ArticleLiterature Review

Psychotherapy for bulimia nervosa on symptoms of depression: A meta-analysis of randomized controlled trials

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Abstract

Objective: Depressive symptoms are an important risk factor and consequence of binge eating and purging behavior in bulimia nervosa (BN). Although psychotherapy is effective in reducing symptoms of BN in the short- and long-term, it is unclear whether psychotherapy for BN is also effective in reducing depressive symptoms. This meta-analysis examined the efficacy of psychotherapy for BN on depressive symptoms in the short- and long-term. Method: Randomized controlled trials (RCTs) on BN that assessed depressive symptoms as an outcome were identified. Twenty-six RCTs were included. Results: Psychotherapy was more efficacious at reducing symptoms of depression at post-treatment (g = 0.47) than wait-lists. This effect was strongest when studies delivered therapist-led, rather than guided self-help, treatment. No significant differences were observed between psychotherapy and antidepressants. There was no significant post-treatment difference between CBT and other active psychological comparisons at reducing symptoms of depression. However, when only therapist-led CBT was analyzed, therapist-led CBT was significantly more efficacious (g = 0.25) than active comparisons at reducing depressive symptoms. The magnitude of the improvement in depressive symptoms was predicted by the magnitude of the improvement in BN symptoms. Discussion: These findings suggest that psychotherapy is effective for reducing depressive symptoms in BN in the short-term. Whether these effects are sustained in the long-term is yet to be determined, as too few studies conducted follow-up assessments. Moreover, findings demonstrate that, in addition to being the front-running treatment for BN symptoms, CBT might also be the most effective psychotherapy for improving the symptoms of depression that commonly co-occur in BN.

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... Treatment effects for CBT relative to other treatments have been established through several meta-analyses of randomized controlled trials (RCTs). CBT has demonstrated effectiveness in reducing eating-disordered cognitions [30] depressive symptoms [31] and increasing quality of life [32]. Furthermore, reduction of ED psychopathology predicted the reduction of behavioral symptoms for BN and BED samples [30], and reduction of binge/purge symptoms have been found to predict greater reduction of depressive symptoms in BN samples receiving CBT, compared to other treatments [31]. ...
... CBT has demonstrated effectiveness in reducing eating-disordered cognitions [30] depressive symptoms [31] and increasing quality of life [32]. Furthermore, reduction of ED psychopathology predicted the reduction of behavioral symptoms for BN and BED samples [30], and reduction of binge/purge symptoms have been found to predict greater reduction of depressive symptoms in BN samples receiving CBT, compared to other treatments [31]. These findings lend preliminary support for the cognitive-behavioral model of EDs, and thus the core behavioral and cognitive symptoms as principal targets of therapeutic interventions. ...
... Inferences as to the effect of other specified therapeutic approaches have, however, been difficult to make from meta-analyses of RCTs, e.g., [30][31][32][33][34][35] because effect sizes have been based on differences between treatment arms containing heterogenous interventions (e.g. different combinations of active experimental treatments, multimodal interventions and different variants of treatment as usual or active psychotherapy control conditions). ...
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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.
... Some meta-analytic evidence has been found for speci c treatment effects for CBT relative to other treatments. CBT has demonstrated effectiveness in reducing eating-disordered cognitions (28) depressive symptoms (29) and increasing quality of life (30). Furthermore, reduction of ED psychopathology predicted the reduction of behavioral symptoms for BN and BED samples (28), and reduction of binge/purge symptoms have been found to predict greater reduction of depressive symptoms in BN samples receiving CBT, compared to other treatments (29). ...
... CBT has demonstrated effectiveness in reducing eating-disordered cognitions (28) depressive symptoms (29) and increasing quality of life (30). Furthermore, reduction of ED psychopathology predicted the reduction of behavioral symptoms for BN and BED samples (28), and reduction of binge/purge symptoms have been found to predict greater reduction of depressive symptoms in BN samples receiving CBT, compared to other treatments (29). These ndings lend preliminary support for the cognitive-behavioral model of EDs, and thus the core behavioral and cognitive symptoms as principal targets of therapeutic interventions. ...
... However, inferences as to the effect of different speci ed therapeutic approaches have been di cult to make from meta-analytic inquiries, e.g., (28)(29)(30)(31)(32)(33). This di culty is due to the often multi-modal and methodologically heterogenous nature of the treatments under study and their comparator-treatments (e.g., different combinations of active psychotherapies, treatment as usual, or wait-list conditions). ...
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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.
... Hypercortisolemia, elevation of urinary free cortisol, and alteration of the circadian rhythm of cortisol may be present in patients with normal weight who present with bulimia (BN), as well as in symptoms of psychological stress and depression [5]. Linardon et al. reported that the symptoms of depression are an important risk factor and a consequence of binge eating and purging in BN [6]. On the other hand, changes in the salivary cortisol concentration are more commonly detected in patients with anorexia nervosa, since the patients with BN normally present normal weight or are underweight, making the clinical diagnosis difficult [7]. ...
... Linardon et al. reported that the depressive symptoms are an important risk factor and a consequence of the behavior of binge eating and purging in BN. Some hypotheses have risen for this association, one of them regards serotonin [6]. ...
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Purpose The imposition of the thin body as an ideal of beauty and the changes that occur in adolescence lead to a constant concern with adolescents’ body weight, putting them at risk for eating disorders. Thus, the study sought to investigate associations between eating disorders and salivary cortisol concentrations, nutritional status and depressive symptoms in female adolescents with bulimia. Methods A cross-sectional study was carried out with 1435 adolescents aged 10–19 years. The Bulimic Investigatory Test of Edinburgh (BITE) and Body Shape Questionnaire (BSQ) questionnaires were used. A follow-up study was conducted from a random selection of female adolescents diagnosed with Bulimia Development and Well-Being Assessment—(DAWBA) to assess associations with salivary cortisol concentrations and nutritional status. Results The prevalence of body dissatisfaction among adolescents with symptoms of bulimia was 37%. There was a significant difference between salivary cortisol and bulimia (Risk Group = 0.33 ± 0.20 μg/100 ml, Diagnostic Group = 0.44 ± 0.21 μg/100 ml p = 0.040), and correlation positive between the risk of bulimia with symptoms of depression (0.355 p = 0.002) and with Body Mass Index (0.259 p = 0.028). High concentrations of salivary cortisol in bulimic adolescents may be associated with hyperactivity of the hypothalamic–pituitary–adrenal axis and depressive symptoms. Conclusions Nutritional status indicators cannot be used alone for the diagnosis of bulimia, since cortisol levels seem to be a reliable parameter in the identification of bulimia, provided they are used with other diagnostic criteria. Level III Evidence obtained from cross-sectional study.
... Treatment studies paint a similarly complex picture. While comorbid DDs were associated with lower remission rates after treatment [9] and even persisted after the remission of an ED [10], other studies found depression to decrease during treatment for bulimia nervosa (BN) despite not being explicitly targeted [11,12]. Anhedonia might remain after the remission of depression in AN and rather constitute a trait of these patients than a psychiatric comorbidity [13]. ...
... The assumed emotion regulation functionality of disordered eating [27] would predict a decrease in depressive symptoms with the successful treatment of the ED if the depressive symptoms were completely dependent on the ED symptoms. While this in part may hold true [11], the fact that depression or anhedonia often remain after ED treatment [9,10,13] suggests that some variance of depression in EDs cannot be explained by the ED. ...
Article
Background: While it is know that depressive symptoms are common in eating disorders (EDs), it is unclear whether these symptoms differ from those in depressive disorders (DDs) with regard to severity and quality. Methods: Beck Depression Inventory II (BDI-II) scores at admission to treatment of 4.895 inpatients with a unipolar DD and 3.302 inpatients with an ED were compared by means of independent t-tests and Cohen's d effect sizes with regard to: (1) overall severity (BDI-II total score), (2) six facets of depression identified by non-metric multidimensional scaling of the German BDI-II validation sample, and (3) individual items. Results: (1) The two groups did not differ with regard to the BDI-II total score. (2) There was no difference in the facet Depressive Core Symptoms. Patients with DDs had higher scores for Diminished Activation (d = 0.40) and patients with EDs had higher scores for Negative View of Self (d = 0.40). (3) Patients with DDs showed higher score on the item Loss of Energy (d = 0.48), while patients with EDs sored higher on Self-Dislike (d = 0.48) and Changes of Appetite (d = 0.48). Conclusions: Depression in EDs seems to be as severe as in DDs and may show similar core aspects (e.g., Sadness, Loss of Pleasure). Qualitative differences suggested that individual additional symptoms of depression need to be differently addressed in therapy. The pronounced Negative View of Self in EDs is in line with the "core low self-esteem", a central component of the prevalent transdiagnostic model of EDs.
... These findings are consistent with recent meta-analyses on the Table 5 The empirical status of third-wave behaviour therapies for the treatment of adult eating disorders. Therapy effects of specific psychological treatments for eating disorders, including DBT (Lenz et al., 2014), MBIs (Godfrey et al., 2015), and CBT (Linardon et al., 2017a;Linardon & Brennan, 2017;Linardon, Wade, De la Piedad Garcia, & Brennan, 2017b;Vocks et al., 2010), for eating disorders, and also on the effects of MBIs for disordered eating symptoms in non-clinical samples (Katterman, Kleinman, Hood, Nackers, & Corsica, 2014). The above findings were based on the pre-post effect size. ...
