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The empirical status of the third-wave behaviour therapies for the treatment of eating disorders: A systematic review
Abstract
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.
... and commitment therapy, and mindfulness and mindful eating interventions. [10][11][12] Evidence suggests that structured cognitive behavioral therapy protocols can be quite valuable. [11,12] A guided self-help program (GSHP) uses cognitive behavioral principles in an accessible, low-intensity format. ...
... [10][11][12] Evidence suggests that structured cognitive behavioral therapy protocols can be quite valuable. [11,12] A guided self-help program (GSHP) uses cognitive behavioral principles in an accessible, low-intensity format. Studies of GSHP in obese individuals demonstrated decreased bingeeating behavior. ...
... [18,19] Systematic reviews have noted that although tertiary mindfulness-based therapies were reported to have positive effects on emotional eating behavior, evidence regarding the effect of a cognitive behavioral therapybased GSHP on this behavior was inadequate. [12,20] ...
... Mindfulness is a practice that has been incorporated into what is referred to as the thirdwave of behavioral theory (Hofmann and Asmundson 2008;Linardon et al. 2017;Ost 2008;Trammel 2018). These third-wave therapies build on cognitive-behavioral theory but also distinctively pivot in a new direction that emphasizes regulating emotions after they have been activated rather than preventing emotions from arising (Hofmann and Asmundson 2008;Linardon et al. 2017;Ost 2008). ...
... Mindfulness is a practice that has been incorporated into what is referred to as the thirdwave of behavioral theory (Hofmann and Asmundson 2008;Linardon et al. 2017;Ost 2008;Trammel 2018). These third-wave therapies build on cognitive-behavioral theory but also distinctively pivot in a new direction that emphasizes regulating emotions after they have been activated rather than preventing emotions from arising (Hofmann and Asmundson 2008;Linardon et al. 2017;Ost 2008). Moving away from a focus on symptomology only, third-wave behavioral approaches focus on holistic well-being related to the context and function of behavior through mindfulness, acceptance, non-judgment, self-compassion, and emotional awareness (Hofmann and Asmundson 2008;Linardon et al. 2017;Ost 2008). ...
... These third-wave therapies build on cognitive-behavioral theory but also distinctively pivot in a new direction that emphasizes regulating emotions after they have been activated rather than preventing emotions from arising (Hofmann and Asmundson 2008;Linardon et al. 2017;Ost 2008). Moving away from a focus on symptomology only, third-wave behavioral approaches focus on holistic well-being related to the context and function of behavior through mindfulness, acceptance, non-judgment, self-compassion, and emotional awareness (Hofmann and Asmundson 2008;Linardon et al. 2017;Ost 2008). Because the focus is on observing the mind-body processes in a given moment, these approaches naturally incorporate metacognition, values, and spirituality which were often left out of traditional CBT methods. ...
Mindfulness is increasingly implemented as a tool in mental health practice for coping
and self-care. Some Christians worry that these practices might be in conflict with their own tradition, while other Christian contexts are reclaiming the contemplative aspects of the faith. Though
clinicians are not trained to teach on religious topics and ethically must avoid pushing religion onto
clients, conceptualization and research extend the benefits of mindfulness practices for religious
clients. This paper will discuss the evidence for using mindfulness in mental health treatment and
connect mindfulness to the Christian tradition. The authors explore how intentional awareness and
embodiment of the present moment are supported in Christian theology through the incarnation of
Jesus and God’s attention of the physical body in the Christian scriptures. The authors also discuss
how sacraments and prayer naturally overlap with mindfulness practices for the dual purposes of
emotional healing and spiritual growth. To bolster the benefits of mindfulness in the psychological
and religious realms, the purpose of this paper is to empower therapists to address client concerns of
whether mindfulness is in conflict with Christianity, support clients in expanding current Christian
religious coping, and provide Christian leaders with more information about how mindfulness
elements are already present in Christian rituals and beliefs.
... CBT is recognised as the first-line treatment for adults with BN [80] (see Section 3.1). In addition to CBT, several other therapeutic approaches have received attention from researchers as potential treatment options [81,82]. This section will first provide an overview of the available evidence regarding the use of interpersonal psychotherapy (IPT), dialectical behaviour therapy (DBT), psychodynamic psychotherapy, and pharmacotherapy in the treatment of BN, followed by a detailed review of the evidence base supporting CBT. ...
... Current empirical evidence indicates that DBT treatments produce significant reductions in disordered eating behaviours at post-treatment in comparison to waitlist control (WLC). However, the evidence base is relatively weak, mainly consisting of small sample sizes and very few studies assessing the maintenance of improvements at follow-up [82,91]. ...
Bulimia nervosa is an eating disorder characterised by marked impairment to one's physical health and social functioning, as well as high rates of chronicity and comorbidity. This literature review aims to summarise existing academic research related to the symptom profile of BN, the costs and burden imposed by the illness, barriers to the receipt of care, and the evidence base for available psychological treatments. As a consequence of well-documented difficulties in accessing evidence-based treatments for eating disorders, efforts have been made towards developing innovative, diverse channels to deliver treatment, with several of these attempting to harness the potential of digital platforms. In response to the increasing number of trials investigating the utility of online treatments, this paper provides a critical review of previous attempts to examine digital interventions in the treatment of eating disorders. The results of a focused literature review are presented, including a detailed synthesis of a knowledgeable selection of high-quality articles with the aim of providing an update on the current state of research in the field. The results of the review highlight the potential for online self-help treatments to produce moderately sized reductions in core behavioural and cognitive symptoms of eating disorders. However, concern is raised regarding the methodological limitations of previous research in the field, as well as the high rates of dropout and poor adherence reported across most studies. The review suggests directions for future research, including the need to replicate previous findings using rigorous study design and methodology, as well as further investigation regarding the utility of clinician support and interactive digital features as potential mechanisms for offsetting low rates of engagement with online treatments.
... The focus is on making change despite cognitions and emotions rather than on trying to change them. Acceptance based approaches have demonstrated positive effects when applied to individuals with schizophrenia (e.g., El Ashry et al. 2021), but are not superior to cognitive behavioral therapy for AN (Linardon et al. 2017). But again, these approaches have not been tested specifically in individuals with AN experiencing delusions. ...
Numerous studies of the beliefs of people with anorexia nervosa (AN) suggest that a subset of such individuals may experience delusions. We first describe what makes a belief delusional and conclude that such characteristics can be appropriately applied to some beliefs of people with AN. Next, we outline how delusional beliefs may relate to the broader psychopathological process in AN, including: (1) they may be epiphenomenal; (2) they may be an initial partial cause of AN; (3) they may be caused by aspects of AN; or (4) they may be sustaining causes, possibly involved in reciprocal causal relations with aspects of AN. We argue that there is good reason to believe that delusional beliefs of people with AN are not merely epiphenomenal, but rather that they’re causally connected to AN. Because of this, empirical studies can be designed to test for the presence of causal relations. We describe how these studies should be designed. The results of such studies have important implications for understanding the experience of individuals with AN and for the treatment of AN. We outline these implications.
... Effectiveness studies into these alternative treatment options are promising but they are still relatively limited in number and size compared to the studies on CBT. To date, comparative studies for these alternative treatment options have not shown superiority over CBT (Hayes & Hofmann, 2021;Linardon et al., 2017;Rozakou-Soumalia et al., 2021). Treatment remains difficult especially for patients with BED or BN, who often have comorbidities such as anxiety disorders, major depressive disorder, and personality disorders (Groff, 2015). ...
Binge eating disorder (BED) and bulimia nervosa (BN) are characterized by recurrent binge eating, episodes of consuming large amounts of food in a discrete period of time associated with a loss of control. Implementation intentions are explicit if-then plans that engender goal-directed action, and rely less on cognitive control than standard treatment options. In a sample with BED and BN, we compared two implementation intention conditions to a control condition. In the behavior-focused condition, implementation intentions targeted binge eating behaviors. In the emotion-focused condition, implementation intentions targeted negative affect preceding binge eating. In the control condition, only goal intentions were set. Each condition comprised three sessions. Participants kept food diaries for four weeks. Compared to the control condition both implementation intention conditions showed significant and large reductions of binge eating that persisted for six months. Effects did not differ between the behavior-focused and emotion-focused implementation intention conditions. These results demonstrate that three sessions on implementation intention formation can lead to long-term reductions in binge eating in patients with BED or BN. Learning how to form implementation intentions seems a recommendable addition to the current standard treatment. Future research could investigate the added value of fully personalized implementation intentions. CLINICAL TRIAL REGISTRATION NUMBER: NL52600.068.15.
... Other treatments, such as Dialectical Behavioural Therapy (DBT) are effective in targeting emotion regulation deficits in individuals with eating disorders (Lammers et al., 2022;Linardon et al., 2017;Telch et al., 2001). DBT subscribes more closely to the affect regulation model of binge eating than CBT does, and teaches skills to specifically target emotion dysregulation to facilitate treatment (Telch et al., 2001). ...
Objective:
Emotion dysregulation (i.e., a multi-component term comprising nonacceptance of emotional responses, difficulty engaging in goal-directed behaviour, impulse control difficulties, lack of emotional awareness, limited access to emotion regulation strategies, and lack of emotional clarity) is a well-established transdiagnostic risk and maintenance factor for eating disorders. To date, there is limited information on how varying scores on subdomains of emotion dysregulation may yield distinct profiles in individuals with binge-spectrum eating disorders (B-EDs), and how these emotion dysregulation profiles may inform resultant symptomatology.
Method:
In the current study, treatment-seeking individuals with B-EDs (n = 315) completed the Difficulties in Emotion Regulation Scale (DERS) and Eating Disorder Examination. Latent profile analysis was conducted on the six subscales of the DERS. Identified latent profiles were examined as predictors of eating disorder pathology using linear regression, and a two-class model of emotion dysregulation fit the data.
Results:
Class 1 (n = 113) was low in all of the DERS subscales, while Class 2 (n = 202) was high in all of the DERS subscales. Individuals in Class 2 had a significantly higher frequency of compensatory behaviours in the past month (F(1,313) = 12.97, p < 0.001), and significantly higher restraint scores (F(1,313) = 17.86, p < 0.001). The classes also significantly differed in terms of eating concern (F(1,313) = 20.89, p < 0.001) and shape concern (F(1,313) = 4.59, p = 0.03), with both being higher for Class 2.
Discussion:
We found only two distinct classes of emotion dysregulation in B-ED's such that individuals were simply high or low in emotion dysregulation. These results suggest that it may be more valuable for future research to evaluate emotion dysregulation as a cohesive whole rather than conceptualising the construct as having truly distinct subdomains.
... 11 There is currently little consensus on a first-line therapeutic model for EDs. 12 Treatment typically includes psychosocial interventions and pharmacotherapy, in which the goal is to overcome dysfunctional beliefs and restore healthy eating behaviors and weight. 13,14 However, long-term cessation of ED behaviors is difficult to achieve considering significant rates of avoidance, drop-out, and treatment resistance. ...
Eating disorders (ED) are a group of potentially severe mental disorders characterized by abnormal energy balance, cognitive dysfunction and emotional distress. Cognitive inflexibility is a major challenge to successful ED treatment and dysregulated serotonergic function has been implicated in this symptomatic dimension. Moreover, there are few effective treatment options and long-term remission of ED symptoms is difficult to achieve. There is emerging evidence for the use of psychedelic-assisted psychotherapy for a range of mental disorders. Psilocybin is a serotonergic psychedelic which has demonstrated therapeutic benefit to a variety of psychiatric illnesses characterized by rigid thought patterns and treatment resistance. The current paper presents a narrative review of the hypothesis that psilocybin may be an effective adjunctive treatment for individuals with EDs, based on biological plausibility, transdiagnostic evidence and preliminary results. Limitations of the psychedelic-assisted psychotherapy model and proposed future directions for the application to eating behavior are also discussed. Although the literature to date is not sufficient to propose the incorporation of psilocybin in the treatment of disordered eating behaviors, preliminary evidence supports the need for more rigorous clinical trials as an important avenue for future investigation.
