ArticleLiterature Review

The empirical status of the third-wave behaviour therapies for the treatment of eating disorders: A systematic review

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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.

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... CBT typically consists of self-monitoring, dietary change, and cognitive restructuring aimed to promote healthy eating patterns, change maladaptive eating attitudes, address interpersonal stressors, and improve emotion regulation (Fairburn, 2008). Moreover, in recent years, dialectical behavior therapy (DBT), acceptance and commitment therapy (ACT), and mindfulness-based interventions (MBI) have emerged and are increasingly incorporated into eating pathology treatment (Linardon et al., 2017). ...
... These interventions typically include primary components of CBT as well as methods related to acceptance, mindfulness, and psychological flexibility (Hayes et al., 2011;Linardon et al., 2017). The efficacy of these therapies for eating pathology has not yet been well established (Linardon et al., 2017). ...
... These interventions typically include primary components of CBT as well as methods related to acceptance, mindfulness, and psychological flexibility (Hayes et al., 2011;Linardon et al., 2017). The efficacy of these therapies for eating pathology has not yet been well established (Linardon et al., 2017). Motivational interviewing (MI), which is intended for enhancing readiness and motivation for change by exploring beliefs and self-efficacy regarding change, has also been utilized to address eating pathology (Cassin et al., 2008). ...
Article
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Bariatric surgery is the most effective treatment for severe obesity; however, a subset of patients experience suboptimal outcomes. Psychosocial interventions that address eating pathology may ameliorate negative consequences, although their efficacy has not been examined. Thus, a systematic review to evaluate the impact of psychosocial randomized controlled trials (RCTs) on eating pathology in adults pre and post-bariatric surgery was conducted. Six scientific databases were searched for psychosocial trials assessing eating pathology as an outcome. Ten RCTs representing seven distinct interventions were identified (i.e., four preoperative and six postoperative). Trials utilized cognitive-behavioral therapy, mindfulness-based approaches, acceptance-based treatment, motivational interviewing, and psychoeducational interventions. Findings provide initial support for reducing eating pathology pre and postoperatively in the short-term (i.e., 6 months); however, the small number of RCTs and heterogeneity among postoperative trials made it difficult to draw conclusions. Additional longitudinal studies are needed to determine the long-term impact of psychosocial interventions that address eating pathology in bariatric surgery patients endorsing significant eating pathology.
... MABTs integrate traditional behavioral therapies with psychological strategies such as distress tolerance, mindful awareness, emotion modulation, and values-based decision making to facilitate behavior change (Baumeister, Heatherton, & Tice, 1994;Forman & Butryn, 2015;Shapiro, Carlson, Astin, & Freedman, 2006;Zimmerman, 2000). MABTs have quickly become one of the most frequently used treatments in clinical practice for EDs (Linardon, Fairburn, Fitzsimmons-Craft, Wilfley, & Brennan, 2017) and preliminary evidence supports the efficacy of MABTs for EDs like bulimia nervosa (BN) and binge eating disorder (BED) (Godfrey, Gallo, & Afari, 2015;Katterman, Kleinman, Hood, Nackers, & Corsica, 2014;Linardon, Fairburn, et al., 2017), with recent meta-analyses showing moderate-to-large improvements in primary outcomes (i.e., global eating pathology, remission, and binge eating frequency; (Linardon, Fairburn, et al., 2017). However, Cognitive ...
... MABTs integrate traditional behavioral therapies with psychological strategies such as distress tolerance, mindful awareness, emotion modulation, and values-based decision making to facilitate behavior change (Baumeister, Heatherton, & Tice, 1994;Forman & Butryn, 2015;Shapiro, Carlson, Astin, & Freedman, 2006;Zimmerman, 2000). MABTs have quickly become one of the most frequently used treatments in clinical practice for EDs (Linardon, Fairburn, Fitzsimmons-Craft, Wilfley, & Brennan, 2017) and preliminary evidence supports the efficacy of MABTs for EDs like bulimia nervosa (BN) and binge eating disorder (BED) (Godfrey, Gallo, & Afari, 2015;Katterman, Kleinman, Hood, Nackers, & Corsica, 2014;Linardon, Fairburn, et al., 2017), with recent meta-analyses showing moderate-to-large improvements in primary outcomes (i.e., global eating pathology, remission, and binge eating frequency; (Linardon, Fairburn, et al., 2017). However, Cognitive ...
... MABTs integrate traditional behavioral therapies with psychological strategies such as distress tolerance, mindful awareness, emotion modulation, and values-based decision making to facilitate behavior change (Baumeister, Heatherton, & Tice, 1994;Forman & Butryn, 2015;Shapiro, Carlson, Astin, & Freedman, 2006;Zimmerman, 2000). MABTs have quickly become one of the most frequently used treatments in clinical practice for EDs (Linardon, Fairburn, Fitzsimmons-Craft, Wilfley, & Brennan, 2017) and preliminary evidence supports the efficacy of MABTs for EDs like bulimia nervosa (BN) and binge eating disorder (BED) (Godfrey, Gallo, & Afari, 2015;Katterman, Kleinman, Hood, Nackers, & Corsica, 2014;Linardon, Fairburn, et al., 2017), with recent meta-analyses showing moderate-to-large improvements in primary outcomes (i.e., global eating pathology, remission, and binge eating frequency; (Linardon, Fairburn, et al., 2017). However, Cognitive ...
Article
Objective Although existing research supports the efficacy of mindfulness- and acceptance-based treatments (MABTs) for eating disorders (EDs), few studies have directly compared outcomes from MABTs to standard CBT. Method Participants (N = 44), treatment-seeking adults with bulimia-spectrum EDs, were screened for eligibility, consented, and randomized to receive 20 sessions of outpatient, individual CBT or MABT treatment. Treatment outcomes (binge eating and compensatory behavior episodes, global ED severity, depressive symptoms, quality of life, emotional awareness/clarity, distress tolerance, values-based decision-making, and emotion modulation) were measured at pre-treatment, post-treatment, and 6-month follow up. Data on feasibility and acceptability are also presented. Results Treatment and assessment retention rates were comparable between MABT and CBT (p range = .51–.73) and between-group differences on acceptability measures were very small (d range = 0.03–0.19). Both conditions produced notable and generally comparable changes in most treatment outcomes at post-treatment (within group d range = 0.06–1.77). Discussion The MABT and CBT conditions demonstrated comparable degrees of feasibility, acceptability, and symptom improvement, suggesting that MABTs warrant further evaluation as ED treatments.