... CBT has been evaluated in numerous RCTs, and has consistently outperformed inactive, active, and pharmacological comparisons in BN, BED, and related disorders. In addition, meta-analyses have also documented the efficacy of CBT for BN and BED over inactive and active psychological controls, with large and small effect sizes, respectively (Brownley et al., 2016;Cuijpers, Donker, Weissman, Ravitz, & Cristea, 2016;Linardon et al., 2017aLinardon et al., , 2017b. IPT has also been investigated in several RCTs, and has been shown to be superior to wait-lists in BED (Wilfley et al., 1993) and behavioral weight loss in BED (Wilson, Wilfley, Agras, & Bryson, 2010), and not statistically different to CBT for BN at long-term follow-up Fairburn, Jones, Peveler, Hope, & O'Connor, 1993). ...
Article
Although third-wave behaviour therapies are being increasingly used for the treatment of eating disorders, their efficacy is largely unknown. This systematic review and meta-analysis aimed to examine the empirical status of these therapies. Twenty-seven studies met full inclusion criteria. Only 13 randomized controlled trials (RCT) were identified, most on binge eating disorder (BED). Pooled within- (pre-post change) and between-groups effect sizes were calculated for the meta-analysis. Large pre-post symptom improvements were observed for all third-wave treatments, including dialectical behaviour therapy (DBT), schema therapy (ST), acceptance and commitment therapy (ACT), mindfulness-based interventions (MBI), and compassion-focused therapy (CFT). Third-wave therapies were not superior to active comparisons generally, or to cognitive-behaviour therapy (CBT) in RCTs. Based on our qualitative synthesis, none of the third-wave therapies meet established criteria for an empirically supported treatment for particular eating disorder subgroups. Until further RCTs demonstrate the efficacy of third-wave therapies for particular eating disorder subgroups, the available data suggest that CBT should retain its status as the recommended treatment approach for bulimia nervosa (BN) and BED, and the front running treatment for anorexia nervosa (AN) in adults, with interpersonal psychotherapy (IPT) considered a strong empirically-supported alternative.
... 21 Meta-analyses of Randomised Controlled Trials (RCTs) that include waitlist controls report that CBT is particularly effective for BN and BED. [22][23][24][25][26] In Japan, there are two reports on the effectiveness and feasibility of CBT for BN or BED, 27 28 and the national health insurance has covered CBT in Japan since 2018. However, according to a meta-analysis of RCTs, the dropout rate for CBT is approximately 24%, 29 and there are large individual differences in treatment responsiveness. ...
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Introduction Anorexia nervosa is a refractory psychiatric disorder with a mortality rate of 5.9% and standardised mortality ratio of 5.35, which is much higher than other psychiatric disorders. The standardised mortality ratio of bulimia nervosa is 1.49; however, it is characterised by suicidality resulting in a shorter time to death. While there is no current validated drug treatment for eating disorders in Japan, cognitive–behavioural therapy (CBT) is a well-established and commonly used treatment. CBT is also recommended in the Japanese Guidelines for the Treatment of Eating Disorders (2012) and has been covered by insurance since 2018. However, the neural mechanisms responsible for the effect of CBT have not been elucidated, and the use of biomarkers such as neuroimaging data would be beneficial. Methods and analysis The Eating Disorder Neuroimaging Initiative is a multisite prospective cohort study. We will longitudinally collect data from 72 patients with eating disorders (anorexia nervosa and bulimia nervosa) and 70 controls. Data will be collected at baseline, after 21–41 sessions of CBT and 12 months later. We will assess longitudinal changes in neural circuit function, clinical data, gene expression and psychological measures by therapeutic intervention and analyse the relationship among them using machine learning methods. Ethics and dissemination The study was approved by The Ethical Committee of the National Center of Neurology and Psychiatry (A2019-072). We will obtain written informed consent from all patients who participate in the study after they had been fully informed about the study protocol. All imaging, demographic and clinical data are shared between the participating sites and will be made publicly available in 2024. Trial registration number UMIN000039841
... There was no evidence that CBT was more effective in improving self-esteem than non-CBT interventions. This finding goes against recent meta-analyses reporting the superiority of CBT over non-CBT interventions in reducing eating disorder psychopathology (Brownley et al., 2016;Linardon, 2018a;Linardon et al., 2017a), quality of life impairment (Linardon & Brennan, 2017), and depressive symptoms (Linardon, Wade, De la Piedad Garcia, & Brennan, 2017b;Vocks et al., 2010) in BN and BED. However, the lack of significant differences between treatments in this study may have been a result of insufficient statistical power. ...
Article
Objectives This meta‐analysis examined the effects of psychotherapy for bulimia nervosa (BN) and binge‐eating disorder (BED) on self‐esteem improvement. Method Randomized controlled trials (RCTs) of psychological treatments that assessed self‐esteem change in eating disorders were included. Thirty‐four RCTs were included; most sampled BED and then BN. Hedge's g effects were entered into random effects models. Results Psychotherapy for BN led to significantly greater post‐treatment improvements in self‐esteem than control conditions (g = 0.45; 95% CI [0.17, 0.73]). This effect was smaller when only analysing low risk of bias trials (g = 0.28; 95% CI [0.05, 0.51]). Psychotherapy for BED also led to significantly greater post‐treatment improvements in self‐esteem than controls (g = 0.20; 95% CI [0.05, 0.35]), with some evidence that guided self‐help was associated with the largest effects. This effect, however, was overestimated after adjustment for publication bias (g = 0.10; 95% CI [−0.05, 0.26]). There was no evidence that cognitive‐behavioural therapy was superior to non‐cognitive‐behavioural therapy interventions in improving self‐esteem. There was no relationship between symptom improvement and self‐esteem improvement in a meta‐regression. Conclusions Psychotherapy may lead to small improvements in self‐esteem in BN and BED. Additional RCTs with follow‐up assessments are required to make more definitive conclusions about the effects of psychotherapy for eating disorders on self‐esteem in the long‐term.
... A summary of these meta-analyses is presented in Table 1 of the supplementary materials. Compared with wait-list or active controls, therapist-led CBT consistently results in greater improvements in eating disorder symptoms in BN and BED (Hay, Bacaltchuk, Stefano, & Kashyap, 2009;Linardon, Wade, De la Piedad Garcia, & Brennan, 2017). Moreover, specific modes (e.g., E-therapy CBT) or formats (e.g., group-based CBT) have also been shown to be superior to wait-list controls in BN and BED (Loucas et al., 2014;Polnay et al., 2014). ...
Article
Objective: This meta-analysis examined the efficacy of cognitive-behavioral therapy (CBT) for eating disorders. Method: Randomized controlled trials of CBT were searched. Seventy-nine trials were included. Results: Therapist-led CBT was more efficacious than inactive (wait-lists) and active (any psychotherapy) comparisons in individuals with bulimia nervosa and binge eating disorder. Therapist-led CBT was most efficacious when manualized CBT-BN or its enhanced version was delivered. No significant differences were observed between therapist-led CBT for bulimia nervosa and binge eating disorder and antidepressants at posttreatment. CBT was also directly compared to other specific psychological interventions, and therapist-led CBT resulted in greater reductions in behavioral and cognitive symptoms than interpersonal psychotherapy at posttreatment. At follow-up, CBT outperformed interpersonal psychotherapy only on cognitive symptoms. CBT for binge eating disorder also resulted in greater reductions in behavioral symptoms than behavioral weight loss interventions. There was no evidence that CBT was more efficacious than behavior therapy or nonspecific supportive therapies. Conclusions: CBT is efficacious for eating disorders. Although CBT was equally efficacious to certain psychological treatments, the fact that CBT outperformed all active psychological comparisons and interpersonal psychotherapy specifically, offers some support for the specificity of psychological treatments for eating disorders. Conclusions from this study are hampered by the fact that many trials were of poor quality. Higher quality RCTs are essential. (PsycINFO Database Record
... Studies were included if (a) it was a published RCT, (b) that included a psychotherapy condition, (c) to individuals with BN, and (d) reported an outcome of behavioral symptom abstinence and the number of patients who achieved abstinence at either post-treatment or follow-up. Consistent with earlier reviews, psychotherapy was defined as an intervention in which the central element was verbal communication between a client and a clinician, or as a psychological treatment in the form of a book or a website which the participant worked through somewhat independently but with guided support from a clinician (Cuijpers et al., 2014;Linardon, Wade, De la Piedad Garcia, & Brennan, 2017b). Thus, pure self-help interventions and studies that combined a psychological and pharmacological intervention were excluded. ...
Article
Objectives: It is unclear how many patients with bulimia nervosa (BN) completely abstain from the core behavioral symptoms after receiving psychological treatment. The present meta-analysis of randomized controlled trials (RCTs) aimed to (a) estimate the prevalence of patients who abstain from binge eating and/or purging following all psychological treatments for BN, and (b) test whether these abstinence estimates are moderated by the type of treatment modality delivered, the definition of abstinence applied, and trial quality. Method: Forty-five RCTs were included, with 78 psychotherapy conditions. Pooled event rates were calculated using random effects models. Results: At post-treatment, the total weighted percentage of treatment-completers who achieved abstinence was 35.4% (95% CI = 29.6, 41.7), while the total weighted percentage of abstinence for all randomized patients (intention-to-treat) was 29.9% (95% CI = 25.7, 33.2). Abstinence estimates were highest in trials that used behavioral-based treatments (e.g., cognitive-behavioral therapy, behavior therapy). There was also evidence that guided self-help interventions produced the lowest post-treatment abstinence rates, but with no difference at follow-up from clinician-led treatments, and studies that used a shorter timeframe for defining abstinence (i.e., 14 days symptom-free compared to 28-days symptom-free) produced the highest abstinence rates. Abstinence estimates at follow-up for both the completer (34.6%; 95% CI = 29.3, 40.2) and intention-to-treat (28.6%; 95% CI = 25.1, 32.3) analyses were essentially the same as the post-treatment estimates. Discussion: Over 60% of patients fail to fully abstain from core BN symptoms even after receiving our most empirically-supported treatments. The present findings highlight the urgency toward improving the effectiveness of psychological treatments for BN.