... The main theoretical framework in the literature in cases of AN is Cognitive-Behavioral Therapy (Linardon et al., 2017). Thus, we believe that Narrative Therapy (NT) also conveys very positive results, considering its philosophy and given that it is also contextualized as a recent dimension of the cognitive model (Chimpén-López & Muñoz, 2021). ...
Anorexia is an eating disorder characterized by a morbid fear of gaining weight, excessive restriction of food and intense and exaggerated practice of physical exercise. There are two subtypes of anorexia: restrictive and purgative. Its prevalence is mainly in female adolescents aged 15 to 19 and entails multiple harmful physical, psychological, social, and emotional consequences. Anorexia is portrayed as a multifactorial disorder, requiring a biopsychosocial perspective and a multidisciplinary intervention to address all the affected areas of the individual. In this article, we approach the appliance of Narrative Therapy by White and Epston (1989), which advocates that the psychotherapeutic treatment can be carried out together – psychologist, client and family – with the literature supporting it. Anorexia is an egosyntonic disorder associated with a high mortality rate. It should be noted that the cure for anorexia is not granted since there is an increased number of relapses and treatment dropouts. For this reason, an innovative approach like narrative therapy can be approached with promising results.
... The attenuation of difficulties with emotion regulation is particularly important, as we found that such difficulties have a direct effect on depression and poor mental HRQoL in this population. Taking this into consideration, psychological therapies that focus on training in emotion-regulation skills (e.g., dialectical behavior therapy) are known to be useful to address mental-health complications and eating-disorder symptoms in people with BED and comorbid difficulties with emotion regulation [40], but are under researched [41,42]. Overall, it may be beneficial that clinicians working with treatment models that focus mostly on the reduction of eating-disorder symptoms consider adding skills training on emotion-regulation and stress-management interventions to their treatment plans for clients with BED. ...
Citation: da Luz, F.Q.; Mohsin, M.; Jana, T.A.; Marinho, L.S.; Santos, E.d.; Lobo, I.; Pascoareli, L.; Gaeta, T.; Ferrari, S.; Teixeira, P.C.; et al. An Examination of the Relationships between Eating-Disorder Symptoms, Abstract: Eating disorders, such as binge eating disorder, are commonly associated with difficulties with emotion regulation and mental-health complications. However, the relationship between eating-disorder symptoms, difficulties with emotion regulation, and mental health in people with binge eating disorder is unclear. Thus, we investigated associations between eating-disorder symptoms, difficulties with emotion regulation, and mental health in 119 adults with binge eating disorder. Participants were assessed with the Eating Disorder Examination Questionnaire, Loss of Control over Eating Scale, Difficulties in Emotion Regulation Scale, Depression Anxiety and Stress Scale, and the 12-Item Short Form Survey at the pre-treatment phase of a randomized controlled trial. Structural-equation-modelling path analysis was used to investigate relationships between variables. We found that (1) eating-disorder behaviors had a direct association with depression, anxiety, and stress; (2) depression, psychological stress, difficulties with emotion regulation, and eating-disorder psychopathology had a direct association with mental-health-related quality of life; and (3) eating-disorder psychopathology/behaviors and stress had a direct association with difficulties with emotion regulation. Our findings show that depression, stress, difficulties with emotion regulation, and eating-disorder psychopathology were related in important ways to mental-health complications in people with binge eating disorder.
... It is important to note that there is a difference between the number of studies investigating the efficacy and effectiveness of CBT and thirdwave treatments for EDs in adolescents compared to adults. For example, three MA have analyzed the efficacy of third-wave therapies for EDs among patients over 18 years (Godfrey et al., 2015;Lenz et al., 2014;Linardon et al., 2017) versus one MA in adolescence (Buerger et al., 2021) and the study quality is higher in the adult studies while in adolescence a weak quality is predominant. There is a lack of SRs and MA on the efficacy of third-wave therapies different from DBT, as well as other emerging treatments such as neurocognitive treatments or technology based psychological interventions. ...
Eating disorders (EDs) are high prevalent among adolescents with serious consequences. Evidence of effectiveness of psychological interventions for eating disorders in adolescents lacks a systematic synthesis of systematic reviews. The goal of this umbrella review is to summarize evidence from systematic reviews examining effects of psychological interventions for eating disorders targeting adolescents. Web of Science, PsycINFO and Cochrane Database of Systematic Reviews were searched for systematic reviews on effectiveness and/or efficacy of any psychological intervention aiming to treat eating disorders in terms of outcomes in adolescents (improvement of eating-disorder symptoms, weight restoration and treatment retention). The methodological quality of each study was assessed using AMSTAR 2. The original search identified 831 reviews, 9 of which were included in the overview of systematic reviews rated as having a low methodological quality. Predominant psychological interventions for EDs in adolescents are family-based interventions. The efficacy of cognitive behavioral therapy and third-wave treatments has been less researched. Anorexia nervosa and bulimia nervosa are the EDs that have been studied the most. This study provides evidence supporting the positive impact of psychological interventions on eating disorders in adolescents. Family based treatment is the most evidence-based psychological intervention. There is a need for high-quality systematic reviews as well as systematic reviews to examine if psychological interventions are effective for different eating disorders.
... Clinical trials using schema therapy to treat adults with EDs were sought out on the Australian New Zealand Clinical Trials Registry and the US National Library of Medicine Clinical Trials database. References included in reviews on the applications of schema therapy (Taylor et al., 2017) and schema theory in EDs (Linardon et al., 2017;Maher et al., 2022;Pugh, 2015) were also searched to ensure all relevant studies were included. Secondary searches were conducted on the 6 th of May and 17 th of August 2022, both of which identified no further relevant studies. ...
Commonly developing in adolescence and following a chronic course, eating disorders are life-threatening psychological disorders and typically very difficult to treat despite the body of research exploring treatment options. Due to the high levels of severity and the enduring nature of eating disorders, schema therapy has been proposed as a more effective treatment than cognitive behaviour therapy. To assess the effectiveness of schema therapy in adults with eating disorders, the present systematic review was designed in accordance with PRISMA guidelines. A structured search of electronic databases and grey literature was conducted, and the Mixed Methods Assessment Tool was used to assess the quality of each article. Four articles including 151 participants were found which demonstrated that schema therapy is effective at reducing eating disorder symptoms and behaviour and general psychopathology. Despite the limitations of this study, including the scarcity of research available and varying methodologies used, the present systematic review found evidence supporting the use of schema therapy in patients with eating disorders, particularly those experiencing severe and enduring forms.
... O terceiro artigo que apresenta evidências científicas da eficácia do tratamento comportamental dialético de transtornos alimentares é o "Dialectical Behavior Therapy for Bulimia Nervosa", de Safer et al. (2001), selecionado nas referências da Meta-Análise "The empirical status of the third-wave behaviour therapies for the treatment of eating disorders: A systematic review" de Linardon et al. (2017). É necessário reforçar a compreensão de que, ainda que não tenhamos encontrado artigos que apresentem estas evidências, isto não significa que estes artigos não existam, apenas que o procedimento seguido e citado acima não foi suficiente para encontrar estes documentos. ...
Este trabalho teve o objetivo de apresentar práticas que demonstrem tratamentos psicológicos dos transtornos alimentares em quatro abordagens psicológicas, apresentadas em artigos científicos, e que sirvam de suporte empírico da eficácia destas terapias. Para isto, abordou-se a definição e etiologia dos transtornos alimentares e a concepção teórica destes transtornos para a Análise do Comportamento, Gestalt-Terapia, Terapia Cognitivo-Comportamental e Psicanálise, assim como a definição da Prática Baseada em Evidências no contexto da Psicologia. Foram apresentados o processo de intervenção destes transtornos para estas abordagens, um estudo de caso de cada uma delas e ensaios randomizados de tais tratamentos. O procedimento da pesquisa da monografia ocorreu a partir da seleção de meta-análises e revisões bibliográficas que abordam o processo terapêutico pelo qual os psicólogos das abordagens podem atuar no tratamento da Anorexia e/ou Bulimia Nervosas. Estes documentos foram encontrados na Língua Inglesa e traduzidos para o Português. Por fim, buscou-se sistematizar as técnicas, os resultados e as diferenças encontradas, além da discussão da PPBE nas quatro abordagens.
... Two group therapies, cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT), may be suitable for reducing anxiety and disinhibited eating in adolescents at risk for excess weight gain. Both CBT and IPT have been shown to effectively reduce binge-eating episodes in adults [53][54][55][56][57][58]. In adolescents, CBT is a standard-of-care approach for the prevention and the treatment of anxiety [59]. ...
(1) Background: Standard-of-care lifestyle interventions show insufficient effectiveness for the prevention and treatment of excess weight and its associated cardiometabolic health concerns in adolescents, necessitating more targeted preventative approaches. Anxiety symptoms are common among adolescents, especially girls at risk for excess weight gain, and have been implicated in the onset and maintenance of disinhibited eating. Thus, decreasing elevated anxiety in this subset of adolescent girls may offer a targeted approach to mitigating disinhibited eating and excess weight gain to prevent future cardiometabolic health problems. (2) Methods: The current paper describes the protocol for a multisite pilot and feasibility randomized controlled trial of group cognitive behavioral therapy (CBT) and group interpersonal psychotherapy (IPT) in N = 40 adolescent girls (age 12–17 years) with elevated anxiety symptoms and body mass index (BMI; kg/m2) ≥ 75th percentile for age/sex. (3) Results: Primary outcomes are multisite feasibility of recruitment, protocol procedures, and data collection, intervention fidelity, retention at follow-ups, and acceptability of interventions and study participation. (4) Conclusions: Findings will inform the protocol for a future fully-powered multisite randomized controlled trial to compare CBT and IPT efficacy for reducing excess weight gain and preventing adverse cardiometabolic trajectories, as well as to evaluate theoretically-informed treatment moderators and mediators.
... Outcomes from cognitive behavioral therapies (CBTs) for bulimia nervosa (BN) including the enhanced cognitive behavioral therapy (CBT-E) and thirdwave behavioral treatments such as mindfulness-and acceptance-based treatments (MABTs) leave significant room for improvement with nearly 70% of patients remaining symptomatic following receipt of a full course of treatment (Linardon et al., 2017;Linardon, Messer et al., 2018;Linardon & Wade, 2018). Identifying the treatment mechanisms associated with improvement in BN symptoms can improve outcomes by allowing future versions of CBTs to focus on the most impactful treatment components (Jansen, 2016). ...
Overvaluation of shape and weight (OSW) is supported as an important mechanism underlying improvement in bulimia nervosa (BN) during behavioral therapies (CBTs). It is not yet clear, however, whether changes in OSW temporally precede and prospectively predict changes in BN symptoms during CBTs, limiting the ability to establish causality. The present study is the first to examine whether session-by-session changes in OSW prospectively predict session-by-session changes in BN symptoms during CBTs and clinical outcomes at the end-of-treatment. Participants with BN (n = 44) who received 20 sessions of CBTs completed a brief survey at each session assessing OSW and BN symptom frequency during the past week. Results showed small but significant session-by-session reductions in OSW and BN symptoms during CBTs. Session-by-session improvements in OSW in any given week prospectively predicted reductions in restrictive eating, binge eating, and compulsive exercise in the following week but did not prospectively predict improvements in purging, while improvements in restrictive eating and compulsive exercise in any given week prospectively predicted reductions in OSW in the following week. Average session-by-session change in OSW during treatment was positively associated with remission status and improvements in eating pathology at the end-of-treatment. Changes in OSW temporally precede and prospectively predict changes in BN symptoms during CBTs, and vice versa. These findings may have critical implications for treatment planning and implementation.