... Therefore, this review includes studies investigating treatments with multiple components (e.g., FBT integrated with DBT skills), rather than including only studies of "pure" CBT or DBT. Although multiple thirdwave CBTs have been proposed for eating disorders (e.g., acceptance and commitment therapy), we focus on DBT since it is the most widely studied to-date [24]. Given the diversity in diagnosis, treatment type, treatment setting, study methodology, and outcome measurement, a systematic review was deemed most appropriate to summarize the available data, rather than a meta-analysis, which would have yielded an effect estimate that would have been difficult to interpret given the heterogeneity of the data. ...
... Feasibility and acceptability of the interventions was supported by an acceptable average attrition across three studies (M = 28.3%, range: [23][24][25][26][27][28][29][30][31][32][33][34][35][36][37]) [30,48,49] and high post-treatment patient satisfaction in one study [30]. Effectiveness and efficacy were supported by statistically significant improvements in eating disorder psychopathology from pre-to post-treatment with a large effect size in a study evaluating CBT-E [48], and higher rates of abstinence from binge eating at the end of treatment compared to treatment as usual in a study evaluating an adaptation of CBT for adolescents [30]. ...
... All three studies included follow-up data. Average attrition across studies was 26% (range: [17][18][19][20][21][22][23][24][25][26][27][28][29][30][31], n = 3). Acceptability was further supported by high adolescent satisfaction with treatment [52], a preference for a selfhelp format in adolescents wishing to exclude parents from care, and/or seeking increased flexibility and anonymity [53]. ...
Article
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Background Eating disorders have serious psychological and physical consequences. Current evidence-based treatments for adolescents with eating disorders have modest effects, underscoring the need to improve current treatment approaches. Cognitive behavior therapy (CBT) and dialectical behavior therapy (DBT) have been proposed as alternative treatment options, with burgeoning research in this area. This review aims to summarize and critically analyze the current literature on the feasibility, acceptability, effectiveness, and efficacy of CBT and DBT for adolescent eating disorders, and then proposes areas of future research. Methods PsycINFO and PubMed were searched using the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines to identify studies examining the feasibility, acceptability, effectiveness and/or efficacy of CBT or DBT for adolescent eating disorders. Results Eligible studies ( N = 50; CBT: n = 40, DBT: n = 10) indicated that both treatments are reasonably feasible, acceptable, and possibly effective for adolescent eating disorders across diagnoses and levels of care, though efficacy trials are lacking. Conclusions CBT and DBT demonstrate promise as alternatives to family-based approaches for adolescent eating disorders. Adequately powered trials to establish the effectiveness and efficacy of CBT and DBT are needed, particularly ones that compare these treatments against other leading approaches. Plain English summary Despite high rates of relapse and likelihood for severe and enduring illness, there is a dearth of evidence-based treatment options for adolescents with eating disorders. Potentially viable but less well-studied treatments for adolescents with eating disorders include cognitive behavior therapy (CBT) and dialectical behavior therapy (DBT). This systematic review of CBT and DBT for adolescent eating disorders focuses on feasibility (i.e., how easy it was to implement the treatment), acceptability (i.e., how well the intervention was received by patients and therapists), effectiveness (i.e., how well the intervention performed under routine, real-world circumstances), and efficacy (i.e., how well the intervention performed in highly-controlled research settings). This review concludes that research supports the feasibility and acceptability of these approaches, as well as preliminary evidence of their effectiveness. However, the field is lacking studies that systematically compare CBT and DBT to other evidence-based approaches. Recommendations to advance research on CBT and DBT for adolescent eating disorders are provided, including a call for efficacy studies that clarify their performance compared to other leading approaches.
... 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. ...
Article
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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.
... Dialectical Behaviour Therapy (DBT) for BED and BN was developed in response to patients who do not always benefit from Cognitive Behaviour Therapy (CBT)-focused treatments [62], but this and other third-wave interventions such as acceptance and commitment therapy (ACT), compassion-focused therapy (CFT) and mindfulness have wider potential in the treatment of people with EDs [63]. Their relevance in this context comes from the fact that in contrast to pure CBT which attempts to prevent strong negative emotions being activated, third wave interventions are response-focused [64]: centred around accepting, managing and finding adaptive ways to moderate the experience of strong emotions when they arise. The existing evidence suggests that CBT may be more effective than third wave therapies [63][64][65], but these analyses all focus on a time prior to Covid-19. ...
... Their relevance in this context comes from the fact that in contrast to pure CBT which attempts to prevent strong negative emotions being activated, third wave interventions are response-focused [64]: centred around accepting, managing and finding adaptive ways to moderate the experience of strong emotions when they arise. The existing evidence suggests that CBT may be more effective than third wave therapies [63][64][65], but these analyses all focus on a time prior to Covid-19. Whether third wave, response-focus therapies might be useful at a time when people have limited control over the antecedents of negative emotion is an intriguing query for future researchers. ...