... A strong positive association between ADHD symptoms in adulthood and levels of self-perceived stress has also been reported (24). Furthermore, EDs, including binge/purging type (e.g., BN) and restrictive type [e.g., anorexia nervosa (AN)], are often comorbid with anxiety, depression, and/or mood disorders (25)(26)(27). Thus, it is possible that disordered eating may not be directly related to ADHD, and may be mediated (at least in part) by comorbid anxiety disorders and mood disorders (28)(29)(30). ...
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IntroductionIt is unclear whether core symptoms of attention deficit hyperactivity disorder (ADHD) relate to specific types of disordered eating and little is known about the mediating mechanisms. We investigated associations between core symptoms of ADHD and binge/disinhibited eating and restrictive eating behavior and assessed whether negative mood and/or deficits in awareness and reliance on internal hunger/satiety cues mediate these relationships.Methods In two independent studies, we used a dimensional approach to study ADHD and disordered eating. In Study 1, a community-based sample of 237 adults (72.6% female, 18–60 years [M = 26.8, SE = 0.6]) completed an online questionnaire, assessing eating attitudes/behaviors, negative mood, awareness, and reliance on internal hunger/satiety cues and ADHD symptomatology. In Study 2, 142 students (80.3% female, 18–32 years [M = 19.3, SE = 0.1]) were recruited to complete the same questionnaires and complete tasks assessing interoceptive sensitivity and impulsivity in the laboratory.ResultsIn each study, core symptoms of ADHD correlated positively with both binge/disinhibited and restrictive eating and negative mood mediated the relationships. Deficits in awareness and reliance on internal hunger/satiety signals also mediated the association between inattentive symptoms of ADHD and disordered eating, especially binge/disinhibited eating. The results from both studies demonstrated that inattentive symptoms of ADHD were also directly related to binge/disinhibited eating behavior, while accounting for the indirect pathways of association via negative mood and awareness and reliance on internal hunger/satiety signals.Conclusion This research provides evidence that core symptoms of ADHD are associated with both binge/disinhibited eating and restrictive eating behavior. Further investigation of the role of inattentive symptoms of ADHD in disordered eating may be helpful in developing novel treatments for both ADHD and binge eating.
... A strong positive association between ADHD symptoms in adulthood and levels of self-perceived stress has also been reported (24). Furthermore, EDs, including binge/purging type (e.g., BN) and restrictive type [e.g., anorexia nervosa (AN)], are often comorbid with anxiety, depression, and/or mood disorders (25)(26)(27). Thus, it is possible that disordered eating may not be directly related to ADHD, and may be mediated (at least in part) by comorbid anxiety disorders and mood disorders (28)(29)(30). ...
... Department of Health and Human Services, National Institutes of Health, National Institute of Mental Health, 2015). Skills from CBT (e.g., cognitive reframing, goal setting, problem solving, behavior activation) have also been successfully used in behavior change interventions targeting health behaviors in adolescents (Beck, 2011;Hoying, Melnyk, & Arcoleo, 2016;Linardon, Wade, de la Piedad Garcia, & Brennan, 2017;Lock, 2015;Wilfley, Kolko, & Kass, 2011;Winkler, Dörsing, Rief, Shen, & Glombiewski, 2013). Le Grange, Lock, Agras, Bryson, and Jo (2015) implemented a CBT-based intervention for adolescents with an eating disorder that indicated a significant longitudinal reduction in binge/ purge behaviors. ...
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Objective: Guided by cognitive theory, this study tested an explanatory model for adolescents' beliefs, feelings, and healthy lifestyle behaviors and sex differences in these relationships. Methods: Structural equation modeling evaluated cross-sectional data from a healthy lifestyle program from 779 adolescents 14 through 17 years old. Results: Theoretical relationships among thoughts, feelings, and behaviors were confirmed and sex differences identified. Thoughts had a direct effect on feelings and an indirect effect through feelings on healthy behaviors for both sexes. A direct effect from thoughts to behaviors existed for males only. Discussion: Findings provide strong support for the thinking-feeling-behaving triangle for adolescents. To promote healthy lifestyle behaviors in adolescents, interventions should incorporate cognitive behavioral skills-building activities, strengthening healthy lifestyle beliefs, and enhancing positive health behaviors.
... Although there is considerable evidence that antidepressants have some beneficial effect, 27 the most recent National Institute for Health and Care Excellence (NICE 39 ) treatment guidelines recommend not offering medication as the sole treatment for BN, as relapse when medication is tapered is common, and evidence suggests no difference in outcome between psychotherapy and antidepressants at posttreatment. 40,41 Safety planning when self-harm and/or suicidality is present should be highly specific and operationalized. A link to one such plan is provided in Table 2. ...
Article
Estimates of lifetime bulimia nervosa (BN) range from 4% to 6.7% across studies. There has been a decrease in the presentation of BN in primary care but an increase in disordered eating not meeting full diagnostic criteria. Regardless of diagnostic status, disordered eating is associated with long-term significant impairment to both physical and mental quality of life, and BN is associated with a significantly higher likelihood of self-harm, suicide, and death. Assessment should adopt a motivationally enhancing stance given the high level of ambivalence associated with BN. Cognitive behavior therapy specific to eating disorders outperforms other active psychological comparisons.
... While much heterogeneity exists across eating disorder presentations, common across all phenotypes is a need for improved treatment outcomes. Recent metaanalyses have illustrated that leading evidence-based treatments typically render approximately 30% of those with bulimia nervosa abstinent of behavioral symptoms (Linardon, Wade, de la Piedad Garcia, & Brennan, 2017). In anorexia nervosa, several lines of evidence suggest that leading evidence-based psychosocial treatments typically result in full symptom remission in approximately one-third of adolescent presentations by the end of treatment, with one-third of those maintaining symptom remission at long-term follow-up (Lock & Le Grange, In Press). ...
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Current evidence suggests that the majority of patients with eating disorders will not fully recover during treatment, and little doubt can exist around the urgent need for improved treatment outcomes across the field of eating disorders. While empirical efforts are underway to optimize outcomes, this article reviews treatment-related research findings published in Eating Disorders: The Journal of Treatment & Prevention during 2018. Importantly, this review encapsulates research addressing (i) barriers to access and the uptake of empirically supported treatments, (ii) research assessing the delivery of empirically supported treatments across the full spectrum of patient care, and (iii) research aiming to isolate treatment mechanisms and optimize treatment outcomes across a transdiagnostic array of eating disorders. Ultimately, while much ground has been covered in 2018, further research is needed to enhance the accessibility and uptake existing treatments, since only a fraction of those with eating disorders are currently engaged in treatment. Further, with the expanding scope of non-outpatient eating disorder treatment settings, further research is required to adapt and assess the implementation of empirically supported treatments in higher levels of patient care. Lastly, in aiming to optimize patient outcomes, treatment outcome research must seek to identify (i) mechanisms that underlie illness eating disorder psychopathology, and (ii) the active mechanisms of existing treatments.
... Studies such as Fairburn et al. [8] and Turner et al. [9] had already shown that CBT-ED has positive impacts on other, comorbid aspects of psychopathology, such as depression and anxiety. That finding has been extensively consolidated in the past five years, with evidence that CBT-ED has a particular impact on comorbid depression, anxiety, selfesteem, and quality of life [12 & , [28][29][30]. ...
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Purpose of review: This review summarizes recent developments in cognitive-behavioural therapy for eating disorders (CBT-ED). More specifically, the past five years were covered, with the latest UK and Dutch guidelines for eating disorders as a starting benchmark, and with special consideration of the past 18 months. Recent findings: The new research can be divided into findings that have: (1) reinforced our existing understanding of CBT-ED's models and impact; (2) advanced our understanding and the utility of CBT-ED, including its application for the 'new' disorder Avoidant/Restrictive Food Intake Disorder (ARFID); (3) suggested new directions, which require further exploration in clinical and research terms. These include learning from the circumstances of the COVID-19 pandemic. Summary: CBT-ED has developed substantially in the past 5 years, with consolidation of its existing evidence base, further support for real-life implementation, extension of methods used, and the development of new approaches for working with younger people - particularly in the form of treatments for ARFID. Over the past 18 months, even more promising changes in delivery occurred in response to the COVID19 pandemic, showing that we can adapt our methods in order to work effectively via remote means. Challenges remain regarding poor outcomes for anorexia nervosa.
... Like bulimia nervosa, binge-eating disorder is characterized by repeated episodes of hyperphagia but without the repetitive inappropriate compensatory behavior seen in bulimia nervosa [1]. Several meta-analyses of randomized controlled trials (RCTs) that included wait list controls have reported that cognitive behavioral therapy (CBT) is effective for bulimia nervosa and binge-eating disorder [3,[4][5][6][7]. Our research group has recently conducted a single-arm study that confirmed the effectiveness of guided self-help CBT for Japanese patients with bulimia nervosa [8]. ...