... The search flow is reported in Fig. 1. Out of 884 articles, 55 MAs and 4 NMAs were included (Albano et al., 2019;Bacaltchuk et al., 1999;Josue Josué Bacaltchuk et al., 2000;Josue Bacaltchuk et al., 2000;Josué Josue Bacaltchuk et al., 2000;Josué Bacaltchuk et al., 2000;Bacaltchuk and Hay, 2003;Barakat et al., 2019;Berkman et al., 2015;Brownley et al., 2016;Cassioli et al., 2020;Claudino et al., 2006;Couturier et al., 2013;Cuijpers et al., 2016;de Vos et al., 2014;Dold et al., 2015;Fisher et al., 2018Fisher et al., , 2010Fornaro et al., 2016;Ghaderi et al., 2018;Ghaderi and Andersson, 1999;Grenon et al., 2018a;Hagan et al., 2020;Hasselbalch et al., 2020;Hay et al., 2019Hay et al., , 2015Hay et al., , 2004Hay et al., , 2001Hay et al., , 2009Hilbert et al., 2019;Kishi et al., 2012;Lebow et al., 2013;Linardon, 2018b;Linardon et al., 2020Linardon et al., , 2019Linardon et al., , 2017aLinardon et al., , 2017bLinardon et al., , 2017cLoucas et al., 2014;Low et al., 2021;Machado and Ferreira, 2014;Murray et al., 2019;Nakash-Eisikovits et al., 2002;Ng et al., 2013;Nourredine et al., 2020;Palavras et al., 2017;Peat et al., 2017;Perkins et al., 2006;Polnay et al., 2014;Reas and Grilo, 2008;Eric Slade et al., 2018;Stefano et al., 2008Stefano et al., , 2006Svaldi et al., 2019;Swift et al., 2017;Thompson-Brenner et al., 2003;Traviss-Turner et al., 2017;van den Berg et al., 2019;Vocks et al., 2010;Zeeck et al., 2018). Publications excluded after full-text assessment, with reason for exclusion are available in supplementary reported on inpatients, and in AN only; eight (13.6%) reported on outpatients; and the others on any or unspecified settings. ...
MONTELEONE, A.M., F. Pellegrino, G. Croatto, M. Carfagno, A. Hilbert, J. Treasure, T. Wade, C. Bulik, S. Zipfel, P. Hay, U. Schmidt, G. Castellini, A. Favaro, F. Fernandez-Aranda, J. Il Shin, U. Voderholzer, V. Ricca, D. Moretti, D. Busatta, G. Abbate-Daga, F. Ciullini, G. Cascino, F. Monaco, C.U. Correll and M. Solmi. Treatment of Eating Disorders: a systematic meta-review of meta-analyses and network meta-analyses. NEUROSCI BIOBEHAV REV 21(1) XXX-XXX, 2022.-
Treatment efficacy for eating disorders (EDs) is modest and guidelines differ. We summarized findings/quality of (network) meta-analyses (N)MA of randomized controlled trials (RCTs) in EDs.
Systematic meta-review ((N)MA of RCTs, ED, active/inactive control), using (anorexia or bulimia or eating disorder) AND (meta-analy*) in PubMed/PsycINFO/Cochrane database up to December 15th, 2020. Standardized mean difference, odds/risk ratio vs control were summarized at end of treatment and follow-up.
Interventions involving family (family-based therapy, FBT) outperformed active control in adults/adolescents with anorexia nervosa (AN), and in adolescents with bulimia nervosa (BN). In adults with BN, individual cognitive behavioural therapy (CBT)-ED had the broadest efficacy versus active control; also, antidepressants outperformed active. In mixed age groups with binge-eating disorder (BED), psychotherapy, and lisdexamfetamine outperformed active control. Antidepressants, stimulants outperformed placebo, despite lower acceptability, as did CBT-ED versus waitlist/no treatment.
Family-based therapy is effective in AN and BN (adolescents). CBT-ED has the largest efficacy in BN (adults), followed by antidepressants, as well as psychotherapy in BED (mixed). Medications have short-term efficacy in BED (adults).
... Adults For adults who have difficulty accessing a first line therapy and/or who do not respond, or only have partial improvement, a second line treatment may be considered. Second line psychotherapies in adults include 'third-wave' [64] psychological therapies such as mindfulness-based therapy and Acceptance and Commitment Therapy (ACT). These have less evidence of efficacy compared to first line treatments, but may be helpful options when first line treatments have not been effective. ...
Introduction:
The prevalence of eating disorders is high in people with higher weight. However, despite this, eating disorders experienced by people with higher weight have been consistently under-recognised and under-treated, and there is little to guide clinicians in the management of eating disorders in this population.
Aim:
The aim of this guideline is to synthesise the current best practice approaches to the management of eating disorders in people with higher weight and make evidence-based clinical practice recommendations.
Methods:
The National Eating Disorders Collaboration Steering Committee auspiced a Development Group for a Clinical Practice Guideline for the treatment of eating disorders for people with higher weight. The Development Group followed the 'Guidelines for Guidelines' process outlined by the National Health and Medical Research Council and aim to meet their Standards to be: 1. relevant and useful for decision making; 2. transparent; 3. overseen by a guideline development group; 4. identifying and managing conflicts of interest; 5. focused on health and related outcomes; 6. evidence informed; 7. making actionable recommendations; 8. up-to-date; and, 9. accessible. The development group included people with clinical and/or academic expertise and/or lived experience. The guideline has undergone extensive peer review and consultation over an 18-month period involving reviews by key stakeholders, including experts and organisations with clinical academic and/or lived experience.
Recommendations:
Twenty-one clinical recommendations are made and graded according to the National Health and Medical Research Council evidence levels. Strong recommendations were supported for psychological treatment as a first-line treatment approach adults (with bulimia nervosa or binge-eating disorder), adolescents and children. Clinical considerations such as weight stigma, interprofessional collaborative practice and cultural considerations are also discussed.
Conclusions:
This guideline will fill an important gap in the need to better understand and care for people experiencing eating disorders who also have higher weight. This guideline acknowledges deficits in knowledge and consequently the reliance on consensus and lower levels of evidence for many recommendations, and the need for research particularly evaluating weight-neutral and other more recent approaches in this field.
... High attrition rates plague digital prevention and early-intervention programs for psychological health, with 1 in 4 individuals found to dropout from such programs for disordered eating (Linardon et al., 2017). Wade and Wilksch (2018) argued that low dropout rates reported in some studies are evident if only university students are included vs. higher rates if community and adolescent samples are included. ...
Background
Digital early-intervention programs for a variety of psychological conditions, including eating disorders (EDs) are increasing. Yet, none to date have leveraged gamification and vicarious learning components grounded in empirically-supported therapeutic approaches to engage young people at risk for developing EDs in behaviour change.
Purpose
The current paper describes the development and preliminary acceptability and feasibility testing of AcceptME, a novel self-directed, gamified digital ED early-intervention program based on Acceptance and Commitment Therapy (ACT). AcceptME helps women and girls identified at risk for an ED relate differently to their thoughts and feelings, such that these experiences do not have undue influence over their behaviour and actions can instead be guided by personal values.
Methods
Users learned skills of psychological flexibility by helping a third-person avatar (a main character in a storyline) navigate situations that elicit distressing thoughts/feelings, and via interactive exercises, practiced applying these skills to their own experiences. Young women and girls in the Republic of Cyprus with high weight concern scores (N = 58, Mage = 15.27, SD = 2.25) completed six 30-min digital sessions and reported on session and intervention acceptability.
Results
Attrition was 46.55%. Of those who completed treatment, the majority of participants were either “Very” (40%) or “Mostly” (57%) Satisfied with the program. Fifty-two percent reported that the program “Helped a lot,” and 48% said it “Helped a bit.” Conclusion: Digital technology and gamification have advantages for engagement and delivery. The current study suggests a promising direction for early ED interventions to reach at risk youth and preliminary data to guide development.
... In a systematic review, Linardon, Fairburn, et al. (2017) evaluated seven randomized controlled trials of DBT-BED. While most studies compared DBT to a waitlist or a nonspecific supportive psychotherapy, one study (Chen et al., 2017) directly compared DBT-BED to cognitive behavior therapy (CBT), the current treatment of choice for BED recommended by practice guidelines (e.g., Hay et al., 2014;NICE, 2017). ...
Objective:
To evaluate whether the results of a quasi-randomized study, comparing dialectical behavior therapy for binge-eating disorder (DBT-BED) and an intensive, outpatient cognitive behavior therapy (CBT+) in individuals with BED, would be replicated in a nonrandomized study with patients who more closely resemble everyday clinical practice.
Method:
Patients with (subthreshold) BED (N = 175) started one of two group treatments: DBT-BED (n = 42) or CBT+ (n = 133), at a community eating disorder service. Measures of eating disorder pathology, emotion regulation, and general psychopathology were examined at end of treatment (EOT) and at 6-month follow-up using generalized linear models with multiple imputation.
Results:
Both treatments lead to substantial decreases on primary and secondary measures. Statistically significant, medium-size differences between groups were limited to global eating disorder psychopathology (d = -.62; 95% CI = .231, .949) at EOT and depressive symptoms at follow-up (d = -.45; 95% CI = .149, 6.965), favoring CBT+. Dropout of treatment included 15.0% from CBT+ and 19.0% from DBT-BED (difference nonsignificant).
Discussion:
Decreases in global eating disorder psychopathology were achieved faster with CBT+. Overall, improvements in DBT-BED were comparable to those observed in CBT+. Findings of the original trial, favoring CBT+ on the number of OBE episodes, emotional dysregulation and self-esteem at EOT, and on eating disorder psychopathology and self-esteem at follow-up, were not replicated. With similar rates of treatment dropout and about half of the therapy time used in CBT+, DBT-BED can be considered a relevant treatment for BED in everyday clinical practice.
Public significance:
In this effectiveness study, dialectical behavior therapy (DBT) resulted in clinically relevant improvements in individuals with binge eating disorder. Changes were broadly comparable to those of cognitive behavior therapy (CBT), the current treatment of choice. Although CBT resulted in decreases in eating disorder psychopathology faster, there was a trend toward relapse in CBT at 6-month follow-up. Therefore, the less costly DBT-program can be considered a relevant treatment in clinical practice.
... Empirically supported psychotherapies for EDs include cognitive behavioural therapy (CBT), ED focused enhanced CBT (E-CBT), family-based therapy, and interpersonal psychotherapy (IPT) [16,19,20]. There is emerging evidence for the efficacy of other psychotherapies, including dialectical behavioural therapy (DBT) and acceptance and commitment therapy (ACT) [21][22][23]. The highly manualised psychotherapies implemented in clinical trials are known to be less rigorously implemented in terms of fidelity in community environments [24]. ...
Plain English Summary
Eating disorders can result from a variety of factors including previous trauma and sociocultural influences. Critical feminist perspectives acknowledge these influences are core contributing factors to the development and maintenance of eating disorder behaviours and postulate the exploration of the eating disorder in relation to these wider factors as crucial to the treatment process. Therefore, treatment interventions that utilise feminist frameworks and approaches that are integrative of a variety of psychological therapies to suit individual needs may be useful to address underlying factors while also managing eating disorder behaviours. However, there have been few experimental studies that have evaluated these interventions. This article aims to address this gap in current eating disorder literature by describing and evaluating the effectiveness of a counselling therapy for eating disorders that employs feminist practice and a variety of psychological therapies. The results indicate that eating disorder symptoms, stress, and mental health recovery improved after 10 sessions of the counselling intervention for a sample of 80 participants receiving eating disorder treatment. The results from this study provide initial evidence for the usefulness of feminist-informed practice and individualised counselling interventions for the treatment of eating disorders.
... In a meta-analysis of 13 RCTs (i.e. studies that included a control comparison), Linardon et al. (2017) found that third-wave therapies for the treatment of eating disorders showed beneficial effects when compared to no treatment, but not when compared to active control groups or to alternative treatments (such as cognitive behaviour therapy). As such, they concluded that these therapies did not meet the criteria for empirically supported treatments for eating disorders. ...
Mindful eating is increasingly being used to try to promote healthy eating and weight management. However, the term refers to a diverse set of practices that could have quite different effects on behaviour. This narrative review provides a guide to the concept of mindful eating as well as a comprehensive overview of research in the area. This includes the ways in which mindful eating has been operationalised and measured as well as evidence for effects and potential mechanisms of action. The research reviewed suggests that multi‐component mindfulness‐based interventions may be beneficial for disordered eating and weight management, but it is unclear whether these benefits exceed those obtained by alternative treatments. Some studies suggest that specific mindful eating strategies may have immediate effects on eating, but more research is needed to reach any definitive conclusions. These studies also suggest that effects may vary depending on the characteristics of the individual and/or the specific eating context. As such, research may ultimately point towards a more personalised approach to the application of mindful eating in order to maximise benefits. Finally, mindful eating interventions for children represent a relatively new area of research and there is currently insufficient evidence to draw any firm conclusions about their value. To advance both our understanding and effective application of mindful eating, more experimental research with high levels of methodological rigour is needed as well as research that explores underpinning mechanisms of action.
