 sessions in a health maintenance organization setting over a 12-week period by master's-level interventionists, is more effective than treatment as usual (TAU). In all, 123 individuals (mean age = 37.2; 91.9% female, 96.7% non-Hispanic White) were randomized, including 10.6% with bulimia nervosa (BN), 48% with binge eating disorder (BED), and 41.4% with recurrent binge eating in the absence of BN or BED. Baseline, posttreatment, and 6- and 12-month follow-up data were used in intent-to-treat analyses. At 12-month follow-up, CBT-GSH resulted in greater abstinence from binge eating (64.2%) than TAU (44.6%; number needed to treat = 5), as measured by the Eating Disorder Examination (EDE). Secondary outcomes reflected greater improvements in the CBT-GSH group in dietary restraint (d = 0.30); eating, shape, and weight concern (ds = 0.54, 1.01, 0.49, respectively; measured by the EDE Questionnaire); depression (d = 0.56; Beck Depression Inventory); and social adjustment (d = 0.58; Work and Social Adjustment Scale), but not weight change. CBT-GSH is a viable first-line treatment option for the majority of patients with recurrent binge eating who do not meet diagnostic criteria for BN or anorexia nervosa.
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The aim of this study was to compare two cognitive-behavioral treatments for outpatients with eating disorders, one focusing solely on eating disorder features and the other a more complex treatment that also addresses mood intolerance, clinical perfectionism, low self-esteem, or interpersonal difficulties. A total of 154 patients who had a DSM-IV eating disorder but were not markedly underweight (body mass index over 17.5), were enrolled in a two-site randomized controlled trial involving 20 weeks of treatment and a 60-week closed period of follow-up. The control condition was an 8-week waiting list period preceding treatment. Outcomes were measured by independent assessors who were blind to treatment condition. Patients in the waiting list control condition exhibited little change in symptom severity, whereas those in the two treatment conditions exhibited substantial and equivalent change, which was well maintained during follow-up. At the 60-week follow-up assessment, 51.3% of the sample had a level of eating disorder features less than one standard deviation above the community mean. Treatment outcome did not depend on eating disorder diagnosis. Patients with marked mood intolerance, clinical perfectionism, low self-esteem, or interpersonal difficulties appeared to respond better to the more complex treatment, with the reverse pattern evident among the remaining patients. These two transdiagnostic treatments appear to be suitable for the majority of outpatients with an eating disorder. The simpler treatment may best be viewed as the default version, with the more complex treatment reserved for patients with marked additional psychopathology of the type targeted by the treatment.
Article
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.
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
The development and validation of a new measure, the Eating Disorder Inventory (EDI) is described. The EDI is a 64 item, self-report, multiscale measure designed for the assessment of psychological and behavioral traits common in anorexia nervosa (AN) and bulimia. The EDI consists of eight subscales measuring: Drive for Thinness, Bilimia, Body Dissatisfaction, Ineffectiveness, Perfectionism, Interpersonal Distrust, Interoceptive Awareness and Maturity Fears. Reliability (internal consistency) is established for all subscales and several indices of validity are presented. First, AN patients (N=113) are differentiated from femal comparison (FC) subjects (N=577) using a cross-validation procedure. Secondly, patient self-report subscale scores agree with clinician ratings of subscale traits. Thirdly, clinically recovered AN patients score similarly to FCs on all subscales. Finally, convergent and discriminant validity are established for subscales. The EDI was also administered to groups of normal weight bulimic women, obese, and normal weight but formerly obese women, as well as a male comparison group. Group differences are reported and the potential utility of the EDI is discussed.
Article
Objective: This study examined predictors and moderators of outcome in 2 treatments for bulimia nervosa (BN). Method: Eighty adults with BN symptoms at 1 of 2 sites were randomized to 21 sessions of integrative cognitive-affective therapy for BN (ICAT-BN) or enhanced cognitive behavior therapy (CBT-E). Generalized linear models examined predictors and moderators of improvements in bulimic behavior and eating disorder psychopathology at end of treatment (EOT) and 4-month follow-up (FU). Results: At EOT, individuals with higher dietary restraint had greater reductions in bulimic behavior. At FU, individuals with higher weight and shape concern had greater reductions in bulimic behavior, whereas those with greater baseline depression had less improvement in eating disorder psychopathology. Individuals higher in stimulus seeking had greater reductions in bulimic behavior and eating disorder psychopathology at follow up in ICAT-BN than in CBT-E, whereas individuals lower in stimulus seeking had greater reductions in bulimic behavior in CBT-E than in ICAT-BN. Finally, individuals with higher affective lability had greater reductions in eating disorder psychopathology in ICAT-BN than in CBT-E, whereas improvements were comparable across treatments for individuals with lower affective lability. Conclusions: This study identified 3 nonspecific predictors of outcome (i.e., dietary restraint, weight and shape concern, and depression) and 2 moderators (i.e., affective lability and stimulus seeking). All moderator effects emerged at FU rather than at EOT, suggesting that the moderating effects of treatment were not immediately apparent. These results suggest that individuals with higher affective lability and stimulus seeking may benefit more from treatment with a greater focus on affective states and self-regulation. (PsycINFO Database Record
Article
Objective: A subset of individuals with bulimia nervosa (BN) have borderline personality disorder (BPD) symptoms, including chronic negative affect and interpersonal problems. These symptoms predict poor BN treatment outcome in some studies. The broad version of Enhanced Cognitive Behavior Therapy (CBT-E) was developed to address co-occurring problems that interfere with treatment response. The current study investigated the relative effects, predictors, and moderators of CBT-E for BN with BPD and co-occurring mood/anxiety disorders. Method: Fifty patients with BN and threshold or sub-threshold BPD and current or recent Axis I mood or anxiety disorders were randomly assigned to receive focused CBT-E (CBT-Ef) or broad CBT-E (CBT-Eb) specifically including an interpersonal module and additional attention to mood intolerance. Results: Forty-two percent of the sample reported remission from binge eating and purging at termination. Significant changes across symptom domains were observed at termination and at 6-month follow-up. Though CBT-Ef predicted good outcomes in multivariate models, the severity of affective/interpersonal problems moderated treatment effects: participants with higher severity showed better ED outcomes in CBT-Eb, whereas those with lower severity showed better outcomes in CBT-Ef. Severity of affective/interpersonal BPD symptoms at baseline predicted negative outcomes overall. Follow-up BPD affective/interpersonal problems were predicted by baseline affective/interpersonal problems and by termination EDE score. Discussion: This study supports the utility of CBT-E for patients with BN and complex comorbidity. CBT-Ef appears to be more efficacious for patients with relatively less severe BPD symptoms, whereas CBT-Eb appears to be more efficacious for patients with more severe BPD symptoms. © 2015 Wiley Periodicals, Inc. (Int J Eat Disord 2015;).
Article
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.