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BACKGROUND A major problem in providing mental health services is the lack of access to treatment, especially in remote areas. Thus far, no clinical studies have demonstrated the feasibility of Internet-based cognitive behavioral therapy (ICBT) with real-time therapist support via videoconference for bulimia nervosa (BN) and binge-eating disorder (BED) at the same time in Japan. OBJECTIVE To evaluate the feasibility of ICBT via videoconference for patients with BN or BED. METHODS Five Japanese subjects (mean age 35.4 ± 9.2 years) with BN and BED received 16 weekly sessions of individualized ICBT via videoconference with real-time therapist support. Treatment included CBT tailored specifically to the presenting diagnosis. The primary outcome was a reduction in the Eating Disorder Examination interview-16 (EDE 16) for BN and BED: the combined objective binge and purging episodes; objective binge episodes; purging episodes. The secondary outcomes were the EDE-Q, the Bulimic Investigatory Test, Edinburgh, body mass index for eating symptoms, the Motivational Ruler for motivation to change, the EuroQol-5 Dimension for quality of life, the Patient Health Questionnaire-9 for depression, the Generalized Anxiety Disorder questionnaire-7 for anxiety, and the Working Alliance Inventory-Short Form (WAI-SF). All outcomes were assessed at week 1 (baseline) and at weeks 8 (mid intervention), and 16 (post intervention) during therapy. Patients were asked about adverse events at each session. For the primary analysis, treatment-related changes were assessed by comparing participant scores and the 95% confidence intervals using the paired t-test. RESULTS Although the mean combined objective binge episodes and purging episodes improved from 47.60 to 13.60 (71% reduction) and showed a medium effect size (Cohen’s d, -0.76), there was no significant reduction in the combined these episodes (EDE 16D, -41; 95% confidence interval -2.089, 0.576; P = 0.17). There were no significant treatment-related changes in the secondary outcomes. The WAI-SF scores remained consistently high (64.8–66.0) during treatment. CONCLUSIONS ICBT via videoconference is feasible in Japanese patients with BN and BED. CLINICALTRIAL UMIN000029426
... Like bulimia nervosa, binge-eating disorder is characterized by repeated episodes of hyperphagia but without the repetitive inappropriate compensatory behavior seen in bulimia nervosa [1]. Several meta-analyses of randomized controlled trials (RCTs) that included wait list controls have reported that cognitive behavioral therapy (CBT) is effective for bulimia nervosa and binge-eating disorder [3,[4][5][6][7]. Our research group has recently conducted a single-arm study that confirmed the effectiveness of guided self-help CBT for Japanese patients with bulimia nervosa [8]. ...
Article
Full-text available
Background: A major problem in providing mental health services is the lack of access to treatment, especially in remote areas. Thus far, no clinical studies have demonstrated the feasibility of internet-based cognitive behavioral therapy (ICBT) with real-time therapist support via videoconference for bulimia nervosa and binge-eating disorder in Japan. Objective: The goal of the research was to evaluate the feasibility of ICBT via videoconference for patients with bulimia nervosa or binge-eating disorder. Methods: Seven Japanese subjects (mean age 31.9 [SD 7.9] years) with bulimia nervosa and binge-eating disorder received 16 weekly sessions of individualized ICBT via videoconference with real-time therapist support. Treatment included CBT tailored specifically to the presenting diagnosis. The primary outcome was a reduction in the Eating Disorder Examination Edition 16.0D (EDE 16D) for bulimia nervosa and binge-eating disorder: the combined objective binge and purging episodes, objective binge episodes, and purging episodes. The secondary outcomes were the Eating Disorders Examination Questionnaire, Bulimic Investigatory Test, Edinburgh, body mass index for eating symptoms, Motivational Ruler for motivation to change, EuroQol-5 Dimension for quality of life, 9-item Patient Health Questionnaire for depression, 7-item Generalized Anxiety Disorder scale for anxiety, and Working Alliance Inventory–Short Form (WAI-SF). All outcomes were assessed at week 1 (baseline) and weeks 8 (midintervention) and 16 (postintervention) during therapy. Patients were asked about adverse events at each session. For the primary analysis, treatment-related changes were assessed by comparing participant scores and 95% confidence intervals using the paired t test. Results: Although the mean combined objective binge and purging episodes improved from 47.60 to 13.60 (71% reduction) and showed a medium effect size (Cohen d=–0.76), there was no significant reduction in the combined episodes (EDE 16D –41; 95% CI –2.089 to 0.576; P=.17). There were no significant treatment-related changes in secondary outcomes. The WAI-SF scores remained consistently high (64.8 to 66.0) during treatment. Conclusions: ICBT via videoconference is feasible in Japanese patients with bulimia nervosa and binge-eating disorder. Trial Registration: UMIN Clinical Trials Registry UMIN000029426; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000033419
... Potential sources of bias are scored as either 'Low Risk', 'High Risk,' or 'Some Concerns.' Consistent with previous reviews, items not applicable to psychological interventions, including blinding of participants, were excluded [25,26]. Masking of assessors was rated as low risk of bias if the study described appropriate methods of masking, or if all relevant outcome measures were self-report and did not require interaction with the assessor. ...
Article
Endometriosis is a common gynecological condition associated with debilitaing pain and poor mental health. This review examines the evidence for psychological and mind-body (PMB) interventions to improve endometriosis pain, psychological distress, sleep and fatigue. Electronic databases searched included PsychINFO, MEDLINE, CINAHL, EMBASE, Cochrane Library, Scopus, and PubMed. Inclusion criteria were women with endometriosis, and interventions that used psychological or mind-body interventions; there were no exclusion criteria regarding study design. Studies were identified and coded using standard criteria, and risk of bias was assessed with established tools relevant to the study design. A total of 12 publications relating to 9 separate studies were identified:- 3 randomized controlled trials, 1 controlled trial, 2 single-arm studies, 1 retrospective cohort study, and 2 case series. Interventions included yoga, mindfulness, relaxation training, cognitive behavioural therapy combined with physical therapy, Chinese medicine combined with psychotherapy, and biofeedback. Results indicate that no studies have yet used gold-standard methodology and, thus, definitive conclusions cannot be offered about PMB efficacy. However, the results of these pilot studies suggest that PMB interventions show promise in alleviating pain, anxiety, depression, stress and fatigue in women with endometriosis, and future well-designed RCTs including active control groups are warranted.
Chapter
Eating disorders are common and have a high morbidity and mortality rates. They present with a range of comorbid features and require specialized treatment to achieve a positive outcome. The literature on eating disorders has expanded rapidly in the past 20 years and this article reviews diagnostic and defining features, assessment, etiology, comorbidities and treatment options. Recent advances in the understanding and treatment of eating disorders can be expected to produce positive outcomes in most cases.
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This Virtual Issue of the International Journal of Eating Disorders (IJED) is released to mark the XXIVth Eating Disorder Research Society (EDRS) meeting in Sydney, Australia. This is the second EDRS meeting in Australia, reflecting the strong contribution of Australian researchers to eating disorder research internationally. Attendees at the Sydney EDRS meeting will be able to access the top 10 cited papers from IJED by Australian authors in 2016–2017, cited an average of 10.2 times each. It is pleasing to note the strong representation of early career researchers and the range of topics addressed.
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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
Background While randomized controlled trials (RCTs) inform the efficacy and effectiveness of treatments, we need to understand that even RCTs can be associated with sub‐optimal execution. This is of special pertinence to eating disorders given the majority of treatment studies involving cognitive behaviour therapy are of poor quality with respect to managing risk of bias adequately. Methods The current paper outlines the components of a good RCT for psychotherapy, and examines ways to improve the conduct, interpretation, and usefulness of RCTs. Results This includes managing reporting bias, recognizing the limits of randomization, applicability, and ethical considerations. Conclusions We highlight a number of strategies for future research, including issues related to utilizing a variety of designs to examine treatment outcomes, integrity, openness and reproducibility.
Article
Objective: Cognitive-behavioral therapy (CBT) is efficacious for a range of eating disorder presentations, yet premature dropout is one factor that might limit CBTs effectiveness. Improved understanding of dropout from CBT for eating disorders is important. This meta-analysis aimed to study dropout from CBT for eating disorders in randomized controlled trials (RCTs), by (a) identifying the types of dropout definitions applied, (b) providing estimates of dropout, (c) comparing dropout rates from CBT to non-CBT interventions for eating disorders, and (d) testing moderators of dropout. Method: RCTs of CBT for eating disorders that reported rates of dropout were searched. Ninety-nine RCTs (131 CBT conditions) were included. Results: Dropout definitions varied widely across studies. The overall dropout estimate was 24% (95% CI = 22-27%). Diagnostic type, type of dropout definition, baseline symptom severity, study quality, and sample age did not moderate this estimate. Dropout was highest among studies that delivered internet-based CBT and was lowest in studies that delivered transdiagnostic enhanced CBT. There was some evidence that longer treatment protocols were associated with lower dropout. No significant differences in dropout rates were observed between CBT and non-CBT interventions for all eating disorder subtypes. Conclusion: Present study dropout estimates are hampered by the use of disparate dropout definitions applied. This meta-analysis highlights the urgency for RCTs to utilize a standardized dropout definition and to report as much information on patient dropout as possible, so that strategies designed to minimize dropout can be developed, and factors predictive of CBT dropout can be more easily identified.
Chapter
It is known that women’s health presents particularities and is closely related to the different phases of life: childhood and adolescence, menarche, fertile age, gestation and puerperium, and menopause. Eating disorders are much more frequent in women while reaching gender ratios of up to 10:1 in anorexia nervosa and bulimia nervosa. These disorders involve inadequate eating patterns and eating behavior, causing major social, functional, and nutritional impact, and are among the highest mortality rates among mental disorders, due to either clinical complications or the high rates of suicide. The presence of psychiatric comorbidities in these individuals is frequent, and the correct identification allows for the most appropriate therapeutic intervention. The rates of comorbidity with personality disorders range from 25% to 69% and generally establish a more unfavorable prognosis, with higher rates of hospitalization, chronification, and suicide attempts. The study of this comorbid condition allows for a more individualized approach, influencing the course, prognosis, and treatment of these patients.