Article
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Objective The Covid-19 pandemic has wrought disruption to everyday life and services, and emerging evidence suggests that those with eating disorders (EDs) are likely to experience marked distress and exacerbation of their symptoms. However, little is known around the most relevant factors to symptom change; whether certain emotion regulation and coping strategies are linked to better outcomes; and how people with EDs are adjusting to psychological interventions moving online. Method In a mixed-method design, we collected qualitative and quantitative data from 207 (76 males) self-selected UK residents with self-reported ED, who described and ranked impacts of the pandemic on their symptoms. Regression analysis examined whether emotion regulation strategies were associated with self-reported symptom change, ED symptomatology, and negative emotional states. Thematic analysis explored participants’ experiences of the pandemic, particularly factors affecting their ED, coping strategies used, and experiences of psychological intervention. Results Most participants (83.1%) reported worsening of ED symptomatology, though factors affecting symptom change differed between specific EDs. Emotion regulation, such as having fewer strategies, poorer emotional clarity, and non-acceptance of emotions, explained nearly half of the variance in emotional distress during the pandemic. Qualitative findings indicated that difficult emotions (such as fear and uncertainty), changes to routine, and unhelpful social messages were triggering for participants during the pandemic. While some participants described employing positive coping strategies (such as limiting social media exposure), many reported using ED behaviours (among other maladaptive strategies, like alcohol use) to cope with the pandemic. Finally, loss of treatment support, feeling underserving of support and experiencing a ‘detached connection’ online were further exacerbating factors for these participants. Discussion While our sample was self-selected and may not represent all people with EDs, our results suggest that people with EDs have been strongly affected by the pandemic. Some aspects of online treatment were found to be beneficial but our findings suggest it also needs some improvement. Our paper discusses implications for online treatment such as taking into account personal circumstances and, in a time where people have limited control over the antecedents of negative emotion, the need to develop skills to manage emotions when they arise.
... Furthermore, given the transdiagnostic nature of emotion dysregulation (Keenan, 2000;Sloan et al., 2017), it might be an effective target for early intervention programs, both for eating disorder prevention and general mental health prevention (see Forbes et al., 2019 for review). A recent metaanalysis on the effectiveness of programs targeting emotion dysregulation (e.g., DBT, mindfulness training) found that these types of programs are effective in reducing eating disorder behaviours among at-risk populations (Linardon et al., 2017). Similarly, experimental studies have shown that using emotion regulation strategies can reduce negative affect as well as eating disorder behaviours (Fitzpatrick et al., 2019;Svaldi et al., 2019), indicating that these strategies could be used to prevent engagement in eating disorder behaviours and provide relief from psychological distress, which typically rises in the early phase of treatment while regular eating and weight is being restored. ...
... Given the growing evidence of intervention programs using emotion dysregulation based interventions among adults with eating disorders (Linardon et al., 2017), and the evidence summarised in this review regarding the role of emotion dysregulation in adolescents with eating disorders, the question remains as to whether these treatments may be similar if not more effective among adolescents. However, at present, the evidence base for such interventions is in its infancy, as outlined in a recent review by Reilly et al. (2020) that found that studies using DBT to treat eating disorders in adolescents were few and limited to small samples. ...
Article
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Background Emotion dysregulation has frequently been theorised as a core component of internalising disorders, including eating disorders. However, it remains unclear at which points in the developmental and aetiological chain emotion dysregulation contributes to eating pathology. The current review synthesises the existing literature and theoretical models of eating disorders to illustrate the role of emotion dysregulation in eating pathology, and the corresponding implications for both theory and treatment. Specifically, the review discusses the implications of including emotional dysregulation in the transdiagnostic model of eating disorders (CBT-E model). Taking a lifespan approach, the review places particular importance on examining adolescence as a key developmental period of emotional turmoil and eating disorder onset. Findings The reviewed literature suggests that emotion dysregulation is an important factor in eating pathology broadly, as well as having associations with multiple specific eating disorder behaviours. Additionally, this review suggests that it is the interplay between emotion dysregulation – a transdiagnostic factor – and weight/shape concerns – an eating disorder-specific factor – that may contribute to the maintenance and potential development of eating disorders. Conclusion This review proposes that emotion dysregulation is a key maintenance factor of eating pathology, and adaptations to reflect this should be considered for the CBT-E model. Furthermore, treatments targeting emotion dysregulation for adolescents and adults represent a promising avenue for further development. Further research should explore the potential of emotion dysregulation as a risk factor proceeding eating disorder development.
... Farstad and colleagues (2016) also concluded that it is important to capitalize on knowledge about personality in the treatment of EDs, for instance, by tailoring treatments based on personality dimensions. In addition, it may be fruitful to examine the effectiveness of treatments on ED symptom remission and well-being specifically targeting personality functioning, such as dialectical behaviour therapy (DBT) and schema therapy [10]. ...
... Achieving things in the own environment is related to environmental mastery (PWB) [3]. Third-wave behavior therapies, such as acceptance and commitment therapy and compassion focused therapy may be especially effective in promoting mental health because they target these responsefocused emotion regulation strategies by fostering acceptance, mindfulness, metacognition, psychological flexibility, and reducing experiential avoidance [10]. ...
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Purpose Personality functioning is strongly linked to well-being in the general population. Yet, there is a lack of scientific knowledge about the pathways between personality trait facets and emotional, psychological and social well-being in ED patients. The general aim was to examine potential associations between maladaptive personality trait facets and the three main dimensions of well-being. Methods Participants were 1187 female eating disorder patients who were referred for specialized treatment. Patients were diagnosed with anorexia nervosa (31.7%), bulimia nervosa (21.7%), binge eating disorder (11%) and other specified eating disorders (35.5%). The Personality Inventory for the DSM 5 (PID-5) was used to measure 25 trait facets, and well-being was measured with the Mental Health Continuum Short Form (MHC-SF). Multiple hierarchical regression analyses were applied to examine potential associations between personality and well-being while controlling for background and illness characteristics. Results Personality trait facets led to a statistically significant increase of the explained variance in emotional (38%), psychological (39%), and social well-being (26%) in addition to the background and illness characteristics. The personality trait facets anhedonia and depression were strongly associated with all three well-being dimensions. Conclusion Personality traits may play an essential role in the experience of well-being among patients with EDs. To promote overall mental health, it may be critical for clinicians to address relevant personality trait facets, such as anhedonia and depression, associated with well-being in treatment. Level of evidence Level V, cross-sectional descriptive study.
... BN: SMD = 0.07, 95% CI: -0.10-0. 24). An additional subgroup analysis examined whether age made any difference to treatment effect (Fig. 6B). ...
... Second, ve studies in this meta-analysis were considered as having a high risk of bias because of their random sequence generation. Third, to identify potential factors that could cause interference, more detailed patient information is needed, such as session, gender, and the number of patients that dropped out of treatment [24]. Given the lack of this type of data, we could not perform subgroup analysis; yet, these factors could have an impact on the results. ...