... Siendo, la TCC efectiva para mejorar el comportamiento y los factores cognitivos presentes en las personas con BN y TPA. Por ello, es la terapia más aceptada y utilizada en la actualidad (25), como consecuencia a la repercusión positiva sobre la salud, las emociones y la capacidad de funcionar en ámbitos importantes de la vida en jóvenes y adolescentes. ...
Eating Disorders (ED) are a severe mental illness that causes physical and psychosocial problems. This illness has a higher prevalence among young women, and between athletes. cognitive behavioural therapy (CBT) is the current treatment for this type of disorder. However, more and more programs are including physical exercise (PE) and nutritional therapy (TN) for eating disorders treatment. Objective. To carry out an exploratory systematic review of the literature that allows us to know the current state of intervention programs through physical exercise and nutritional therapy for the treatment of eating disorders. Materials and methods. For the reference search thesame search phrase was used. The terms were entered in English in the following computerized databases: SCOPUS, Web of Science, and PubMed. To limit the search, four inclusion criteria were introduced. Results. The review included five scientific articles related to the study topic, which met the inclusion criteria. Conclusion. Intervention programs for the treatment of eating disorders that include physical exercise and nutritional therapy are shown as an alternative or complementary tool to conventional therapy. These programs involve a reduction in the severity of ED symptoms and an improvement in anthropometric parameters and physical condition. More studies that combine PE and TN programs for people with ED are required.
... More recent theories posit emotional difficulties and associated traits as central factors in ED aetiology and maintenance (Haynos & Fruzzetti, 2011;Pearson et al., 2015;Treasure & Schmidt, 2013). The role of emotion dysregulation in ED maintenance has received increased attention in both research and treatment (Linardon et al., 2017;Prefit et al., 2019;Schaefer et al., 2020), including the notion of behavioural ED symptoms as maladaptive strategies for emotion regulation. Negative and critical ways of evaluating oneself is also a central feature in EDs. ...
Objectives:
Eating disorders (EDs) are severe disorders with unsatisfactory outcome. Emotion dysregulation and self-image are suggested maintenance factors; this study examined emotion dysregulation as potential predictor and/or mechanism of change in relation to ED outcome, and associations between change in emotion dysregulation and self-image in relation to outcome.
Design:
Registry data from initial and 1-year follow-up assessments for 307 patients with a wide range of EDs in specialized ED treatment were used.
Methods:
Initial and change (∆) in emotion dysregulation were examined as predictors of 1-year outcome. Direct and indirect associations between ∆emotion dysregulation and ∆self-image as either independent variable or mediator in relation to ∆ED psychopathology as dependent were also examined.
Results:
Higher initial emotion dysregulation was weakly associated with higher follow-up ED psychopathology, but not remission, while relative increase in emotion dysregulation was associated with both higher follow-up psychopathology and increased risk of still having a diagnosis. Change in emotion dysregulation primarily had an indirect effect (through change in self-image), while change in self-image had a direct effect, on change in ED psychopathology improvement (such that improvement in one was associated with improvement in the other).
Conclusions:
Results identify emotion dysregulation as a potential mechanism of change in relation to ED outcome. However, this association was mainly mediated by change in self-image. Results indicate that, in order to improve emotion regulation as a means to reduce ED psychopathology, improving self-image is essential.
... Accumulating evidence suggests that ACT holds potential for the treatment and prevention of EDs [4,[10][11][12]. ACT has been shown to have efficacy for reducing ED symptoms relative to a waitlist control and treatment as usual (TAU) [13,14] and to have greater effects compared to cognitive therapy in one trial of ED symptoms secondary to anxiety or depression [15]. ...
Eating disorders (ED) constitute a serious public health issue affecting predominantly women and appearing typically in adolescence or early adulthood. EDs are extremely difficult to treat, as these disorders are ego-syntonic, and many patients do not seek treatment. It is vital to focus on the development of successful early-intervention programs for individuals presenting at risk and are on a trajectory towards developing EDs. This study is a randomized controlled trial evaluating an innovative digital gamified Acceptance and Commitment early-intervention program (AcceptME) for young females showing signs and symptoms of an ED and at high risk for an ED. Participants (n = 92; Mage = 15.30 years, SD = 2.15) received either AcceptME (n = 62) or a waitlist control (n = 30). Analyses indicated that the AcceptME program effectively reduced weight and shape concerns with large effects when compared to waitlist controls. Most participants scored below the at-risk cut-off (WCS score < 52) in the AcceptME at end-of-intervention (57.1%) compared to controls (7.1%), with odds of falling into the at-risk group being 14.5 times higher for participants in the control group. At follow-up, 72% of completers reported scores below the at-risk cut-off in the AcceptME group. The intervention also resulted in a decrease in ED symptomatology and increased body image flexibility. Overall, results suggest that the AcceptME program holds promise for early-intervention of young women at risk for developing an ED.
... Other psychological interventions, such as Interpersonal psychotherapy (IPT), Family therapy and family interventions and Focal Psychodynamic therapy, are also suggested, and several authors supported the equivalent efficacy of these interventions as compared with CBT-E [133,134]. Based on available evidence, none of the third-wave therapies such as Schema Therapy met established criteria for an empirically supported treatment for particular ED subgroups [135]. Since its first development, Fairburn's trans-diagnostic model [136] of maintenance of EDs has been widely adopted as the theoretical frame for psychological interventions aimed at interrupting pathological eating behaviours. ...
Cognitive, psychodynamic, and phenomenological scholars converged their attention on abnormal bodily phenomena as the core psychopathological feature of eating disorders (EDs). While cognitive approaches focus their attention on a need for “objective” (i.e., observable, measurable) variables (including behaviours and distorted cognitions), the phenomenological exploration typically targets descriptions of persons’ lived experience. According to a new emerging phenomenological perspective, the classic behavioural and cognitive symptoms of EDs should be considered as epiphenomena of a deeper core represented by a disorder of the embodiment. The cognitive–behavioural model is the most studied and, up till now, clinically efficacious treatment for EDs. However, as any coherent and scientifically grounded model, it presents some limitations in its application. Numerous patients report a chronic course, do not respond to treatment and develop a personality structure based on pathological eating behaviours, since “being anorexic” becomes a new identity for the person. Furthermore, the etiopathogenetic trajectory of EDs influences the treatment response: for example, patients reporting childhood abuse or maltreatment respond differently to cognitive-behavioural therapy. To obtain a deeper comprehension of these disorders, it seems important to shift attention from abnormal eating behaviours to more complex and subtle psycho(patho)logical features, especially experiential ones. This characterisation represents the unavoidable premise for the identification of new therapeutic targets and consequently for an improvement of the outcome of these severe disorders. Thus, the present review aims to provide an integrated view of cognitive, psychodynamic, and phenomenological perspectives on EDs, suggesting new therapeutic targets and intervention strategies based on this integrated model. Level of Evidence: Level V.
Level of evidence Level V: Opinions of authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.
... Accumulating evidence suggests that ACT holds potential for the treatment and prevention of EDs [4,[10][11][12]. ACT has been shown to have efficacy for reducing ED symptoms relative to a waitlist control and treatment as usual (TAU) [13,14], and to have greater effects compared to cognitive therapy in one trial of ED symptoms secondary to anxiety or depression [15]. ...
Eating Disorders (ED) constitute a serious public health issue affecting predominantly women and appearing typically in adolescence or early adulthood. EDs are extremely difficult to treat as these disorders are ego-syntonic and many patients do not seek treatment. It is vital to focus on the development of successful early-intervention programs for individuals presenting at-risk and are on a trajectory towards developing EDs. This study is a randomized controlled trial evalu-ating an innovative digital gamified Acceptance and Commitment early-intervention program (AcceptME) for young females showing signs and symptoms of an ED and at high-risk for an ED. Participants (N=92; Mage=15.30 years, SD=2.15) received either AcceptME (N=62) or a waitlist control (N=30). Analyses indicated that the AcceptME program effectively reduced weight and shape concerns, with large effects when compared to waitlist controls. Most participants scored below the at-risk cut-off (WCS score<52) in the AcceptME at end-of-intervention (57.1%) com-pared to controls (7.1%) with odds of falling into the at-risk group being 14.5 times higher for participants in the control group. At follow-up, 72% of completers reported scores below the at-risk cut-off in the AcceptME group. The intervention also resulted in a decrease in ED symp-tomatology and increased body image flexibility. Overall, results suggest that the AcceptME program holds promise for early-intervention of young women at-risk for developing an ED.
... In other disorders, such as anxiety or substance use, the grounding of intervention approaches in either an avoidance-based fear model, or an approach-based reward model has been critical to the development of successful empirically-based treatment approaches (Moos, 2007;Norton & Price, 2007). Given the overall lag in the development of such treatments for some types of eating disorders, particularly AN (Hay, 2013;Linardon, Fairburn, Fitzsimmons-Craft, Wilfley, & Brennan, 2017), increasing our understanding of the types of models that might be useful frameworks for successful intervention approaches would be highly valuable. ...
Objective:
The pursuit of thinness and fear of gaining weight have been found to play an important role in eating disorder symptomatology. While these dimensions have typically been considered conjointly, emerging evidence suggests they may be distinct dimensions. The aim of this study was to explore the subjective experiences of fear of fatness and drive for thinness in young women with body image concerns.
Method:
Young women endorsing weight concerns (N = 29, mean age = 20.86, SD = 2.70 years) were interviewed and asked to describe an experience of fear of fat and drive for thinness, respectively.
Results:
Qualitative analysis was conducted and identified four themes: (1) precipitating events; (2) physiological, emotional, cognitive, and proprioceptive experiences; (3) coping strategies; and (4) sociocultural influences. While similarities emerged, the experiences of fear of fatness, and of drive for thinness also evidenced clear differences situating the former in the context of fear-based avoidance patterns, and the latter in approach-based reward models.
Discussion:
These findings provide additional support for the usefulness of considering fear of fat and drive for thinness as distinct constructs. Further research examining the contributions of each of these constructs to eating pathology is warranted.
Binge-eating disorder (BED), characterized by recurrent binge eating in the absence of regular weight-compensatory behaviors, is the most common eating disorder, associated with pronounced mental and physical sequelae. An increasing body of research documents the efficacy of diverse approaches to the treatment of this disorder, summarized in meta-analyses. This research update narratively reviewed randomized-controlled trials (RCTs) on the psychological and medical treatment of BED published between January 2018 to November 2022, identified through a systematic literature search. A total of 16 new RCTs and 3 studies on previous RCTs providing efficacy- and safety-related data were included. Regarding psychotherapy, confirmatory evidence supported the use of integrative-cognitive therapy and, with lower effects, brief emotion regulation skills training for binge eating and associated psychopathology. Behavioral weight loss treatment was revealed to be efficacious for binge eating, weight loss, and psychopathology, but its combination with naltrexone-bupropion did not augment efficacy. New treatment approaches were explored, including e-mental-health and brain-directed treatments, mostly targeting emotion and self-regulation. Additionally, different therapeutic approaches were evaluated in complex stepped-care models. In light of these advances, future research is necessary to further optimize effects of evidence-based treatments for BED, through improvement of existing or development of new treatments, based on mechanistic and/or interventional research, and/or tailoring treatments to personal characteristics in a precision medicine approach.