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Empirical evidence continues to suggest that the majority of patients with eating disorders will not fully recover during treatment, and that treatment gains are vulnerable to relapse in the longer term. The urgent need for improved treatment options for those with eating disorders cannot be overstated. This review article provides an overview of treatment-related research findings published in Eating Disorders: The Journal of Treatment & Prevention during 2019. Importantly, this review encapsulates research (i) outlining guidelines in managing the medical risk inherent to the treatment of eating disorders, (ii) examining the treatment of eating disorders in cross-cultural contexts, (iii) expanding treatment research to novel and atypical eating disorder populations, and (iv) augmenting existing treatment approaches for anorexia nervosa and bulimia nervosa in novel contexts. These articles represent important contributions to the ongoing evolution of the treatment of eating disorders. However, further work is needed in precisely identifying the mechanisms of eating disorder psychopathology, such that emerging treatment efforts may be mapped onto specific targets.
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BACKGROUND: Several meta-analyses have shown that psychotherapy is effective for reducing depressive symptom severity. However, the impact on quality of life (QoL) is as yet unknown. AIMS: To investigate the effectiveness of psychotherapy for depression on global QoL and on the mental health and physical health components of QoL. METHOD: We conducted a meta-analysis of 44 randomised clinical trials comparing psychotherapy for adults experiencing clinical depression or elevated depressive symptoms with a control group. We used subgroup analyses to explore the influence of various study characteristics on the effectiveness of treatment. RESULTS: We detected a small to moderate effect size (Hedges' g = 0.33, 95% CI 0.24-0.42) for global QoL, a moderate effect size for the mental health component (g = 0.42, 95% CI 0.33-0.51) and, after removing an outlier, a small but statistically significant effect size for the physical health component (g = 0.16, 95% CI 0.05-0.27). Multivariate meta-regression analyses showed that the effect size of depressive symptoms was significantly related to the effect size of the mental health component of QoL. The effect size of depressive symptoms was not related to global QoL or the physical health component. CONCLUSIONS: Psychotherapy for depression has a positive impact on the QoL of patients with depression. Improvements in QoL are not fully explained by improvements in depressive symptom severity.
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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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Objectives: This clinical practice guideline for treatment of DSM-5 feeding and eating disorders was conducted as part of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) Clinical Practice Guidelines (CPG) Project 2013-2014. Methods: The CPG was developed in accordance with best practice according to the National Health and Medical Research Council of Australia. Literature of evidence for treatments of anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), other specified and unspecified eating disorders and avoidant restrictive food intake disorder (ARFID) was sourced from the previous RANZCP CPG reviews (dated to 2009) and updated with a systematic review (dated 2008-2013). A multidisciplinary working group wrote the draft CPG, which then underwent expert, community and stakeholder consultation, during which process additional evidence was identified. Results: In AN the CPG recommends treatment as an outpatient or day patient in most instances (i.e. in the least restrictive environment), with hospital admission for those at risk of medical and/or psychological compromise. A multi-axial and collaborative approach is recommended, including consideration of nutritional, medical and psychological aspects, the use of family based therapies in younger people and specialist therapist-led manualised based psychological therapies in all age groups and that include longer-term follow-up. A harm minimisation approach is recommended in chronic AN. In BN and BED the CPG recommends an individual psychological therapy for which the best evidence is for therapist-led cognitive behavioural therapy (CBT). There is also a role for CBT adapted for internet delivery, or CBT in a non-specialist guided self-help form. Medications that may be helpful either as an adjunctive or alternative treatment option include an antidepressant, topiramate, or orlistat (the last for people with comorbid obesity). No specific treatment is recommended for ARFID as there are no trials to guide practice. Conclusions: Specific evidence based psychological and pharmacological treatments are recommended for most eating disorders but more trials are needed for specific therapies in AN, and research is urgently needed for all aspects of ARFID assessment and management. Expert reviewers: Associate Professor Susan Byrne, Dr Angelica Claudino, Dr Anthea Fursland, Associate Professor Jennifer Gaudiani, Dr Susan Hart, Ms Gabriella Heruc, Associate Professor Michael Kohn, Dr Rick Kausman, Dr Sarah Maguire, Ms Peta Marks, Professor Janet Treasure and Mr Andrew Wallis.
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Background: Despite effective treatment approaches, relapses are frequent in eating disorders. Posttreatment care is essential to enhance continuous recovery and prevent deterioration. This study evaluated the effects of an Internet-based intervention following routine care. Materials and methods: One hundred five women who received treatment for bulimia nervosa and related eating disorders not otherwise specified were randomly assigned either to an immediate Internet-based support program (EDINA) over 4 months or to a 4-month waiting-list treatment as usual (TAU) control condition. The primary outcome was eating disorder-related attitudes at baseline and after 4 months assessed by the Eating Disorder Examination Questionnaire (EDE-Q). Results: The program proved feasible and was well accepted. A significant reduction in eating disorder-related attitudes could be shown for both groups at the end of the 4 months. There was a tendency for participants of the aftercare intervention to show better results on all outcome measures. In total, 40.6% (13/32) of the EDINA participants and 24.4% (10/41) of the TAU participants showed statistically reliable improvement on the EDE-Q total score by the end of the intervention period [χ(2)(1)=2.195, p=0.138]. Conclusions: The Internet-based support program was feasible and well accepted but did not prove efficacious in a heterogeneous sample of patients following routine care.
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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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Objective: No recent meta-analysis has examined the effects of cognitive-behavioural therapy (CBT) for adult depression. We decided to conduct such an updated meta-analysis. Methods: Studies were identified through systematic searches in bibliographical databases (PubMed, PsycINFO, Embase, and the Cochrane library). We included studies examining the effects of CBT, compared with control groups, other psychotherapies, and pharmacotherapy. Results: A total of 115 studies met inclusion criteria. The mean effect size (ES) of 94 comparisons from 75 studies of CBT and control groups was Hedges g = 0.71 (95% CI 0.62 to 0.79), which corresponds with a number needed to treat of 2.6. However, this may be an overestimation of the true ES as we found strong indications for publication bias (ES after adjustment for bias was g = 0.53), and because the ES of higher-quality studies was significantly lower (g = 0.53) than for lower-quality studies (g = 0.90). The difference between high- and low-quality studies remained significant after adjustment for other study characteristics in a multivariate meta-regression analysis. We did not find any indication that CBT was more or less effective than other psychotherapies or pharmacotherapy. Combined treatment was significantly more effective than pharmacotherapy alone (g = 0.49). Conclusions: There is no doubt that CBT is an effective treatment for adult depression, although the effects may have been overestimated until now. CBT is also the most studied psychotherapy for depression, and thus has the greatest weight of evidence. However, other treatments approach its overall efficacy.
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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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There is a need to improve treatment for individuals with bulimic disorders. It was hypothesised that a focus in treatment on broader emotional and social/interpersonal issues underlying eating disorders would increase treatment efficacy. This study tested a novel treatment based on the above hypothesis, an Emotional and Social Mind Training Group (ESM), against a Cognitive Behavioural Therapy Group (CBT) treatment. 74 participants were randomised to either ESM or CBT Group treatment programmes. All participants were offered 13 group and 4 individual sessions. The primary outcome measure was the Eating Disorder Examination (EDE) Global score. Assessments were carried out at baseline, end of treatment (four months) and follow-up (six months). There were no differences in outcome between the two treatments. No moderators of treatment outcome were identified. Adherence rates were higher for participants in the ESM group. This suggests that ESM may be a viable alternative to CBT for some individuals. Further research will be required to identify and preferentially allocate suitable individuals accordingly. ISRCTN61115988.
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The cardinal feature of bulimia nervosa as well as an important feature in some cases of anorexia nervosa, binge eating is central to the proposed Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) scheme for classifying eating disorders. Despite its prevalence, no one volume has been devoted to synthesizing all that is known about binge eating and its treatment. Bridging a gap in the literature, this . . . text brings together significant, original contributions from leading experts from a wide variety of fields. A valuable resource for all clinicians and researchers interested in eating problems and their treatment, "Binge Eating" also serves as a text for advanced courses on eating disorders, or as supplementary reading for students of psychopathology. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Objective: Meta-analyses have documented the efficacy of cognitive-behavioral therapy (CBT) for reducing symptoms of eating disorders. However, it is not known whether CBT for eating disorders can also improve quality of life (QoL). This meta-analysis therefore examined the effects of CBT for eating disorders on subjective QoL and health-related quality of life (QoL). Method: Studies that assessed QoL before and after CBT for eating disorders were searched in the PsycInfo and Medline database. Thirty-four articles met inclusion criteria. Pooled within and between-groups Hedge's g were calculated at post-treatment and follow-up for treatment changes on both subjective and HRQoL using a random effects model. Results: CBT led to significant and modest improvements in subjective QoL and HRQoL from pre to post-treatment and follow-up. CBT led to greater subjective QoL improvements than inactive (i.e., wait-list) and active (i.e., a combination of bona fide therapies, psychoeducation) comparisons. CBT also led to greater HRQoL improvements than inactive, but not active, comparisons. Prepost QoL improvements were larger in studies that delivered CBT individually and by a therapist or according to the cognitive maintenance model of eating disorders (CBT-BN or CBT-E); though this was not replicated at follow-up CONCLUSIONS: Findings provide preliminary evidence that CBT for eating disorders is associated with modest improvements in QOL, and that CBT may be associated with greater improvements in QOL relative to comparison conditions.