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Purpose: Interpersonal psychotherapy (IPT) has been proposed as a treatment strategy for eating disorders (EDs). However, cognitive behavioral therapy (CBT) is the treatment more effectively and widely used than IPT. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to compare the effectiveness of IPT versus CBT on EDs. Methods: We systematically searched PubMed, Embase, Medline, Cochrane, Web of Science, and the Clinical Trials Database for RCTs that compared IPT and CBT. Results: Of 468 studies initially identified, 10 were suitable for incorporation into our meta-analysis (N = 833 participants). In those studies, IPT and CBT had comparable effects in terms of primary outcome (i.e., ED score) (SMD = 0.08), while IPT had a better effect in terms of secondary outcome (i.e., Inventory of Interpersonal Problems) (SMD = 0.32) than CBT. Compared with CBT, IPT had a better treatment effect for ED populations with lower Body Mass Index (SMD = 0.27) and age (SMD = 0.43). IPT and CBT both had follow-up effects of pre-test and follow-up comparison after fewer than 6 months (SMD = 1.61, 1.83), 6–12 months (SMD =1.48, 1.65), and more than 12 months (SMD = 1.29, 1.33). At the same time, only CBT showed a dose-response relationship trend (β = 0.017, p = 0.067). Conclusion: The meta-analysis provided clear evidence that IPT is an effective treatment measure for patients with EDs. This review also suggested that future research is needed to determine the effects of IPT in the treatment of EDs. Level of evidence Level I, systematic review and meta-analysis.
... Given the promise of MABTs, an increasing number of researchers are evaluating treatment approaches that combine traditional behavioral treatment recommendations with mindfulness and acceptance-based skills in an effort to improve outcomes for individuals with binge eating. Though research is nascent and results variable, preliminary evidence suggests such treatments are efficacious (Godfrey, Gallo, & Afari, 2015;Katterman, Kleinman, Hood, Nackers, & Corsica, 2014;Linardon, Fairburn, Fitzsimmons-Craft, Wilfley, & Brennan, 2017). In addition to the growing research interest, MABTs have quickly become one of the most frequently used treatments in clinical practice for individuals with binge eating (Linardon et al., 2017). ...
... Though research is nascent and results variable, preliminary evidence suggests such treatments are efficacious (Godfrey, Gallo, & Afari, 2015;Katterman, Kleinman, Hood, Nackers, & Corsica, 2014;Linardon, Fairburn, Fitzsimmons-Craft, Wilfley, & Brennan, 2017). In addition to the growing research interest, MABTs have quickly become one of the most frequently used treatments in clinical practice for individuals with binge eating (Linardon et al., 2017). The conceptual fit, preliminary efficacy, and widespread clinical use of MABTs for binge-eating spectrum disorders support the need for additional research on these approaches. ...
Article
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Outcomes from cognitive behavioral therapy for binge‐eating spectrum disorders are suboptimal, possibly due in part to deficits in self‐regulation (i.e., the ability to control behavior in pursuit of long‐term goals despite internal challenges). Mindfulness and acceptance‐based treatments (MABTs) integrate behavioral treatment with psychological strategies designed to enhance self‐regulation, yet little is known about how and for whom they are effective. The present study will utilize the multiphase optimization strategy to identify which of four MABT components (mindful awareness, distress tolerance, emotion modulation, values‐based decision making) to include in a fully powered clinical trial. Participants (n = 256) will be randomized to 16 sessions in one of 16 conditions, each a different combination of MABT components being included or excluded from a base behavioral treatment. Our primary aim is to evaluate each component's independent efficacy on disordered eating symptoms. Our secondary aims are to confirm each component's target engagement (i.e., whether each component improves the targeted variable and outcomes), and test that each component's efficacy is moderated by baseline weaknesses in the same component (e.g., that participants with poor distress tolerance at baseline benefit most from the distress tolerance component). Our exploratory aim is to quantify the component interaction effects.
... To date, three meta-analyses have analysed the efficacy of third-wave therapies for EDs [25][26][27]. The metaanalysis (n = 9) by Lenz et al. (2014) examined the efficacy of DBT for individuals with EDs and co-occurring depressive symptoms. ...
... It is therefore reasonable to assume differential effects of any given treatment on AN, BN and BED. Indications of this can be seen in Linardon et al. (2017). However, since many of the studies in children and adolescents were based on transdiagnostic samples (n = 7), and the sample sizes were too small to conduct sub-analyses for each diagnosis, the results largely refer to the efficacy of DBT on the general category of ED. ...
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Context Third-wave therapies have demonstrated efficacy as a treatment option for EDs in adulthood. Data on the suitability for EDs in adolescence are lacking. Objective To estimate the efficacy of third-wave interventions to reduce ED symptoms in adolescents in randomized controlled trials (RCTs) and uncontrolled studies. Data sources We systematically reviewed the databases PubMed (1976-January 2021), PsycINFO (1943-January 2021), and the Cochrane database (1995-January 2021) for English-language articles on third-wave therapies. References were screened for further publications of interest. Study selection RCTs and pre-post studies without control group, comprising patients aged 11–21 years (mean age = 15.6 years) with an ED diagnosis (anorexia nervosa, bulimia nervosa, binge eating disorder, eating disorder not otherwise specified) investigating the efficacy of third-wave psychological interventions were included. Efficacy had to be evaluated according to the Eating Disorder Examination or Eating Disorder Examination-Questionnaire, the Eating Disorder Inventory-2, the Eating Disorder Inventory-3, or the Structured Interview for Anorexic and Bulimic Disorders for DSM-IV and ICD-10. The outcome assessed in the meta-analysis was the EDE total score. Data extraction Independent extraction of data by two authors according to a pre-specified data extraction sheet and quality indicators. Data synthesis We identified 1000 studies after removal of duplicates, assessed the full texts of 48 articles for eligibility, and included 12 studies with a total of 487 participants (female 97.3%/male 2.6%) in the qualitative synthesis and seven studies in the meta-analysis. Articles predominantly reported uncontrolled pre-post trials of low quality, with only two published RCTs. Treatments focused strongly on dialectical behaviour therapy ( n = 11). We found moderate effects of third-wave therapies on EDE total score interview/questionnaire for all EDs (d = − 0.67; z = − 5.53; CI95% = − 0.83 to − 0.59). Descriptively, the effects appeared to be stronger in patients with BN and BED. Conclusion At this stage, it is not feasible to draw conclusions regarding the efficacy of third-wave interventions for the treatment of EDs in adolescence due to the low quality of the empirical evidence. Since almost all of the identified studies used DBT, it is unfortunately not possible to assess other third-wave treatments’ efficacy.