Psychiatric comorbidity is the norm in the assessment and treatment of eating disorders (EDs), and traumatic events and lifetime PTSD are often major drivers of these challenging complexities. Given that trauma, PTSD, and psychiatric comorbidity significantly influence ED outcomes, it is imperative that these problems be appropriately addressed in ED practice guidelines. The presence of associated psychiatric comorbidity is noted in some but not all sets of existing guidelines, but they mostly do little to address the problem other than referring to independent guidelines for other disorders. This disconnect perpetuates a “silo effect,” in which each set of guidelines do not address the complexity of the other comorbidities. Although there are several published practice guidelines for the treatment of EDs, and likewise, there are several published practice guidelines for the treatment of PTSD, none of them specifically address ED + PTSD. The result is a lack of integration between ED and PTSD treatment providers, which often leads to fragmented, incomplete, uncoordinated and ineffective care of severely ill patients with ED + PTSD. This situation can inadvertently promote chronicity and multimorbidity and may be particularly relevant for patients treated in higher levels of care, where prevalence rates of concurrent PTSD reach as high as 50% with many more having subthreshold PTSD. Although there has been some progress in the recognition and treatment of ED + PTSD, recommendations for treating this common comorbidity remain undeveloped, particularly when there are other co-occurring psychiatric disorders, such as mood, anxiety, dissociative, substance use, impulse control, obsessive–compulsive, attention-deficit hyperactivity, and personality disorders, all of which may also be trauma-related. In this commentary, guidelines for assessing and treating patients with ED + PTSD and related comorbidity are critically reviewed. An integrated set of principles used in treatment planning of PTSD and trauma-related disorders is recommended in the context of intensive ED therapy. These principles and strategies are borrowed from several relevant evidence-based approaches. Evidence suggests that continuing with traditional single-disorder focused, sequential treatment models that do not prioritize integrated, trauma-focused treatment approaches are short-sighted and often inadvertently perpetuate this dangerous multimorbidity. Future ED practice guidelines would do well to address concurrent illness in more depth.
Clinical psychology and psychotherapy are disciplines that have made significant contributions to the treatment of mental health disorders. Evidence-based treatments should be available to people who suffer from mental health problems. In this regard, cognitive behavioral therapy (CBT) for adults, groups, and couples, the third-wave CBT, metacognitive therapies, and rehabilitation and recovery programs are presented and discussed. A psychotherapeutic relationship and alliance in combination with the implementation of cognitive and behavioral interventions such as CBT contributes to a dynamic context, which leads to recovery and reintegration with society. The importance of the training in CBT is mentioned. CBT focuses on the content of thoughts and beliefs and how they can change. Metacognitive therapies focus on the thoughts about thoughts and beliefs. Rehabilitation focuses on the improvement of cognitive functions, social skills, and problem-solving. Recovery programs provide better insights into the disorder and the coping mechanisms. In this regard, third-wave CBT contributes to a better understanding and acceptance of and process of coping with the disorders. Clinical and research implications are discussed. This chapter shares a very positive message about the possibilities of coping with mental health disorders.KeywordsClinical psychologyCognitive behavioral psychotherapyMetacognitive therapiesRecoveryRehabilitation
In this chapter, the authors discuss the role that self-concept plays as a modulator in disordered eating. While there are many models for self-concept, all models recognize that the development of positive self-esteem is multidimensional, and an individual’s perception of self can be affected by the environment in both positive and negative ways. Effective prevention and intervention programs must recognize the importance of this concept and integrate self-esteem in their programs. Numerous theoretical frameworks have been proposed to explain and predict the process of health behavior change. The Transtheoretical Model (TTM) developed by Prochaska and DiClemente as a model of intentional behavior change is highlighted in this chapter. Targeted educational programs to prevent disordered eating for female athletes are presented and contact information for more details for research-based effective programs are provided in a summary format. Lastly, a concept called mindfulness has been introduced specifically as it relates to eating disorders.
Anorexia nervosa (AN) is a chronic and debilitating psychiatric disorder. Unfortunately, current treatments are lacking, with only 30-50% of individuals with AN recovering after treatment. We developed a beta-version of a digital mindfulness-based intervention for AN called Mindful Courage-Beta, which includes: (a) one foundational multimedia module; (b) 10 daily meditation mini-modules; (c) emphasis on a core skill set called the BOAT (Breathe, Observe, Accept, Take a Moment); and (d) brief phone coaching for both technical and motivational support. In this open trial, we aimed to evaluate (1) acceptability and feasibility; (2) intervention skill use and its association with state mindfulness in daily life; and (3) pre-to-post changes in target mechanisms and outcomes. Eighteen individuals with past-year AN or past-year atypical AN completed Mindful Courage-Beta over 2 weeks. Participants completed measures of acceptability, trait mindfulness, emotion regulation, eating disorder symptoms, and body dissatisfaction. Participants also completed ecological momentary assessment of skill use and state mindfulness. Acceptability ratings were good (ease-of-use: 8.2/10, helpfulness: 7.6/10). Adherence was excellent (100% completion for foundational module and 96% for mini-modules). Use of the BOAT in daily life was high (1.8 times/day) and was significantly associated with higher state mindfulness at the within-person level. We also found significant, large improvements in the target mechanisms of trait mindfulness (d = .96) and emotion regulation (d = .76), as well as significant, small-medium to medium-large reductions in eating disorder symptoms (ds = .36-.67) and body dissatisfaction (d = .60). Changes in trait mindfulness and emotion regulation had medium-large size correlations with changes in global ED symptoms and body dissatisfaction (rs = .43 - .56). Mindful Courage-Beta appears to be promising and further research on a longer, refined version is warranted.
Tıkınırcasına yeme bozukluğu, obezite ile güçlü bir şekilde ilişkilidir ve obez bireylerde en sık karşılaşılan yeme bozukluklarından biridir. Tıkınırcasına yeme bozukluğu; telafi edici davranışlar olmaksızın, tekrarlayan aşırı yeme epizodları ile karakterize bir bozukluktur. Aynı zamanda; depresyon, düşük benlik saygısı ve dürtüsellik gibi çeşitli yeme bozukluğu semptomları ile de ilişkilendirilmektedir. Bu yeme bozukluğunun tedavisinde; bilişsel davranışçı terapi, davranışçı vücut ağırlık kaybı terapisi ve kişilerarası ilişkiler terapisi gibi yaklaşımlar kullanılmaktadır. Son yıllarda, üçüncü dalga bilişsel davranışçı terapiler; özellikle farkındalık temelli müdahaleler tıkınırcasına yeme bozukluğu tedavisinde dikkat çekici şekilde öne çıkmaktadır. Bilinçli farkındalık ve özellikle yeme farkındalığı; sağlıklı beslenmeyi desteklemek için yeni yaklaşımlar olarak ortaya çıkmıştır. Bilinçli farkındalık kavramı; kasıtlı olarak, yargılamadan şimdiki zamanda kalma ve dikkat göstermeyi ifade etmektedir. Bu uygulama; anksiyete ve depresyon için başarılı bir birincil ve yardımcı tedavi yöntemi olarak kullanılmasının yanı sıra, yeme bozukluklarında yoğun olarak hissedilen dürtüselliği tersine çevirebilmektedir. Yeme farkındalığı ise bireyin aç ve tok olma durumunun, duygularının ve tükettiği besinlerin farkına varmasına odaklanır. Bu derleme; tıkınırcasına yeme bozukluğunun ve klinik sonuçlarının daha iyi anlaşılması ile birlikte, tıkınırcasına yeme bozukluğu olan farklı popülasyonlarda bilinçli farkındalık uygulamalarının sonuçlarını inceleyen güncel literatür verilerini sunmayı amaçlamaktadır.
Recent studies have found increasing rates of overweight and obesity in bulimia nervosa (BN). However, the relationships between body mass index (BMI) and BN symptoms and other clinically relevant constructs are unknown. Participants (N = 152 adults with BN) were assigned to three groups by BMI: group with no overweight or obesity (NOW-BN; BMI <25; N = 32), group with overweight (OW-BN; BMI ≥25 and <30; N = 66), and group with obesity (O-BN; BMI ≥30; N = 54). We compared the groups on demographics, diet and weight histories, body esteem, BN symptoms, and depression using chi square, analysis of variance, analysis of covariance, and Poisson regression models. The O-BN group was older (d = 0.57) and OW-BN and O-BN groups had greater proportions of race/ethnic minorities than NOW-BN group. The O-BN group was significantly younger at first diet (d = 0.41) and demonstrated significantly higher cognitive dietary restraint (d = 0.31). Compared to NOW-BN, O-BN participants had lower incidence of objective binge eating (incidence rate ratio [IRR] = 4.86) and driven exercise (IRR = 7.13), and greater incidence of vomiting (IRR = 9.30), laxative misuse (IRR = 4.01), and diuretic misuse (d = 2.08). O-BN participants also experienced higher shape (d = 0.41) and weight (d = 0.42) concerns than NOW-BN and OW-BN, although NOW-BN experienced higher shape (d = 0.44) and weight (d = 0.39) concerns than OW-BN. Groups did not differ on depression scores. These results were replicated when examining BMI as a continuous predictor across the full sample, with the exception of objective binge eating and driven exercise, which were not significantly associated with BMI. Individuals with BN and comorbid obesity have distinct clinical characteristics. Existing interventions may need to be adapted to meet clinical needs of these individuals.
Background:
Eating behavior in individuals with chronic mental disorders is affected by several factors such as stress, drugs, and the environment. Eating problems can lead to over-nutrition and obesity. Therefore, the Shared Decision Making Model-based Guided Self-Help Program aimed at solving the eating problems of individuals with bipolar disorder living in the community should be tested with preliminary studies. Thus, it would be appropriate to create a useful, accessible, and applicable program for these individuals to overcome their eating problems.
Case presentation:
In this case study, the effects of the Guided Self-Help Program based on the Shared Decision Making Model (GSHP-SDM) on the eating behaviors of an individual who was diagnosed with bipolar disorder and displayed binge eating and emotional eating behaviors were investigated. In the study, it was determined that implementation of the eight-session GSHP-SDM, during which the participant was interviewed once a week, improved her emotional and uncontrolled eating behaviors.
Conclusions:
This study is the first case study in which the GSHP was implemented to change the eating behavior of an individual with a chronic mental disorder. We observed that the GSHP regulated her eating behavior. We also observed that SDM therapeutic intervention enabled her to decide that she could regulate her eating behaviors.
Objective:
To map and examine the systematic review evidence base regarding the effects of cognitive-behavioral therapy (CBT) for eating disorders (EDs), especially against active interventions.
Method:
This systematic review is an extension of an overview of CBT for all health conditions (CBT-O). We identified ED-related systematic reviews from the CBT-O database and performed updated searches of EMBASE, MEDLINE, and PsychInfo in April 2021 and September 2022.
Results:
The 44 systematic reviews included (21 meta-analyses) were of varying quality. They focused on "high intensity" CBT, delivered face-to-face by qualified clinicians, in BN, BED and mixed, not specifically low-weight samples. ED-specific outcomes were studied most, with little consensus on their operationalization. The, often insufficient, reporting of sample characteristics did not allow assessment of the generalizability of findings. The meta-analytic syntheses show that high intensity one-to-one CBT produces better short-term effects than a mix of active controls especially on ED-specific measures for BED, BN, and transdiagnostic samples. There is little evidence favoring group CBT or low intensity CBT against other active interventions.
Discussion:
While this study found evidence consistent with current ED treatment recommendations, it highlighted notable gaps that need to be addressed. There were insufficient data to allow generalizations regarding sex and gender, age, culture and comorbidity and to support CBT in AN samples. The evidence for group CBT and low intensity CBT against active controls is limited, as it is for the longer-term effects of CBT. Our findings identify areas for future innovation and research within CBT.
Public significance:
This study provides a comprehensive mapping and quality assessment of the current large systematic review research base regarding the effects of cognitive behavioral therapy (CBT) for eating disorders (EDs), with a focus on comparisons to other active interventions. By transcending the more limited scope of individual systematic reviews, this overview highlights the gaps in the current evidence base, and thus provides guidance for future research and clinical innovation.