Article
The therapeutic alliance has demonstrated an association with favorable psychotherapeutic outcomes in the treatment of eating disorders (EDs). However, questions remain about the inter-relationships between early alliance, early symptom improvement, and treatment outcome. We conducted a meta-analysis on the relations among these constructs, and possible moderators of these relations, in psychosocial treatments for EDs. Twenty studies met inclusion criteria and supplied sufficient supplementary data. Results revealed small-to-moderate effect sizes, βs = 0.13 to 0.22 (p < .05), indicating that early symptom improvement was related to subsequent alliance quality and that alliance ratings also were related to subsequent symptom reduction. The relationship between early alliance and treatment outcome was partially accounted for by early symptom improvement. With regard to moderators, early alliance showed weaker associations with outcome in therapies with a strong behavioral component relative to nonbehavioral therapies. However, alliance showed stronger relations to outcome for younger (vs. older) patients, over and above the variance shared with early symptom improvement. In sum, early symptom reduction enhances therapeutic alliance and treatment outcome in EDs, but early alliance may require specific attention for younger patients and for those receiving nonbehaviorally oriented treatments.
Article
Remarkable progress has been made in developing psychosocial interventions for eating disorders and other mental disorders. Two priorities in providing treatment consist of addressing the research-practice gap and the treatment gap. The research-practice gap pertains to the dissemination of evidence-based treatments from controlled settings to routine clinical care. Closing the gap between what is known about effective treatment and what is actually provided to patients who receive care is crucial in improving mental health care, particularly for conditions such as eating disorders. The treatment gap pertains to extending treatments in ways that will reach the large number of people in need of clinical care who currently receive nothing. Currently, in the United States (and worldwide), the vast majority of individuals in need of mental health services for eating disorders and other mental health problems do not receive treatment. This article discusses the approaches required to better ensure: (1) that more people who are receiving treatment obtain high-quality, evidence-based care, using such strategies as train-the-trainer, web-centered training, best-buy interventions, electronic support tools, higher-level support and policy; and (2) that a higher proportion of those who are currently underserved receive treatment, using such strategies as task shifting and disruptive innovations, including treatment delivery via telemedicine, the Internet, and mobile apps.
Article
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.
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
Objective: Undertake a meta-analysis to provide a quantitative synthesis of longitudinal studies that assessed the direction of effects between eating pathology and depression. A second aim was to use meta-regression to account for heterogeneity in terms of study-level effect modifiers. Method: A systematic review was conducted on 42 studies that assessed the longitudinal relationship between eating pathology and depression. Of these 42 studies, multilevel random-effects meta-analyses were conducted on 30 eligible studies. Results: Meta-analysis results showed that eating pathology was a risk factor for depression (rm = 0.13) and that depression was a risk factor for eating pathology (rm = 0.16). Meta-regression analyses showed that these effects were significantly stronger for studies that operationalized eating pathology as an eating disorder diagnosis versus eating pathology symptoms, and for studies that operationalized the respective outcome measure as a categorical variable (e.g., a diagnosis of a disorder or where symptoms were "present"/"absent") versus a continuous measure. Results also showed that in relation to eating pathology type, the effect of an eating disorder diagnosis and bulimic symptoms on depression was significantly stronger for younger participants. Discussion: Eating pathology and depression are concurrent risk factors for each other, suggesting that future research would benefit from identifying factors that are etiological to the development of both constructs. Resumen objetivo: Llevar a cabo un meta-análisis para proporcionar una síntesis cuantitativa de los estudios longitudinales que evaluaron la dirección de los efectos entre la alimentación patológica y la depresión. Un segundo objetivo fue utilizar la meta-regresión para dar cuenta de la heterogeneidad en términos de modificadores del efecto a nivel de estudio. MÉTODO: Una revisión sistemática se llevó a cabo en 42 estudios que evaluaron la relación longitudinal entre la alimentación patológica y la depresión. De estos 42 estudios, se realizaron meta-análisis de multinivel de efectos aleatorios en 30 estudios elegibles. Resultados: Los resultados del meta-análisis mostraron que la alimentación patológica era un factor de riesgo para depresión (rm=0.13) y que la depresión era un factor de riesgo para la alimentación patológica (rm=0.16). Los análisis de meta-regresión mostraron que estos efectos eran significativamente más fuertes para estudios que operacionalizaban la alimentación patológica como un diagnóstico de trastorno de la conducta alimentaria versus síntomas de alimentación patológica, y para los estudios que operacionalizaban la medida respectiva de resultado como una variable categórica (e.g., un diagnóstico de trastorno o cuando los síntomas estaban "presentes"/"ausentes") versus una medida continua. Los resultados mostraron que en relación al tipo de alimentación patológica, el efecto de un diagnóstico de trastorno de la conducta alimentaria y síntomas bulímicos en la depresión era significativamente más fuerte para participantes más jóvenes. DISCUSIÓN: La alimentación patológica y la depresión son factores de riesgo concurrentes uno para el otro, lo que sugiere que la investigación futura se beneficiaría de identificar factores que son etiológicos al desarrollo de ambos constructos. © 2015 Wiley Periodicals, Inc. (Int J Eat Disord 2016;49:439-454).
Article
Objective: There is a paucity of randomized clinical trials (RCTs) for adolescents with bulimia nervosa (BN). Prior studies suggest cognitive-behavioral therapy adapted for adolescents (CBT-A) and family-based treatment for adolescent bulimia nervosa (FBT-BN) could be effective for this patient population. The objective of this study was to compare the relative efficacy of these 2 specific therapies, FBT-BN and CBT-A. In addition, a smaller participant group was randomized to a nonspecific treatment (supportive psychotherapy [SPT]), whose data were to be used if there were no differences between FBT-BN and CBT-A at end of treatment. Method: This 2-site (Chicago and Stanford) randomized controlled trial included 130 participants (aged 12-18 years) meeting DSM-IV criteria for BN or partial BN (binge eating and purging once or more per week for 6 months). Outcomes were assessed at baseline, end of treatment, and 6 and 12 months posttreatment. Treatments involved 18 outpatient sessions over 6 months. The primary outcome was defined as abstinence from binge eating and purging for 4 weeks before assessment, using the Eating Disorder Examination. Results: Participants in FBT-BN achieved higher abstinence rates than in CBT-A at end of treatment (39% versus 20%; p = .040, number needed to treat [NNT] = 5) and at 6-month follow-up (44% versus 25%; p = .030, NNT = 5). Abstinence rates between these 2 groups did not differ statistically at 12-month follow-up (49% versus 32%; p = .130, NNT = 6). Conclusion: In this study, FBT-BN was more effective in promoting abstinence from binge eating and purging than CBT-A in adolescent BN at end of treatment and 6-month follow-up. By 12-month follow-up, there were no statistically significant differences between the 2 treatments. Clinical trial registration information: -Study of Treatment for Adolescents With Bulimia Nervosa; http://clinicaltrials.gov/; NCT00879151.
Article
Understanding the factors that predict a favourable outcome following specialist treatment for an eating disorder may assist in improving treatment efficacy, and in developing novel interventions. This review and meta-analysis examined predictors of treatment outcome and drop-out. A literature search was conducted to identify research investigating predictors of outcome in individuals treated for an eating disorder. We organized predictors first by statistical type (simple, meditational, and moderational), and then by category. Average weighted mean effect sizes (r) were calculated for each category of predictor. The most robust predictor of outcome at both end of treatment (EoT) and follow-up was the meditational mechanism of greater symptom change early during treatment. Simple baseline predictors associated with better outcomes at both EoT and follow-up included higher BMI, fewer binge/purge behaviors, greater motivation to recover, lower depression, lower shape/weight concern, fewer comorbidities, better interpersonal functioning and fewer familial problems. Drop-out was predicted by more binge/purge behaviors and lower motivation to recover. For most predictors, there was large interstudy variability in effect sizes, and outcomes were operationalized in different ways. There were generally insufficient studies to allow analysis of predictors by eating disorder subtype or treatment type. To ensure that this area continues to develop with robust and clinically relevant findings, future studies should adopt a consistent definition of outcome and continue to examine complex multivariate predictor models. Growth in this area will allow for stronger conclusions to be drawn about the prediction of outcome for specific diagnoses and treatment types. © 2015 Wiley Periodicals, Inc.
Article
In a clinical population, we estimated the frequency of mood disorders among 271 patients suffering from Anorexia Nervosa (AN) and Bulimia Nervosa (BN) in comparison to a control group matched for age and gender. The frequency of mood disorders was measured using the Mini International Neuropsychiatric Interview (MINI), DSM-IV version. Mood disorders were more frequent among eating disorder (ED) patients than among controls, with a global prevalence of the order of 80% for each ED group. The majority of the mood disorders comorbid with ED were depressive disorders (MDD and dysthymia). The relative chronology of onset of these disorders was equivocal, because mood disorders in some cases preceded and in others followed the onset of the eating disorders. Our sample was characterized by patients with severe ED and high comorbidities, and thus do not represent the entire population of AN or BN. This also may have resulted in an overestimation of prevalence. Mood disorders appear significantly more frequently in patients seeking care for ED than in controls. These results have implications for the assessment and treatment of ED patients, and for the aetio-pathogenesis of these disorders. Copyright © 2015. Published by Elsevier B.V.