... Other psychosocial therapies, such as Acceptance and Commitment Therapy, Interpersonal Therapy, or Nutritional Counselling have been effective in treating bulimia nervosa and binge-eating disorder (Chavez & Insel, 2007). Third-wave behavior therapies such as Dialectical Behavior Therapy, Schema Therapy, Compassion-focused therapy, Mindfulness-based interventions, Acceptance, and Commitment Therapy have also been considered to be an efficacious treatment for eating disorders (Linardon, Fairburn, Fitzsimmons-Craft, Wilfley, & Brennan, 2017). Further, the treatment of severe eating disorders may be extreme that even intensive therapeutic support is not sufficient. ...
Thesis
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Eating disorder has been comprehensively reported in different contexts. Assuming it can also exist in the Philippine context, the exponential in data, from another context, suggests that if eating disorders are not addressed, this can be alarming to the society that an illness could lead to its fatality. Online treatments are widely accepted as a first step in treating eating disorders. This study included four non-sequential phases divided into two aspects: (1a) descriptive; (2a) qualitative; (3b) design; and (4b) evaluation. The study was guided by the Self-Affirmation Theory and Theory of Planned Behavior. The baseline in developing a mobile-based prevention program was explored and enriched for future development. Results indicated that the mobile-based application would be highly feasible and acceptable to both symptomatic individuals and clinicians; and the suggested improvements were noted. The study aims to increase awareness of eating disorders in the Philippines. Recommendations concerning the methodology, psychological program, and technical improvements, and program compliance were discussed.
... Well-being therapy addresses all six aspects of PWB (Fava et al., 1998;Fava et al., 2005;Radstaak et al., 2020). Outcome studies show that these so-called third-wave behavioural treatments effectively alleviate symptoms in ED patients (Linardon et al., 2017). However, little is known about whether these treatments help to improve patients overall mental health. ...
Article
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Objective: Psychometric network analysis has led to new possibilities to assess the structure and dynamics of psychiatric disorders. The current study focuses on mental health networks in patients with anorexia nervosa, bulimia nervosa, binge eating disorder and other specified eating disorders (EDs). Method: Network analyses were applied with five mental health domains (emotional, psychological and social well-being, and general and specific psychopathology) among 905 ED patients. Also, networks of 36 underlying symptoms related to the domains were estimated. The network stability, structure and (bridge) centrality of the nodes were assessed for the total group and each ED type. Network differences between the ED types were also examined. Results: ED psychopathology was only weakly connected with the well-being domains. Psychological well-being was the most central node in the domain network. The most central nodes in the symptom network were feeling depressed, feeling worthless, purpose in life and self-acceptance. Bridge symptoms between well-being and psychopathology were self-acceptance, environmental mastery, interested in life and feeling depressed. There were no network differences between the ED types in both the domain and symptom networks. Conclusions: This study shows novel associations between well-being and psychopathology in ED patients. Central domains and their underlying symptoms may be especially important to consider in treatment for promoting mental health in ED patients.
... As a result of being aware of the meaning of one's own feelings, new sides of the self are revealed. These processes are supported by recent studies on third-wave therapies, which argue for targeting emotion regulation strategies in eating disorders (Linardon et al., 2017). Interventions where concealed and undisclosed feelings are verbalized in therapeutic processes are important and have been highlighted in previous studies on ED (Rørtveit & Severinsson, 2012). ...
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Introduction We developed a group program for patients with binge eating disorders (BED), comprising cognitive therapy, affect consciousness, and therapeutic writing. We wished to investigate how therapeutic writing and affect consciousness were experienced by the patients when integrated in a cognitive behavioral therapy (CBT) program. To our knowledge, such an intervention has not been tried in patients with BED. Aim: To explore patients’ experience of attending a binge eating group program comprising therapeutic writing, affect consciousness, and CBT. Research question: How do patients evaluate their experience of attending an integrative binge eating group program? Method: A qualitative design using an evaluative focus group interview with participants (four women and two men) who had completed the pilot program. Results: Three themes emerged: Enhanced self-awareness about the meaning of feelings; A more generous attitude towards oneself; and On the path to a better grip on the eating difficulties. Discussion: We interpreted the three themes in light of transition processes. The program was described as an essential part of the healing process and seems valuable for enabling new approaches leading to therapeutic changes when suffering from BED.
... Several small trials, mainly in binge eating disorder, were done to examine efficacy in terms of remission. A meta-analytical review showed that these treatments were not superior to comparison treatments (such as CBT) in terms of reduction of binge eating (Linardon et al., 2017). Other promising treatments include integrative cognitive-affective therapy for bulimia nervosa (Wonderlich et al., 2014). ...
... 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]. ...
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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. ...
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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.
... Moreover, our data are in line with recent literature, which suggests that using flexible interventions based on the history of patients that includes specific psychological techniques may improve maladaptive schema or behavioural responses (J. Linardon, Fairburn, et al., 2017;Todisco et al., 2020). ...