Acceptance and Commitment Therapy (ACT) is increasingly used to treat eating disorders (EDs); however, the evidence for ACT with EDs has not been the subject of a systematic review. The current study reviews the evidence of ACT for EDs through January of 2022. PubMed and PsycInfo were searched for treatment studies using three or more ACT processes with adolescents or adults with anorexia nervosa, bulimia nervosa, binge eating disorder and purging disorder spectrum diagnoses. Studies focusing primarily on obesity, weight loss or body image were excluded. Twenty-two intervention studies were identified with a combined total of 674 participants. Five were randomized controlled trials. While the majority of studies focused on anorexia nervosa, these tended to be smaller studies of fewer participants. Results indicated that ACT may show reasonable efficacy for improvements in ED symptoms. However, most studies lacked sufficient methodological rigor and were weak on two or more components of the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies. Future directions and limitations of using the EPHPP for quality assessment of psychological interventions are discussed, as well as strengths and weaknesses of the evidence base in light of the recent ACBS Task Force Report on the Strategies and Tactics of Contextual Behavioral Science Research.
We reviewed treatments for eating disorders that incorporated both mindfulness-and acceptance-based therapy and cognitive behavioral therapy (CBT) content. We included peer-reviewed studies where participants had an eating disorder or subclinical disordered eating and the treatment combined at least some elements from both mindfulness-and acceptance-based therapy and CBT. Although the literature is nascent, preliminary evidence of the acceptability, feasibility, and potential efficacy of these combined treatments is promising. Specifically, the acceptability and feasibility of combined mindfulness-and acceptance-based therapy with CBT is excellent. Combining these treatments have also shown to improve eating disorder symptoms as well as secondary outcomes (e.g., depression, quality of life). Although initial data are promising, most studies have been open trials, had small samples, and had short follow-up periods. Future randomized controlled trials (RCTs) with larger sample sizes and longer follow-up periods are needed to further evaluate combined mindfulness-and acceptance-based therapy and CBT treatments.
Background:
Anorexia nervosa (AN) has high rates of enduring disease and mortality. Currently, there is insufficient knowledge on the predictors of relapse after weight normalization and this is why a systematic literature review was performed.
Methods:
PubMed, EMBASE, PsychInfo, and Cochrane databases were searched for literature published until 13 July 2021. All study designs were eligible for inclusion if they focused on predictors of relapse after weight normalization in AN. Individual study definitions of relapse were used, and in general, this was either a drop in BMI and/or reccurrence of AN symptoms.
Results:
The database search identified 11,507 publications, leaving 9511 publications after the removal of duplicates and after a review of abstracts and titles; 191 were selected for full-text review. Nineteen publications met the criteria and included 1398 AN patients and 39 healthy controls (HC) from adults and adolescents (ages range 11-73 years). The majority used a prospective observational study design (12 studies), a few used a retrospective observational design (6 studies), and only one was a non-randomized control trial (NRCT). Sample sizes ranged from 16 to 191 participants. BMI or measures of body fat and leptin levels at discharge were the strongest predictors of relapse with an approximate relapse rate of 50% at 12 months. Other predictors included signs of eating disorder psychopathology at discharge.
Conclusions:
BMI at the end of treatment is a predictor of relapse in AN, which is why treatment should target a BMI well above 20. Together with the time to relapse, these outcomes are important to include in the evaluation of current and novel treatments in AN and for benchmarking.
Background
Theoretical models highlight the importance of emotion dysregulation as a key risk and maintaining factor for eating disorders. However, most studies testing these theories are cross-sectional. It remains unclear which dimensions of emotion dysregulation account for the onset and persistence of eating disorder behaviours.
Methods
To address these gaps, data were analyzed from 1321 adult women who completed study measures at baseline and eight-month follow-up. The dimensions of emotion dysregulation assessed were five subscales from the abbreviated 16-item Difficulties in Emotion Regulation Scale. Outcomes included the onset (versus asymptomatic) and persistence (versus remission) of binge eating and compensatory behaviours.
Results
Univariate logistic regressions showed that, among initially asymptomatic women, higher baseline levels of each emotion dysregulation dimension (except the “goals” subscale) predicted the onset of binge eating and compensatory behaviours at follow-up. Each dimension also predicted the persistence of compensatory behaviours at follow-up among women endorsing these behaviours at baseline, while the “impulse”, “strategies”, and “non-acceptance” dimensions predicted the persistence of binge eating. In multivariate analyses, only the “strategies” dimension predicted the onset and persistence of binge eating, while the “non-acceptance” dimension predicted the onset and persistence of compensatory behaviours.
Limitations
Only a limited number of emotion dysregulation dimensions were tested.
Conclusion
Findings demonstrate the importance of emotion dysregulation dimensions in accounting for the onset and maintenance of eating disorder behaviours. The delivery of specific intervention strategies designed to address emotion dysregulation may depend on the risk and symptom profile of an individual.
Objective:
Various approaches exist to treat youth with anorexia nervosa (AN). Family-based treatment (FBT) has never been compared to long inpatient, multimodal treatment (IMT) in a randomized controlled trial (RCT). The aim of this study was to compare data on body weight trajectories, change in eating disorder psychopathology, hospital days and treatment costs in RCTs delivering FBT or IMT.
Method:
Review of RCTs published between 2010 and 2020 in youth with AN, delivering FBT or IMT.
Results:
Four RCTs delivering FBT (United States, n = 2; Australia, n = 2), one RCT delivering Family Therapy for AN (United Kingdom) and two RCTs delivering IMT (France, n = 1; Germany, n = 1) were identified from previous meta-analyses. The comparison of studies was limited by (1) significant differences in patient baseline characteristics including pretreated versus non-pretreated patients, (2) use of different psychometric and weight measures and (3) different initial velocity of weight recovery. Minimal baseline and outcome reporting standards for body weight metrics and nature/dose of interventions allowing international comparison are needed and suggestions to developing these standards are presented.
Discussion:
An RCT should investigate, whether FBT is a viable alternative to IMT, leading to comparable weight and psychopathology improvement with less inpatient time and costs.
Objective:
To assess the relationship between mindfulness and glycemia among adolescents with type 1 diabetes (T1D) with suboptimal glycemia, and evaluate the potential mediation by ingestive behaviors, including disordered eating, and impulsivity.
Methods:
We used linear mixed models for hemoglobin A1c (HbA1c) and linear regression for continuous glucose monitoring (CGM) to study the relationship of mindfulness [Child and Adolescent Mindfulness Measure (CAMM)] and glycemia in adolescents with T1D from the 18-month Flexible Lifestyles Empowering Change (FLEX) trial. We tested for mediation of the mindfulness-glycemia relationship by ingestive behaviors, including disordered eating (Diabetes Eating Problem Survey - Revised), restrained eating, and emotional eating (Dutch Eating Behavior Questionnaire); and impulsivity (total, attentional, and motor, Barrett Impulsiveness Scale).
Results:
At baseline, participants (n=152) had a mean age of 14.9 ± 1.1 years and HbA1c of 9.4 ± 1.2% [79±13 mmol/mol]. The majority of adolescents were non-Hispanic white (83.6%), 50.7% were female, and 73.0% used insulin pumps. From adjusted mixed models, a 5-point increase in mindfulness scores was associated with a -0.19% (95%CI -0.29, -0.08, p=0.0006) reduction in HbA1c. We did not find statistically significant associations between mindfulness and CGM metrics. Mediation of the relationship between mindfulness and HbA1c by ingestive behaviors and impulsivity was not found to be statistically significant.
Conclusions:
Among adolescents with T1D and suboptimal glycemia, increased mindfulness was associated with lower HbA1c levels. Future studies may consider mindfulness-based interventions as a component of treatment for improving glycemia among adolescents with T1D, though more data are needed to assess feasibility and efficacy. Words: 250/250 This article is protected by copyright. All rights reserved.
Einer leitliniengerechten Versorgung der Essstörungen kommt aufgrund der potenziell schwerwiegenden körperlichen und psychosozialen Beeinträchtigungen eine hohe Bedeutung zu. Der Beitrag zeigt die Empfehlungen der S3-Leitlinie zur psychotherapeutischen und psychopharmakologischen Behandlung der Anorexia nervosa, Bulimia nervosa und Binge-Eating-Störung und berichtet über neuere Entwicklungen in der Behandlung der Essstörungen.
Previous research investigated the role of social media use and perceived socio-cultural pressure as predictors of the endorsement of ideal body stereotypes. However, not much has been explored concerning cognitive fusion and its role within this framework. The current study investigated social media use as a predictor of ideal body stereotypes and how this relationship is mediated by perceived social pressure. Additionally, we explored the potential moderating roles of cognitive fusion within these relationships. Our sample consisted of 489 participants aged 18 to 53 (73.2% females). The findings suggested that the participants' reported social media use level significantly predicted both the ideal body stereotypes and the perceived social pressure. The overall effect of perceived social pressure on ideal body stereotypes was not significant. However, at low levels of cognitive fusion, the perceived social pressure significantly mediated the relationship between social media use and ideal body stereotype. We consider the current findings significant for their contribution to potential educational programs designed to address the adverse consequences of social media use on psychological and physical well-being.
Objective:
Alexithymia is proposed as a prominent clinical feature of eating disorders (EDs). However, despite theoretical reason to believe that alexithymia could interfere with the success of treatments, few studies have tested whether alexithymia changes over the course of treatment. The goals of the current study were to evaluate (a) changes in alexithymia over the course of intensive Dialectical Behaviour Therapy (DBT) for EDs, and (b) associations between alexithymia and ED symptoms over time.
Method:
A mixed-diagnostic group of patients with EDs (N = 894) completed the Eating Disorders Examination-Questionnaire (EDE-Q) and the Toronto Alexithymia Scale (TAS-20) throughout intensive treatment and at various lengths of follow-up (6, 12, 24 months).
Results:
Results suggested that even after controlling for relevant covariates, there were significant decreases in alexithymia from intake to discharge and discharge to follow-up. Models exploring changes in self-reported ED symptoms indicated that TAS-20 scores significantly related to ED symptoms across timepoints, such that greater alexithymia was associated with greater severity of symptoms.
Conclusions:
Altogether, findings support an association between alexithymia and ED symptoms over treatment and suggest that emotion-focussed therapies like DBT may result in decreases in alexithymia. Future research should explore whether this effect is consistent across therapies without an emotional focus.
Background
One of the major barriers to the dissemination and implementation of psychological treatments is the scarcity of suitably trained therapists. The currently accepted method of training is not scalable. Recently, a scalable form of training, Web-centered training, has been shown to have promise.
Objective
The goal of our research was to conduct a randomized comparison of the relative effects of independent and supported Web-centered training on therapist competence and investigate the persistence of the effects.
Methods
Eligible therapists were recruited from across the United States and Canada. They were randomly assigned to 1 of 2 forms of training in enhanced cognitive behavior therapy (CBT-E), a multicomponent evidence-based psychological treatment for any form of eating disorder. Independent training was undertaken autonomously, while supported training was accompanied by support from a nonspecialist worker. Therapist competence was assessed using a validated competence measure before training, after 20 weeks of training, and 6 months after the completion of training.
Results
A total of 160 therapists expressed interest in the study, and 156 (97.5%) were randomized to the 2 forms of training (81 to supported training and 75 to independent training). Mixed effects analysis showed an increase in competence scores in both groups. There was no difference between the 2 forms of training, with mean difference for the supported versus independent group being –0.06 (95% Cl –1.29 to 1.16, P=.92). A total of 58 participants (58/114, 50.9%) scored above the competence threshold; three-quarters (43/58, 74%) had not met this threshold before training. There was no difference between the 2 groups in the odds of scoring over the competence threshold (odds ratio [OR] 1.02, 95% CI 0.52 to 1.99; P=.96). At follow-up, there was no significant difference between the 2 training groups (mean difference 0.19, 95% Cl –1.27 to 1.66, P=.80). Overall, change in competence score from end of training to follow-up was not significant (mean difference –0.70, 95% CI –1.52 to 0.11, P=.09). There was also no difference at follow-up between the training groups in the odds of scoring over the competence threshold (OR 0.95, 95% Cl 0.34 to 2.62; P=.92).
Conclusions
Web-centered training was equally effective whether undertaken independently or accompanied by support, and its effects were sustained. The independent form of Web-centered training is particularly attractive as it provides a means of training large numbers of geographically dispersed therapists at low cost, thereby overcoming several obstacles to the widespread dissemination of psychological treatments.
Purpose of review:
The current systematic review sought to compare available evidence-based clinical treatment guidelines for all specific eating disorders.