Article
• Previous research on the treatment of outpatients with bulimia nervosa has focused on two treatment strategies: (1) drug therapy, primarily using tricyclic antidepressants, and (2) psychotherapy, often employing behavioral and cognitive behaviorantechniques. We report here the short-term treatment outcome of a 12-week comparison trial of bulimic outpatients who were randomly assigned to one of four treatment cells: (1) imipramine hydrochloride treatment, (2) placebo treatment, (3) imipramine treatment combined with intensive group psychotherapy, and (4) placebo treatment combined with intensive group psychotherapy. All three active treatment cells resulted in significant reductions in target-eating behaviors and in a significant improvement in mood relative to placebo treatment. However, the results also suggested that the amount of improvement obtained with the intensive group psychotherapy component was superior to that obtained with antidepressant treatment alone. The addition of antidepressant treatment to the intensive group psychotherapy component did not significantly improve outcome over intensive group psychotherapy combined with placebo treatment in terms of eating behavior, but did result in more improvement in the symptoms of depression and anxiety.
Article
IntroductionIndividual studiesThe summary effectHeterogeneity of effect sizesSummary points
Article
Bulimia nervosa (BN) treatment studies consistently observe that substantial reductions in purging frequency after four weeks of treatment predict outcome. Although baseline levels of other variables have been compared to change in purging, measures of early change in other domains have not been examined. This study aimed to compare percentage change in purging, depression, and cognitive eating disorder (ED) symptoms for associations with BN remission post-treatment and at six months follow-up. Data from N = 43 patients with BN in a clinical trial comparing the broad and focused versions of enhanced cognitive behavior therapy (CBT-E; Fairburn, 2008) were utilized. Measures included self-reported purging frequency, Beck Depression Inventory (BDI) score, and a mean of items from the Eating Disorder Inventory Body Dissatisfaction and Drive for Thinness subscales. Results indicated that both percentage change in purging frequency and percentage change in BDI score at week four/session eight were significantly associated with remission at termination. The optimal cutoffs for purging change and BDI score change were 65% decrease and 25% decrease respectively. Only change in BDI score at week four significantly predicted remission at six-month follow-up. These data suggest that change in depressive symptoms may be as important as ED symptom change to predict outcome in some groups.
Article
To update new evidence for psychotherapies in eating disorders (EDs) since 2005-September 2012. Completed and published in the English language randomized controlled trials (RCTs) were identified by SCOPUS search using terms "bulimia" or "binge eating disorder" (BED) or "anorexia nervosa" (AN) or "eating disorder" and "treatment," and 36 new RCTs met inclusion criteria. There has been progress in the evidence for family based treatment in adolescents with AN, for cognitive behavior therapy (CBT) in full and guided forms, and new modes of delivery for bulimia nervosa (BN), BED, and eating disorder not otherwise specified with binge eating. Risk of bias was low to moderate in 22 (61%) of RCTs. The evidence base for AN has improved and CBT has retained and extended its status as first-line therapy for BN. However, further research is needed, in particular noninferiority trials of active therapies and the best approach to addressing ED features and weight management in co-morbid BED and obesity. © 2013 by Wiley Periodicals, Inc. (Int J Eat Disord 2013; 46:462-469).
Article
A randomized, placebo-controlled study was conducted examining the singular and combined effects of fluoxetine and a self-help manual on suppressing bulimic behaviors in women with bulimia nervosa. A total of 91 adult women with bulimia nervosa were randomly assigned to one of four conditions: placebo only, fluoxetine only, placebo and a self-help manual, or fluoxetine and a self-help manual. Subjects were treated for 16 weeks. Primary outcome measures included self-reports of bulimic behaviors. Fluoxetine and a self-help manual were found to be effective in reducing the frequency of vomiting episodes and in improving the response rates for vomiting and binge-eating episodes. Furthermore, both factors were shown to be acting additively on the primary and secondary efficacy measures in this study. Results are discussed in relation to previous research and the implications for treatment of bulimia nervosa.
Article
This study examined the short- and long-term effectiveness of cognitive-behavioural group treatment (CBT), pharmacological treatment with fluoxetine and combined treatment in patients with DSM-III-R bulimia nervosa. Fifty-three patients were randomly assigned to the three conditions. Outcome measures were frequency of bingeing and purging, attitudes toward weight and shape, depression and self-concept. Patients were followed for 1 year post-treatment. Thirty-five patients completed treatment. Drop-out rates were 42 per cent for CBT, 25 per cent for the fluoxetine and 33 per cent for the combined condition. All treatments led to significant improvements in eating disorder symptoms and in other psychological disturbances between pre- and post-treatment, which could be maintained at 1-year follow-up. Abstinence rates for completers were highest for CBT at both post-treatment and follow-up. The short- and long-term results of this study do not favour the combined treatment in comparison to CBT alone. Cultural differences in health systems as well as in the acceptance of treatments offered in a treatment trial are discussed. Copyright © 2002 John Wiley & Sons, Ltd and Eating Disorders Association.
Article
The efficacy of 6 weeks of twice-weekly, cognitive-behavioral group therapy (n = 15) was compared with a waiting list control (n = 15) in 30 women with bulimia by DSM-III. Relaxation techniques and group discussions to alter dysfunctional attitudes regarding eating and appearance was used. A significant decrease in both binge and purge frequency was found in the treated compared with the wait-listed group. Treated subjects who decreased their binging and purging maintained improvement 4 months after treatment termination. However, overall absolute clinical efficacy was limited, as only four treated subjects showed a full remission of binge episodes. Longer treatment with more specifically tailored cognitive- behavioral techniques may be warranted in the search for more efficacious results for bulimia.
Article
The purpose of this paper is to examine the factors that influence treatment response and outcome in 39 patients with bulimia nervosa who were assessed during the course of 8 weeks of cognitive-behavioral therapy, and after an 8-week and 1-year follow-up period. The patients' progress was assessed using data gathered from clinical examination, structured interviews, and self-rating scales. Patients who had a poor clinical response at the end of treatment had greater pretreatment symptom severity, lower body mass index, and were more likely to have personality disorders. Poor response after 1 year was associated with personality disorder, pretreatment symptom severity, and longer duration of illness. Patients without these poor prognostic indicators are more likely to respond to brief psychoeducational interventions. Patients with poor prognostic indicators are more suited to intensive psychological, pharmacologic, and experimental treatment approaches. © 1993 by John Wiley & Sons, Inc.
Article
This treatment development study investigated the acceptability and efficacy of a modified version of dialectical behavior therapy (DBT) for bulimia nervosa (BN), entitled appetite focused DBT (DBT-AF). Thirty-two women with binge/purge episodes at least one time per week were randomly assigned to 12 weekly sessions of DBT-AF (n = 18) or to a 6-week delayed treatment control (n = 14). Participants completed the EDE interview and self-report measures at baseline, 6 weeks, and posttreatment. Treatment attrition was low, and DBT-AF was rated highly acceptable. At 6 weeks, participants who were receiving DBT-AF reported significantly fewer BN symptoms than controls. At posttest, 26.9% of the 26 individuals who entered treatment (18 initially assigned and 8 from the delayed treatment control) were abstinent from binge/purge episodes for the past month; 61.5% no longer met full or subthreshold criteria for BN. Participants demonstrated a rapid rate of response to treatment and achieved clinically significant change. Results suggest that DBT-AF warrants further investigation as an alternative to DBT or cognitive behavior therapy for BN. © 2010 by Wiley Periodicals, Inc. (Int J Eat Disord 2011; 44:249–261)
Article
Objective: To examine psychiatric comorbidity and factors that influence the outcome of bulimia nervosa (BN) in the general population. Method: Women from the nationwide birth cohorts of Finnish twins were screened for lifetime BN (N = 59) by using questionnaires and the Structured Clinical Interview for DSM-IV. We assessed psychiatric comorbidity and other prognostic factors. Results: Among women with lifetime BN, the following were more common than among unaffected women: current major depressive disorder (p = 0.004), lifetime major depressive disorder (p = 0.00001) and heavy drinking (p = 0.01). Decreased likelihood of recovery was associated with a history of lifetime major depressive disorder (hazard ratio (HR) 0.44, 95% confidence interval (CI) 0.23-0.84) and high drive for thinness at time of assessment (HR 0.96, 95% CI 0.93-0.99). Discussion: Heavy drinking and depression present challenges for many women with BN. Major depressive disorder emerged as the only statistically significant prognostic factor of BN in this nationwide cohort; high drive for thinness was characteristic of the persistently ill.
Article
Research suggests that shared genetic factors underlie relationships between eating disorder and depression diagnoses, but no studies to date have examined these associations using dimensional symptom measures. This study examined whether genetic associations observed between eating disorder and depression diagnoses extend to continuous measures of these phenotypes. The sample consisted of 292 young adult female twins from the Michigan State University Twin Registry. Disordered eating was measured using the Minnesota Eating Behavior Survey. Depressive symptoms were assessed using the Beck Depression Inventory. Univariate twin models indicated that genetic factors accounted for 55% to 60% of the variance in disordered eating and depressive symptoms, with the remaining variance accounted for by nonshared environmental effects. Bivariate models indicated that genetic factors primarily accounted for associations between disordered eating and depressive symptoms (r(a) = .70). Phenotypic associations between disordered eating and depressive symptoms appear to be due to common genetic factors.
Article
Most meta-analyses have concluded that psychotherapy and pharmacotherapy yield roughly similar efficacy in the short-term treatment of depression, with psychotherapy showing some advantage at long-term follow-up. However, a recent meta-analysis found that selective serotonin reuptake inhibitors medications were superior to psychotherapy in the short-term treatment of depression. To incorporate results of several recent trials into the meta-analytic literature, we conducted a meta-analysis of trials which directly compared psychotherapy to second-generation antidepressants (SGAs). Variables potentially moderating the quality of psychotherapy or medication delivery were also examined, to allow the highest quality comparison of both types of intervention. Bona fide psychotherapies showed equivalent efficacy in the short-term and slightly better efficacy on depression rating scales at follow-up relative to SGA. Non-bona fide therapies had significantly worse short-term outcomes than medication (d = 0.58). No significant differences emerged between treatments in terms of response or remission rates, but non-bona fide therapies had significantly lower rates of study completion than medication (odds ratio = 0.55). Bona fide psychotherapy appears as effective as SGAs in the short-term treatment of depression, and likely somewhat more effective than SGAs in the longer-term management of depressive symptoms.