Article
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The research into emotional regulation in eating disorders (EDs) has shown specific impairments and maladaptive coping strategies in patients, and there is an increasing interest in the role of the emotional domain in the treatment outcome. This study aims to evaluate the effect of a specialized inpatient treatment characterized by both an intensive and comprehensive standardized multidisciplinary program based on cognitive–behavioral therapy and a flexible and personalized component implemented by third-wave interventions. A cohort of 67 female ED patients (anorexia nervosa = 28, bulimia nervosa = 28, and binge eating disorder = 11) underwent an evaluation of emotional regulation difficulties, alexithymia, and dissociative symptomatology at admission to a specialized ED ward. The psychological modifications were subsequently re-evaluated upon discharge, after an inpatients treatment of 60 days, examining specific changes in the specific psychopathology. A significant improvement after specialized ED treatment was shown in alexithymia, emotional regulation difficulties, and dissociation symptoms, with higher effect sizes in patients with higher alexithymia scores. As regards the specific effect of the psychological improvement, changes into alexithymia scores have shown specific correlations with ED psychopathology (p < 0.010) and with difficulties in emotional regulation (p < 0.010) in patients with higher alexithymia levels at admission. Emotional regulation and dissociation should therefore be evaluated in ED patients and may be improved with specific therapeutic approaches, while alexithymia remains a clinical trait, even with a significant reduction.
... 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]. ...
Article
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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.
... Individuals with BN have demonstrated enhanced reactivity in brain regions associated with the striatal approach system (e.g., nucleus accumbens, caudate, orbitofrontal cortex) and decreased reactivity in regions associated with the limbic threat system (e.g., amygdala) [17][18][19][20][21][22] during exposure to food cues, further supporting the premise that aspects of binge eating (and, potentially, purging) are associated with the processing of desirable affective states. Because binge eating and purging as well as related cues have been shown to be associated with positive reinforcement by increases in positive affect (and activity in the approach network) and negative reinforcement through reduction of negative affect (and decreased activity in the threat network), evidence-based behavioral treatments of BN have generally focused on immediate precipitants and consequences of these behaviors [23]. However, given that the majority of individuals with BN (~75%) plan some or most of their binge-eating and purging episodes [16,24], the rewarding effects of these behaviors may also occur long before the occurrence of the behavior during the distal anticipation stage, which is not emphasized in current models of BN. ...
Article
The purpose of this investigation is to identify the anticipatory reward mechanisms that maintain binge eating and purging in bulimia nervosa. Emerging data indicate the importance of reward and anticipatory processes as maintenance mechanisms of bulimia nervosa that can be targeted in treatment. The proposed research will identify neurobiological and psychological anticipatory mechanisms of binge eating and purging using functional magnetic resonance imaging (fMRI), and ecological momentary assessment (EMA) in the natural environment. In this investigation, 60 adults (30 with bulimia nervosa and 30 matched comparison participants) will undergo negative and positive mood inductions followed by an fMRI food selection task (and a comparison shopping task) to examine neurobiological and affective responses to food and non-food reward anticipation. Participants with bulimia nervosa will complete two weeks of EMA examining real-time affect changes in relation to the anticipation of binge eating and purging. These methods will facilitate rigorous assessment of the links between neurobiological (fMRI) and naturalistic (EMA) data in anticipatory reward processes. Findings from this investigation will inform the conceptualization and treatment of bulimia nervosa by identifying the role of reward anticipation in symptom maintenance, providing a crucial framework for targeting these anticipatory processes in existing and novel interventions.
... 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. ...
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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. ...
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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.
... 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. ...
Article
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Cognitive, psychodynamic, and phenomenological scholars converged their attention on abnormal bodily phenomena as the core psychopathological feature of eating disorders (EDs). While cognitive approaches focus their attention on a need for “objective” (i.e., observable, measurable) variables (including behaviours and distorted cognitions), the phenomenological exploration typically targets descriptions of persons’ lived experience. According to a new emerging phenomenological perspective, the classic behavioural and cognitive symptoms of EDs should be considered as epiphenomena of a deeper core represented by a disorder of the embodiment. The cognitive–behavioural model is the most studied and, up till now, clinically efficacious treatment for EDs. However, as any coherent and scientifically grounded model, it presents some limitations in its application. Numerous patients report a chronic course, do not respond to treatment and develop a personality structure based on pathological eating behaviours, since “being anorexic” becomes a new identity for the person. Furthermore, the etiopathogenetic trajectory of EDs influences the treatment response: for example, patients reporting childhood abuse or maltreatment respond differently to cognitive-behavioural therapy. To obtain a deeper comprehension of these disorders, it seems important to shift attention from abnormal eating behaviours to more complex and subtle psycho(patho)logical features, especially experiential ones. This characterisation represents the unavoidable premise for the identification of new therapeutic targets and consequently for an improvement of the outcome of these severe disorders. Thus, the present review aims to provide an integrated view of cognitive, psychodynamic, and phenomenological perspectives on EDs, suggesting new therapeutic targets and intervention strategies based on this integrated model. Level of Evidence: Level V. Level of evidence Level V: Opinions of authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.
... Hence, treatment aims to address the urge to binge as well as weight loss. Currently, binge eating is primarily managed with psychological therapy, either CBT or structured self-help (Linardon et al. 2017, Vocks et al. 2010. Lisdexamfetamine (LDX), a pro-drug of amphetamine, is the only drug approved by the Food and Drug Administration (FDA) for the treatment of moderate to severe BED in adults. ...
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Background: The prevalence of the three main eating disorders (EDs) anorexia nervosa (AN), bulimia nervosa (BN) and binge eating disorder (BED) is increasing, and a growing number of patients with EDs is seeking professional help. Thus, there is a need for additional treatment strategies in EDs. The aim of this review was to summarize the literature on the benefits and risks of music as well as the evidence for its therapeutic application in people with EDs. Methods: Following the PRISMA guidelines, we performed a systematic literature review on scientific studies on the effect of music in people with or at risk for EDs using PubMed and the Web of Science database. The search terms used were: "music", "music therapy", "eating disorders", "anorexia nervosa", "bulimia nervosa" and "binge eating disorder". Results: 16 out of 119 identified and screened articles qualified as scientific studies involving a total of 3,792 participants. They reported on the use of music or music therapy in individuals with or at risk of AN and BN, but not BED. In inpatients with AN, listening to classical music was beneficial to food consumption. Singing in a group reduced post-prandial anxiety in AN inpatients and outpatients. Vodcasts which also included positive visual or autobiographical stimuli helped BN patients with anxiety and body image perception. Songwriting and sessions with a Body Monochord helped with the processing of therapeutically relevant topics in AN. Watching music videos, however, reinforced body dissatisfaction, drive for thinness, bodyweight concerns, preoccupation with physical appearance in pre-teenage and teenage girls, and drive for muscularity in adolescent boys. Conclusions: These findings suggest that the therapeutic application of music may be beneficial in patients with AN and BN. However, the availability of studies with a rigorous randomized controlled trial (RCT) design is scarce.