Recent findings:
Nine evidence-based clinical treatment guidelines for eating disorders were located through a systematic search. The international comparison demonstrated notable commonalities and differences among these current clinical guidelines. Consistency across guidelines was greatest for treatments with a larger evidence base, while those with a lower evidence base had recommendations that varied considerably.
Summary:
Evidence-based clinical guidelines represent an important step toward the dissemination and implementation of evidence-based treatments into clinical practice. Despite advances in clinical research on eating disorders, a growing body of literature demonstrates that individuals with eating disorders often do not receive an evidence-based treatment for their disorder. Regarding the dissemination and implementation of evidence-based treatments, current guidelines do endorse the main empirically validated treatment approaches with considerable agreement, but additional recommendations are largely inconsistent. An increased evidence base is critical in offering clinically useful and reliable guidance for the treatment of eating disorders. Because developing and updating clinical guidelines is time-consuming and complex, an international coordination of guideline development, for example, across the European Union, would be desirable.
Background
A major barrier to the widespread dissemination of psychological treatments is the way that therapists are trained. The current method is not scalable.
Objective
Our objective was to conduct a proof-of-concept study of Web-centered training, a scalable online method for training therapists.
Methods
The Irish Health Service Executive identified mental health professionals across the country whom it wanted to be trained in a specific psychological treatment for eating disorders. These therapists were given access to a Web-centered training program in transdiagnostic cognitive behavior therapy for eating disorders. The training was accompanied by a scalable form of support consisting of brief encouraging telephone calls from a nonspecialist. The trainee therapists completed a validated measure of therapist competence before and after the training.
Results
Of 102 therapists who embarked upon the training program, 86 (84.3%) completed it. There was a substantial increase in their competence scores following the training (mean difference 5.84, 95% Cl –6.62 to –5.05; P<.001) with 42.5% (34/80) scoring above a predetermined cut-point indicative of a good level of competence.
Conclusions
Web-centered training proved feasible and acceptable and resulted in a marked increase in therapist competence scores. If these findings are replicated, Web-centered training would provide a means of simultaneously training large numbers of geographically dispersed trainees at low cost, thereby overcoming a major obstacle to the widespread dissemination of psychological treatments.
Background:
There is a lack of evidence pointing to the efficacy of any specific psychotherapy for adults with anorexia nervosa (AN). The aim of this study was to compare three psychological treatments for AN: Specialist Supportive Clinical Management, Maudsley Model Anorexia Nervosa Treatment for Adults and Enhanced Cognitive Behavioural Therapy.
Method:
A multi-centre randomised controlled trial was conducted with outcomes assessed at pre-, mid- and post-treatment, and 6- and 12-month follow-up by researchers blind to treatment allocation. All analyses were intention-to-treat. One hundred and twenty individuals meeting diagnostic criteria for AN were recruited from outpatient treatment settings in three Australian cities and offered 25-40 sessions over a 10-month period. Primary outcomes were body mass index (BMI) and eating disorder psychopathology. Secondary outcomes included depression, anxiety, stress and psychosocial impairment.
Results:
Treatment was completed by 60% of participants and 52.5% of the total sample completed 12-month follow-up. Completion rates did not differ between treatments. There were no significant differences between treatments on continuous outcomes; all resulted in clinically significant improvements in BMI, eating disorder psychopathology, general psychopathology and psychosocial impairment that were maintained over follow-up. There were no significant differences between treatments with regard to the achievement of a healthy weight (mean = 50%) or remission (mean = 28.3%) at 12-month follow-up.
Conclusion:
The findings add to the evidence base for these three psychological treatments for adults with AN, but the results underscore the need for continued efforts to improve outpatient treatments for this disorder. Trial Registration Australian New Zealand Clinical Trials Registry (ACTRN 12611000725965) http://www.anzctr.org.au/.
Background:
No specific psychotherapy for adult anorexia nervosa (AN) has shown superior effect. Maintenance factors in AN (over-evaluation of control over eating, weight and shape) were addressed via Acceptance and Commitment Therapy (ACT). The study aimed to compare 19 sessions of ACT with treatment as usual (TAU), after 9 to 12 weeks of daycare, regarding recovery and risk of relapse up to five years.
Methods:
Patients with a full, sub-threshold or partial AN diagnosis from an adult eating disorder unit at a hospital were randomized to ACT (n = 24) and TAU (n = 19). The staff at the hospital, as well as the participants, were unaware of the allocation until the last week of daycare. Primary outcome measures were body mass index (BMI) and specific eating psychopathology. Analyses included mixed model repeated measures and odds ratios.
Results:
Groups did not differ regarding recovery and relapse using a metric of BMI and the Eating Disorder Examination Questionnaire (EDE-Q). There were only significant time effects. However, odds ratio indicated that ACT participants were more likely to reach good outcome. The study was underpowered due to unexpected low inflow of patients and high attrition.
Conclusion:
Longer treatment, more focus on established perpetuating factors and weight restoration integrated with ACT might improve outcome. Potential pitfalls regarding future trials on AN are discussed. Trial registration number ISRCTN 12106530. Retrospectively registered 08/06/2016.
Eating disorders may be viewed from a transdiagnostic perspective and there is evidence supporting a transdiagnostic form of cognitive behaviour therapy (CBT-E). The aim of the present study was to compare CBT-E with interpersonal psychotherapy (IPT), a leading alternative treatment for adults with an eating disorder. One hundred and thirty patients with any form of eating disorder (body mass index >17.5 to <40.0) were randomized to either CBT-E or IPT. Both treatments involved 20 sessions over 20 weeks followed by a 60-week closed follow-up period. Outcome was measured by independent blinded assessors. Twenty-nine participants (22.3%) did not complete treatment or were withdrawn. At post-treatment 65.5% of the CBT-E participants met criteria for remission compared with 33.3% of the IPT participants (p < 0.001). Over follow-up the proportion of participants meeting criteria for remission increased, particularly in the IPT condition, but the CBT-E remission rate remained higher (CBT-E 69.4%, IPT 49.0%; p = 0.028). The response to CBT-E was very similar to that observed in an earlier study. The findings indicate that CBT-E is potent treatment for the majority of outpatients with an eating disorder. IPT remains an alternative to CBT-E, but the response is less pronounced and slower to be expressed.
ISRCTN 15562271.
Copyright © 2015. Published by Elsevier Ltd.
Mindfulness-based interventions are increasingly used to treat binge eating. The effects of these interventions have not been reviewed comprehensively. This systematic review and meta-analysis sought to summarize the literature on mindfulness-based interventions and determine their impact on binge eating behavior. PubMED, Web of Science, and PsycINFO were searched using keywords binge eating, overeating, objective bulimic episodes, acceptance and commitment therapy, dialectical behavior therapy, mindfulness, meditation, mindful eating. Of 151 records screened, 19 studies met inclusion criteria. Most studies showed effects of large magnitude. Results of random effects meta-analyses supported large or medium-large effects of these interventions on binge eating (within-group random effects mean Hedge’s g = −1.12, 95 % CI −1.67, −0.80, k = 18; between-group mean Hedge’s g = −0.70, 95 % CI −1.16, −0.24, k = 7). However, there was high statistical heterogeneity among the studies (within-group I
2 = 93 %; between-group I
2 = 90 %). Limitations and future research directions are discussed.
Background: The current study presents the results of a meta-analysis of 39 randomized controlled trials on the efficacy of ACT, including 1,821 patients with mental disorders or somatic health problems.
Methods: We searched PsycINFO, MEDLINE, and the Cochrane Central Register of Controlled Trials. Information provided by the Association of Contextual Behavioral Science (ACBS) community was also included. Statistical calculations were conducted using Comprehensive Meta-Analysis software. Study quality was rated using a methodology rating form.
Results: ACT outperformed control conditions (Hedges’s g = 0.57) at post-treatment and follow-up, in completer and intent-to-treat analyses for primary outcomes. ACT was superior to waitlist (Hedges’s g = 0.82), to psychological placebo (Hedges’s g = 0.51) and to TAU (Hedges’ g = 0.64). ACT was also superior on secondary outcomes (Hedges’s g = 0.30), life satisfaction/quality measures (Hedges’s g = 0.37) and process measures (Hedges’s g = 0. 56) when compared to control conditions. The comparison between ACT and established treatments (i.e., CBT) did not reveal any significant differences between these treatments (p = .140).
Conclusions: Our findings indicate that ACT is more effective than treatment as usual or placebo and that ACT may be as effective in treating anxiety disorders, depression, addiction, and somatic health problems as established psychological interventions. More research that focuses on quality of life and processes of change is needed to understand the added value of ACT and its trans diagnostic nature.
This study evaluated the effectiveness of dialectical behavior therapy (DBT) for treating eating disorder episodes and co-occurring depression symptoms among individuals diagnosed with eating disorders. Separate meta-analytic procedures for between-groups and single-group studies were conducted and yielded large effect sizes, indicating that DBT may be efficacious for decreasing disordered episodes among women diagnosed with eating disorders; medium to large effect sizes were noted for treating depression symptoms. Implications for evidence-supported practice and study limitations are discussed.
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.
Objective:
Negative affect precedes binge eating and purging in bulimia nervosa (BN), but little is known about factors that precipitate negative affect in relation to these behaviors. We aimed to assess the temporal relation among stressful events, negative affect, and bulimic events in the natural environment using ecological momentary assessment.
Method:
A total of 133 women with current BN recorded their mood, eating behavior, and the occurrence of stressful events every day for 2 weeks. Multilevel structural equation mediation models evaluated the relations among Time 1 stress measures (i.e., interpersonal stressors, work/environment stressors, general daily hassles, and stress appraisal), Time 2 negative affect, and Time 2 binge eating and purging, controlling for Time 1 negative affect.
Results:
Increases in negative affect from Time 1 to Time 2 significantly mediated the relations between Time 1 interpersonal stressors, work/environment stressors, general daily hassles, and stress appraisal and Time 2 binge eating and purging. When modeled simultaneously, confidence intervals for interpersonal stressors, general daily hassles, and stress appraisal did not overlap, suggesting that each had a distinct impact on negative affect in relation to binge eating and purging.
Conclusions:
Our findings indicate that stress precedes the occurrence of bulimic behaviors and that increases in negative affect following stressful events mediate this relation. Results suggest that stress and subsequent negative affect may function as maintenance factors for bulimic behaviors and should be targeted in treatment.
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
Objective:
This study aimed to determine whether cognitive-behavioral therapy (CBT) for eating disorders can be effective in a routine, primary care clinical setting, and to assess dose response.
Method:
The participants were 47 patients who commenced treatment with a publicly-funded primary care eating disorder service. They attended 7-33 sessions of individual CBT (mean = 17), using an evidence-based approach. Routine measures were collected pre- and post-therapy.
Results:
Three-quarters of the patients completed treatment. Using intention to treat analysis (multiple imputation), the patients showed substantial improvements in eating attitudes, bulimic behaviors, and depression. However, there was no association between the level of improvement and the length of therapy past the 8th to 12th session.
Discussion:
The level of effectiveness shown here is comparable to that previously demonstrated by more specialist services in secondary and tertiary care. The nonlinear association between number of sessions and recovery highlights the importance of early change, across the eating disorders.
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.
Objective:
Pharmacotherapy, cognitive-behavioral therapy (CBT), and psychodynamic therapy are most frequently applied to treat mental disorders. However, whether psychodynamic therapy is as efficacious as other empirically supported treatments is not yet clear. Thus, for the first time the equivalence of psychodynamic therapy to treatments established in efficacy was formally tested. The authors controlled for researcher allegiance effects by including representatives of psychodynamic therapy and CBT, the main rival psychotherapeutic treatments (adversarial collaboration).
Method:
The authors applied the formal criteria for testing equivalence, implying a particularly strict test: a priori defining a margin compatible with equivalence (g=0.25), using the two one-sided test procedure, and ensuring the efficacy of the comparator. Independent raters assessed effect sizes, study quality, and allegiance. A systematic literature search used the following criteria: randomized controlled trial of manual-guided psychodynamic therapy in adults, testing psychodynamic therapy against a treatment with efficacy established for the disorder under study, and applying reliable and valid outcome measures. The primary outcome was "target symptoms" (e.g., depressive symptoms in depressive disorders).