Article
To evaluate in a 6-year follow-up study the course of a large clinical sample of patients with eating disorders (EDs) who were treated with individual cognitive behavior therapy. The diagnostic crossover, recovery, and relapses were assessed, applying both Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and the DSM-V proposed criteria. Patients with EDs move in and out of illness states over time, display frequent relapses, show a relevant lifetime psychiatric comorbidity, and migrate between different diagnoses. A total of 793 patients (including anorexia nervosa, bulimia nervosa, binge eating disorder, and EDs not otherwise specified) were evaluated on the first day of admission, at the end of treatment, 3 years after the end of treatment, and 3 years after the first follow-up. Clinical data were collected through a face-to-face interview; diagnosis was performed by means of the Structured Clinical Interview for DSM-IV and the Eating Disorder Examination Questionnaire was applied. A consistent rate of relapse and crossover between the different diagnoses over time was observed. Mood disorders comorbidity has been found to be an important determinant of diagnostic instability, whereas the severity of shape concern represented a relevant outcome modifier. Using the DSM-V proposed criteria, most patients of EDs not otherwise specified were reclassified, so that the large majority of ED patients seeking treatment would be included in full-blown diagnoses. Among EDs, there are different subgroups of patients displaying various courses and outcomes. The diagnostic instability involves the large majority of patients. An integration of categorical and dimensional approaches could improve the psychopathological investigation and the treatment choices.
Article
Bulimic eating disorders are common among female students, yet the majority do not access effective treatment. Internet-based cognitive-behavioural therapy (iCBT) may be able to bridge this gap. Seventy-six students with bulimia nervosa (BN) or eating disorder not otherwise specified (EDNOS) were randomly assigned to immediate iCBT with e-mail support over 3 months or to a 3-month waiting list followed by iCBT [waiting list/delayed treatment control (WL/DTC)]. ED outcomes were assessed with the Eating Disorder Examination (EDE) at baseline, 3 months and 6 months. Other outcomes included depression, anxiety and quality of life. Students who had immediate iCBT showed significantly greater improvements at 3 and 6 months than those receiving WL/DTC in ED and other symptoms. iCBT with e-mail support is efficacious in students with bulimic disorders and has lasting effects.
Article
Background: A specific manual-based form of cognitive behavioural therapy (CBT) has been developed for the treatment of bulimia nervosa (CBT-BN) and other common related syndromes such as binge eating disorder. Other psychotherapies and modifications of CBT are also used. Objectives: To evaluate the efficacy of CBT, CBT-BN and other psychotherapies in the treatment of adults with bulimia nervosa or related syndromes of recurrent binge eating. Search strategy: Handsearch of The International Journal of Eating Disorders since first issue; database searches of MEDLINE, EXTRAMED, EMBASE, PsycInfo, CURRENT CONTENTS, LILACS, SCISEARCH, CENTRAL and the The Cochrane Collaboration Depression, Anxiety & Neurosis Controlled Trials Register; citation list searching and personal approaches to authors were used. Search date June 2007. Selection criteria: Randomised controlled trials of psychotherapy for adults with bulimia nervosa, binge eating disorder and/or eating disorder not otherwise specified (EDNOS) of a bulimic type which applied a standardised outcome methodology and had less than 50% drop-out rate. Data collection and analysis: Data were analysed using the Review Manager software program. Relative risks were calculated for binary outcome data. Standardised mean differences were calculated for continuous variable outcome data. A random effects model was applied. Main results: 48 studies (n = 3054 participants) were included. The review supported the efficacy of CBT and particularly CBT-BN in the treatment of people with bulimia nervosa and also (but less strongly due to the small number of trials) related eating disorder syndromes.Other psychotherapies were also efficacious, particularly interpersonal psychotherapy in the longer-term. Self-help approaches that used highly structured CBT treatment manuals were promising. Exposure and Response Prevention did not enhance the efficacy of CBT.Psychotherapy alone is unlikely to reduce or change body weight in people with bulimia nervosa or similar eating disorders. Authors' conclusions: There is a small body of evidence for the efficacy of CBT in bulimia nervosa and similar syndromes, but the quality of trials is very variable and sample sizes are often small. More and larger trials are needed, particularly for binge eating disorder and other EDNOS syndromes. There is a need to develop more efficacious therapies for those with both a weight and an eating disorder.
Article
The purpose of the present study was to evaluate reducing perfectionism as a potential treatment target for individuals with Bulimia Nervosa (BN). Forty-eight individuals meeting DSM-IV criteria for BN or eating disorder - not otherwise specified with binge eating [objective or subjective] or purging at least once per week were recruited. Participants were randomly assigned to receive 8 sessions of manual-based guided self-help (GSH) over a 6-week period that was focused on either cognitive behaviour therapy (CBT) for perfectionism, CBT for BN, or a placebo. Individuals were assessed at baseline, pre-treatment, post-treatment and at six-month follow-up on 12 outcome variables, including diagnostic criteria and psychological variables. There was no significant change in any of the outcome variables over a 6-week no-treatment period but at post-treatment and 6-month follow-up there were significant main effects of time for 10 and 8 outcome variables respectively, suggesting that all groups reported significant reductions in bulimic symptomatology and related psychopathology at post-treatment and follow-up. These findings show potential for the use of novel interventions in GSH for BN.
Article
The specificity and magnitude of the effects of cognitive behavior therapy in the treatment of bulimia nervosa were evaluated. Seventy-five patients who met strict diagnostic criteria were treated with either cognitive behavior therapy, a simplified behavioral version of this treatment, or interpersonal psychotherapy. Assessment was by interview and self-report questionnaire, and many aspects of functioning were evaluated. All three treatments resulted in an improvement in the measures of the psychopathology. Cognitive behavior therapy was more effective than interpersonal psychotherapy in modifying the disturbed attitudes to shape and weight, extreme attempts to diet, and self-induced vomiting. Cognitive behavior therapy was more effective than behavior therapy in modifying the disturbed attitudes to shape and weight and extreme dieting, but it was equivalent in other respects. The findings suggest that cognitive behavior therapy, when applied to patients with bulimia nervosa, operates through mechanisms specific to this treatment and is more effective than both interpersonal psychotherapy and a simplified behavioral version of cognitive behavior therapy.
Article
Previous research on the treatment of outpatients with bulimia nervosa has focused on two treatment strategies: (1) drug therapy, primarily using tricyclic antidepressants, and (2) psychotherapy, often employing behavioral and cognitive behavioral techniques. We report here the short-term treatment outcome of a 12-week comparison trial of bulimic outpatients who were randomly assigned to one of four treatment cells: (1) imipramine hydrochloride treatment, (2) placebo treatment, (3) imipramine treatment combined with intensive group psychotherapy, and (4) placebo treatment combined with intensive group psychotherapy. All three active treatment cells resulted in significant reductions in target-eating behaviors and in a significant improvement in mood relative to placebo treatment. However, the results also suggested that the amount of improvement obtained with the intensive group psychotherapy component was superior to that obtained with antidepressant treatment alone. The addition of antidepressant treatment to the intensive group psychotherapy component did not significantly improve outcome over intensive group psychotherapy combined with placebo treatment in terms of eating behavior, but did result in more improvement in the symptoms of depression and anxiety.
Article
This study was designed to assess the additive effects of major components of cognitive-behavioral treatment for bulimia nervosa. Seventy-seven female patients with bulimia nervosa were allocated at random to one of four conditions: wait-list control, self-monitoring of caloric intake and purging behaviors, cognitive-behavioral treatment, and cognitive-behavioral treatment combined with response prevention of vomiting. In the treatment conditions, participants were seen individually for fourteen 1-hr sessions over a 4-month period. All the treatment groups showed significant improvement, whereas the wait-list control group did not. Cognitive-behavioral treatment was, however, the most successful in reducing purging and in promoting positive psychological changes. Fifty-six percent of participants in this condition ceased binge eating and purging by the end of treatment, and the frequency of purging declined by 77.2% during the same period. Of the three treatment conditions, only cognitive-behavioral treatment was superior to the wait-list control. At the 6-month follow-up, 59% of the cognitive-behavioral group were abstinent, and purging had declined by 80%. Cognitive-behavioral treatment was significantly superior to the other treatment groups at this time. Thus, the addition of response prevention of vomiting did not enhance the efficacy of cognitive-behavioral treatment, and the evidence suggests that it may have had a deleterious effect.
Article
In a randomised controlled trial of different types of psychotherapy for bulimia 92 women were assigned to receive cognitive-behaviour therapy (n = 32), behaviour therapy (30), or group therapy (30) for 15 weeks and a further 20 (controls) assigned to remain on a waiting list for 15 weeks. Eating behaviour and psychopathology were assessed by standard methods. At the end of the trial the controls had significantly higher scores than the treated groups on all measures of bulimic behaviour. In terms of behavioural change all three treatments were effective, 71 (77%) of the 92 women having stopped bingeing. In addition, scores on eating and depression questionnaires were reduced and self esteem improved. Follow up was continuing, but of 24 women available at one year, 21 were not bingeing and had maintained their improved scores on psychometric scales. Bulimia nervosa is amenable to treatment by once weekly structured psychotherapy in either individual or group form.