... These findings have important implications for clinical practice, where treatment approaches that directly target emotion dysregulation are increasingly implemented (Reilly et al., 2020). While dialectic behavioral therapy has been increasingly used to treat BN and BED (Linardon, Fairburn, Fitzsimmons-Craft, Wilfley, & Brennan, 2017), our findings highlight the potential utility of considering emotion dysregulation when high levels of fasting are present, independent of diagnostic group. Furthermore, the findings from the current study have important implications for theoretical models. ...
Article
Objective Emotion dysregulation is proposed as a key factor within eating disorder pathology. However, less is known about specific emotion regulation difficulties experienced by adolescents with varying levels of eating disorders symptoms. The present study examined the relationship between eating disorder behaviors and specific facets of emotion dysregulation, and differences in emotion dysregulation between eating disorder diagnostic groups. Method Participants were 2,783 adolescents, 11–19 years (M = 14 years, 9 months, SD = 1 year, 6 months), who completed self-report measures as part of the EveryBODY study. Adolescents were identified as not having eating disorder symptoms (n = 2,122) or meeting diagnostic criteria for symptoms of specific eating disorder, including: anorexia nervosa or atypical anorexia nervosa (n = 57), bulimia nervosa (n = 136), binge-eating disorder (n = 57), other specified feeding or eating disorder characterized by binge eating or purging (n = 381), and unspecified feeding or eating disorder (n = 30). Results Binge eating, driven exercise, and fasting were each uniquely associated with emotion dysregulation, whereas purging was not. Similar findings were obtained within specific domains of emotion dysregulation. Findings from diagnostic groups showed a significant main effect of diagnosis on overall emotion dysregulation and most domains of emotion dysregulation. Adolescents with eating disorder symptoms consistently reported higher emotion dysregulation compared to those without these symptoms. Discussion Findings indicate that emotion dysregulation is a key factor across eating disorder pathology, and potential treatment target across the spectrum of eating disorder diagnoses in adolescents.
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Background: The Renfrew Unified Treatment for Eating Disorders and Comorbidity (UT) is a transdiagnostic, emotion-focused treatment adapted for use in residential group treatment. This study examined the effect of UT implementation across five years of treatment delivery. Methods: Data were collected by questionnaire at admission, discharge (DC), and 6-month follow-up (6MFU). Patient outcomes were measured by the Eating Disorder Examination-Questionnaire, Center for Epidemiologic Studies-Depression Scale, Brief Experiential Avoidance Questionnaire (BEAQ), Anxiety Sensitivity Index, and Southampton Mindfulness Scale. Data were analyzed for N = 345 patients treated with treatment-as-usual (TAU), and N = 2,763 treated with the UT in subsequent years. Results: Results from multilevel models demonstrated a significant interaction between implementation status (TAU vs. UT) and time, both linear and quadratic, for the depression, experiential avoidance, anxiety sensitivity, and mindfulness variables. Patients treated with the UT showed more improvement in these variables on average, as well as more rebound between DC and 6MFU. Results from multilevel models examining eating disorder outcome showed no significant difference between the TAU and UT for the full sample, but a significant three-way interaction indicated that the UT produced more improvement in the EDE-Q relative to the TAU particularly for patients who entered treatment with high levels of experiential avoidance (BEAQ score). Conclusion: This long-term study of a transdiagnostic, evidence-based treatment in residential care for eating disorders and comorbidity suggests implementation was associated with beneficial effects on depression and emotion function outcomes, as well as eating disorder severity for patients with high levels of baseline emotion regulation problems. These effects did not appear to diminish in the 5 years following initial implementation.
Chapter
Eating disorders and obesity have many characteristics in common. In both, weight-related problems play a central role. There is growing interest in identifying their common risk factors, and research shows that unhealthy weight-control behaviors are common antecedents to both obesity and eating disorders. There are currently interventions available that have shown some efficacy, with variability depending on the disorder under consideration. The incorporation of technological resources such as virtual reality, information and communication technologies, and games with physical activity, allows for even higher levels of efficacy, as shown by the randomized controlled studies that have been conducted to date. The available evidence, therefore, permits to recommend this type of applications. Future research must be focused not only on the treatments that are offered once these problems have emerged but also on preventing them.
Article
Body image flexibility refers to the ability to openly experience thoughts or feelings about the body without acting on them or trying to change them. Accumulating evidence has demonstrated that body image flexibility is connected to numerous adaptive processes, and that it is sensitive to change during psychological interventions. However, a quantitative synthesis of empirical research on body image flexibility is lacking. We conducted the first meta-analysis on body image flexibility and its correlates. Sixty-two studies were included. Random effects meta-analyses were conducted on 19 psychological correlates, divided into three clusters: eating and body image disturbances, positive body-related and general psychological constructs, and general psychopathology. Meta-analyses showed inverse correlations between body image flexibility and each construct within the eating and body image disturbances cluster (rs= −.45 to −.67), and the general psychopathology cluster (rs= −.37 to −.58). Body image flexibility was positively associated with each positive psychology construct (rs = .23 – .58). Men reported higher levels of body image flexibility than women (d = 0.32). Psychological interventions were more effective than control groups at enhancing body image flexibility in randomized controlled trials (d = 0.42). Findings confirm that body image flexibility is consistently connected to indices of mental health, and that it can be enhanced during psychological interventions.
Article
This study explored how practicing psychologists make sense of the athletic-body ideal when internalised by their clients. Utilising a grounded theory approach, we interviewed a purposive sample of nine psychologists to explore their understanding of the athletic-body ideal, with a specific focus on diagnostic classification and treatment. Following grounded theory analysis, results indicated the psychologists tended to associate the athletic-body ideal pursuit with positive psychological and physical benefits when it encompasses balance and flexibility. They also perceived healthy or protective factors inherent in the pursuit of the athletic-body ideal. However, the psychologists perceived that when the pursuit is obsessive-compulsive and rigid, functioning will be compromised. Moreover, the psychologists associated eating disorders (such as restrictive eating) and compulsive exercise with pathological athletic-body ideal pursuits. These findings suggest complexity in athletic-body ideal presentation across the languishing and flourishing continuum.