Results:
Twenty-three randomized controlled trials with 2,751 patients were included. The mean study quality was good as demonstrated by reliable rating methods. Statistical analyses showed equivalence of psychodynamic therapy to comparison conditions for target symptoms at posttreatment (g=-0.153, 90% equivalence CI=-0.227 to -0.079) and at follow-up (g=-0.049, 90% equivalence CI=-0.137 to -0.038) because both CIs were included in the equivalence interval (-0.25 to 0.25).
Conclusions:
Results suggest equivalence of psychodynamic therapy to treatments established in efficacy. Further research should examine who benefits most from which treatment.
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.
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.
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.
Background. Early weak treatment response is one of the few trans-diagnostic, treatment-agnostic predictors of poor outcome following a full treatment course. We sought to improve the outcome of clients with weak initial response to guided self-help cognitive behavior therapy (GSH).
Method. One hundred and nine women with binge-eating disorder (BED) or bulimia nervosa (BN) (DSM-IV-TR)
received 4 weeks of GSH. Based on their response, they were grouped into: (1) early strong responders who continued
GSH (cGSH), and early weak responders randomized to (2) dialectical behavior therapy (DBT), or (3) individual and
additional group cognitive behavior therapy (CBT+).
Results. Baseline objective binge-eating-day (OBD) frequency was similar between DBT, CBT+ and cGSH. During treatment,
OBD frequency reduction was significantly slower in DBT and CBT+ relative to cGSH. Relative to cGSH, OBD frequency was significantly greater at the end of DBT (d = 0.27) and CBT+ (d = 0.31) although these effects were small and within-treatment effects from baseline were large (d = 1.41, 0.95, 1.11, respectively). OBD improvements significantly
diminished in all groups during 12 months follow-up but were significantly better sustained in DBT relative to cGSH (d = −0.43). At 6- and 12-month follow-up assessments, DBT, CBT and cGSH did not differ in OBD.
Conclusions. Early weak response to GSH may be overcome by additional intensive treatment. Evidence was insufficient to support superiority of either DBT or CBT+ for early weak responders relative to early strong responders in cGSH; both were helpful. Future studies using adaptive designs are needed to assess the use of early response to efficiently deliver care to large heterogeneous client groups.
Aims
The standardised mean difference (SMD) is one of the most used effect sizes to indicate the effects of treatments. It indicates the difference between a treatment and comparison group after treatment has ended, in terms of standard deviations. Some meta-analyses, including several highly cited and influential ones, use the pre-post SMD, indicating the difference between baseline and post-test within one (treatment group).
Methods
In this paper, we argue that these pre-post SMDs should be avoided in meta-analyses and we describe the arguments why pre-post SMDs can result in biased outcomes.
Results
One important reason why pre-post SMDs should be avoided is that the scores on baseline and post-test are not independent of each other. The value for the correlation should be used in the calculation of the SMD, while this value is typically not known. We used data from an ‘individual patient data’ meta-analysis of trials comparing cognitive behaviour therapy and anti-depressive medication, to show that this problem can lead to considerable errors in the estimation of the SMDs. Another even more important reason why pre-post SMDs should be avoided in meta-analyses is that they are influenced by natural processes and characteristics of the patients and settings, and these cannot be discerned from the effects of the intervention. Between-group SMDs are much better because they control for such variables and these variables only affect the between group SMD when they are related to the effects of the intervention.
Conclusions
We conclude that pre-post SMDs should be avoided in meta-analyses as using them probably results in biased outcomes.
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.
In this review, we examine common usage of the term third wave in the scientific literature, systematically review published meta-analyses of identified third wave therapies, and consider the implications and options for the use of third wave as a metaphor to describe the nature of and relationships among cognitive and behavioral therapies. We demonstrate that the third wave term has grown in its use over time, that it is commonly linked with specific therapies, and that the majority of such therapies have amassed a compelling evidence base attesting to their clinical and public health value. We also consider the extent to which the third wave designation is an effective guide for the future, and we encourage scientific inquiry and self-reflection among those concerned with cognitive and behavioral therapies and the scientific basis of psychotherapy more broadly.
Background:
The best treatment options for binge-eating disorder are unclear.
Purpose:
To summarize evidence about the benefits and harms of psychological and pharmacologic therapies for adults with binge-eating disorder.
Data sources:
English-language publications in EMBASE, the Cochrane Library, Academic OneFile, CINAHL, and ClinicalTrials.gov through 18 November 2015, and in MEDLINE through 12 May 2016.
Study selection:
9 waitlist-controlled psychological trials and 25 placebo-controlled trials that evaluated pharmacologic (n = 19) or combination (n = 6) treatment. All were randomized trials with low or medium risk of bias.
Data extraction:
2 reviewers independently extracted trial data, assessed risk of bias, and graded strength of evidence.
Data synthesis:
Therapist-led cognitive behavioral therapy, lisdexamfetamine, and second-generation antidepressants (SGAs) decreased binge-eating frequency and increased binge-eating abstinence (relative risk, 4.95 [95% CI, 3.06 to 8.00], 2.61 [CI, 2.04 to 3.33], and 1.67 [CI, 1.24 to 2.26], respectively). Lisdexamfetamine (mean difference [MD], -6.50 [CI, -8.82 to -4.18]) and SGAs (MD, -3.84 [CI, -6.55 to -1.13]) reduced binge-eating-related obsessions and compulsions, and SGAs reduced symptoms of depression (MD, -1.97 [CI, -3.67 to -0.28]). Headache, gastrointestinal upset, sleep disturbance, and sympathetic nervous system arousal occurred more frequently with lisdexamfetamine than placebo (relative risk range, 1.63 to 4.28). Other forms of cognitive behavioral therapy and topiramate also increased abstinence and reduced binge-eating frequency and related psychopathology. Topiramate reduced weight and increased sympathetic nervous system arousal, and lisdexamfetamine reduced weight and appetite.
Limitations:
Most study participants were overweight or obese white women aged 20 to 40 years. Many treatments were examined only in single studies. Outcomes were measured inconsistently across trials and rarely assessed beyond end of treatment.
Conclusion:
Cognitive behavioral therapy, lisdexamfetamine, SGAs, and topiramate reduced binge eating and related psychopathology, and lisdexamfetamine and topiramate reduced weight in adults with binge-eating disorder.
Primary funding source:
Agency for Healthcare Research and Quality.
The current study sought to assess the acceptability and feasibility of a compassion-focused therapy (CFT) group as an adjunct to evidence-based outpatient treatment for eating disorders, and to examine its preliminary efficacy relative to treatment as usual (TAU). Twenty-two outpatients with various types of eating disorders were randomly assigned to 12 weeks of TAU (n = 11) or TAU plus weekly CFT groups adapted for an eating disorder population (CFT + TAU; n = 11). Participants in both conditions completed measures of self-compassion, fears of compassion, shame and eating disorder pathology at baseline, week 4, week 8 and week 12. Additionally, participants receiving the CFT group completed measures assessing acceptability and feasibility of the group. Results indicated that the CFT group demonstrated strong acceptability; attendance was high and the group retained over 80% of participants. Participants rated the group positively and indicated they would be very likely to recommend it to peers with similar symptoms. Intention-to-treat analyses revealed that compared to the TAU condition, the CFT + TAU condition yielded greater improvements in self-compassion, fears of self-compassion, fears of receiving compassion, shame and eating disorder pathology over the 12 weeks. Results suggest that group-based CFT, offered in conjunction with evidence-based outpatient TAU for eating disorders, may be an acceptable, feasible and efficacious intervention. Furthermore, eating disorder patients appear to see benefit in, and observe gains from, working on the CFT goals of overcoming fears of compassion, developing more self-compassion and accessing more compassion from others. Copyright © 2016 John Wiley & Sons, Ltd.
Cognitive-behavioural therapy (CBT) is the recommended treatment for binge eating, yet many individuals do not recover, and innovative new treatments have been called for. The current study compares traditional CBT with two augmented versions of CBT; schema therapy, which focuses on early life experiences as pivotal in the history of the eating disorder; and appetite-focused CBT, which emphasises the role of recognising and responding to appetite in binge eating. 112 women with transdiagnostic DSM-IV binge eating were randomized to the three therapies. Therapy consisted of weekly sessions for six months, followed by monthly sessions for six months. Primary outcome was the frequency of binge eating. Secondary and tertiary outcomes were other behavioural and psychological aspects of the eating disorder, and other areas of functioning. No differences among the three therapy groups were found on primary or other outcomes. Across groups, large effect sizes were found for improvement in binge eating, other eating disorder symptoms and overall functioning. Schema therapy and appetite-focused CBT are likely to be suitable alternative treatments to traditional CBT for binge eating.
Objective:
Interpersonal psychotherapy (IPT) has been developed for the treatment of depression but has been examined for several other mental disorders. A comprehensive meta-analysis of all randomized trials examining the effects of IPT for all mental health problems was conducted.
Method:
Searches in PubMed, PsycInfo, Embase, and Cochrane were conducted to identify all trials examining IPT for any mental health problem.
Results:
Ninety studies with 11,434 participants were included. IPT for acute-phase depression had moderate-to-large effects compared with control groups (g=0.60; 95% CI=0.45-0.75). No significant difference was found with other therapies (differential g=0.06) and pharmacotherapy (g=-0.13). Combined treatment was more effective than IPT alone (g=0.24). IPT in subthreshold depression significantly prevented the onset of major depression, and maintenance IPT significantly reduced relapse. IPT had significant effects on eating disorders, but the effects are probably slightly smaller than those of cognitive-behavioral therapy (CBT) in the acute phase of treatment. In anxiety disorders, IPT had large effects compared with control groups, and there is no evidence that IPT was less effective than CBT. There was risk of bias as defined by the Cochrane Collaboration in the majority of studies. There was little indication that the presence of bias influenced outcome.
Conclusions:
IPT is effective in the acute treatment of depression and may be effective in the prevention of new depressive disorders and in preventing relapse. IPT may also be effective in the treatment of eating disorders and anxiety disorders and has shown promising effects in some other mental health disorders.
Binge eating disorder (BED), characterized by recurrent eating episodes in which individuals eat an objectively large amount of food within a short time period accompanied by a sense of loss of control, is the most common eating disorder. While existing treatments, such as cognitive behavioral therapy (CBT), produce remission in a large percentage of individuals with BED, room for improvement in outcomes remains. Two reasons some patients may continue to experience binge eating after a course of treatment are: (a) Difficulty complying with the prescribed behavioral components of CBT due to the discomfort of implementing such strategies; and (b) a lack of focus in current treatments on strategies for coping with high levels of negative affect that often drive binge eating. To optimize treatment outcomes, it is therefore crucial to provide patients with strategies to overcome these issues. A small but growing body of research suggests that acceptance-based treatment approaches may be effective for the treatment of binge eating. The goal of the current paper is to describe the development of an acceptance-based group treatment for BED, discuss the structure of the manual and the rationale and challenges associated with integrating acceptance-based strategies into a CBT protocol, and to discuss clinical strategies for successfully implementing the intervention.
Over the 20 years since the criteria for empirically supported treatments (ESTs) were published, standards for synthesizing evidence have evolved and more systematic approaches to reviewing the findings from intervention trials have emerged. Currently, the APA is planning the development of treatment guidelines, a process that will likely take many years. As an intermediate step, we recommend a revised set of criteria for ESTs that will utilize existing systematic reviews of all of the available literature, and recommendations that address the methodological quality, outcomes, populations, and treatment settings included in the literature.
The author applauds the plan proposed by Tolin, McKay, Forman, Klonsky, and Thombs (2015) for bringing the methodology for identifying empirically supported treatments (ESTs) into the 21st century. She suggests that further attention is required to operationalize (a) what sorts of designs for effectiveness studies will be acceptable to the Committee on Science and Practice, (b) how data on improvement in functioning will be incorporated in the context of brief treatments, and (c) how complications in obtaining clean follow-up data for long-term outcomes will be addressed, and to specify (d) whether noninferiority to an existing EST is acceptable evidence of efficacy. She further cautions that meta-analyses can mask poorly designed studies and bias in their implementation that will require the Committee's careful scrutiny.