Article
Obesity is often associated with mental comorbidity in adults, likely impacting on weight loss success and can indicate treatment that is not covered by the standard program of multimodal behavioral weight loss (BWL) treatment. Using the example of binge-eating disorder (BED) as a frequent comorbid condition, this article discusses current research on the etiology and interventions in cases of comorbidity in order to derive implications for research and treatment. Cognitive-behavioral therapy (CBT), the best established form of treatment for adults with BED, was more efficacious than BWL treatment in improving binge-eating symptomatology, while tending to show lower weight loss effects and only in the short term. Therefore, further development of interventions should focus on gradual adaptations of CBT for improving weight loss in patients with obesity and BED. These interventions could be adapted from BWL treatment and aim at a slight weight loss. Parallel or sequential combinations of these treatments have not consistently demonstrated improved treatment effects. Interventions based on the results of current research on the comorbidity of both disorders could be included on an individual basis in order to enhance the efficacy for eating disorder symptomatology and body weight. New digital treatment modalities could support the transfer into daily life and boost the long-term sustainability of therapeutic gains. These modifications regarding adaptive CBT for adults with obesity and BED should be based on an individual treatment rationale and require confirmation by further experimental treatment research.
Article
There is increasing interest in the potential efficacy of meditation-based mind-body interventions (MBIs) within mental health care. We conducted a systematic meta-review of the published randomized control trial (RCT) evidence. MEDLINE/PubMed, PsycARTICLES and EMBASE were searched from inception to 06/2020 examining MBIs (mindfulness, qigong, tai chi, yoga) as add-on or monotherapy versus no treatment, minimal treatment and passive and active control conditions in people with a mental disorder. The quality of the methods of the included meta-analyses using A Measurement Tool to Assess Systematic Reviews (AMSTAR) and the methodological quality of the RCTs using AMSTAR-Plus. Sixteen (94%) of 17 meta-analyses had good overall methodological quality. The content validity of the included RCTs was considered good in 9 (53%) meta-analyses. In meta-analyses with good methodological quality (AMSTAR 8≤) and content validity (AMSTAR+ 4≤), large effect sizes (0.80 or higher) were observed for mindfulness in schizophrenia and in ADHD, a moderate (0.50≤0.80) effect size for mindfulness in PTSD and a small (0.20<0.50) effect size for yoga in schizophrenia No serious adverse events were reported (n RCTs =43, n in the MBI arms=1774), while the attrition rates were comparable with the rates in passive and active control conditions. Our meta-review demonstrates that mindfulness and to a lesser extent yoga may serve as an efficacious supplement to pharmacotherapy, and psychotherapy and can be complementary in healthy lifestyle interventions for people with mental disorders. Meta-analytic evidence of high methodological quality and content validity of included trials is currently lacking for qigong and tai chi.
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This is a cross-sectional study comparing adolescents diagnosed with anorexia nervosa (AN), those in the remission period of the disease and adolescents without any psychiatric disease, in terms of perfectionism, rumination, emotion regulation and mindfulness skills. Additionally, the relationship of these variables with symptoms of eating disorders, symptoms of depression and anxiety was evaluated. Seventy six adolescents between the ages 12-18 were enrolled in the study, 20 in AN group, 16 in remission group and 40 in healthy control group that matched for age, gender and socioeconomic-sociocultural level. Schedule for Affective Disorders and Schizophrenia for School Age Children- Present and Lifetime Version (K-SADS-PL) was use to confirm previous and current AN disease in research group and to exclude any psychiatric disease in healthy control group. All adolescents completed Eating Disorder Examination Questionnaire –EDE-Q, Five Facets Mindfulness Questionaire-FFMQ, The Difficulties in Emotion Regulation Scale –DERS, Body Image Satisfaction Questionnaire –BISQ,Frost Multidimensional Perfectionism Scale - FMPS, Ruminative Response Scale Short Version – RRS-SV. Additionally, Beck Depression Inventory (BDI), Screen for Child Anxiety and Related Disorders (SCARED) were used. As a result, it was shown that adolescents with AN had higher eating disorder severity, had more emotional regulation difficulties, perfectionism, brooding thinking and had less mindfulness skills, thus when scale scores were corrected according to depression and anxiety levels, only the difference in eating disorder symptom severity showed significance. While dissatisfaction from body areas in the AN group was predictive of eating disorder symtoms, difficulties in emotion regulation were predictive of mindfulness. When the whole sample was evaluated, it was determined that dissatisfaction from body areas and depressive symptoms were predictive of eating disorder symptoms, and emotion regulation difficulties and perfectionism were predictive of midfulness skills.
Article
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.
Article
Mindfulness is a two-component skill that includes mindful awareness (attentional monitoring of present moment experience) and mindful acceptance (adopting an attitude of acceptance toward this experience). Although mindfulness-based interventions (MBIs) are efficacious for many conditions, there is a lack of research on MBIs for eating disorders (EDs). We propose that MBIs may be promising for EDs given their potential to mobilize not one, but multiple associative-learning change mechanisms in EDs–defined as adaptive processes of change involving one of two forms of associative-learning: Pavlovian and operant learning. We hypothesize how MBIs–via increasing either mindful awareness or mindful acceptance–may mobilize up to eight associative-learning change mechanisms, two involving Pavlovian learning, and six involving operant learning. We also elaborate on similarities and differences between MBIs and CBT approaches for EDs, as well as opportunities for synergy. Finally, we present recommendations for future research related to the development and evaluation of novel MBI interventions for EDs and the testing of mechanisms and patient-treatment matching hypotheses.
Article
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.
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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.
Article
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.
Article
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.
Article
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.
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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.
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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.
Article
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.
Article
The efficacy of individual CBT for eating disorders can be assessed by investigating the potential predictors, mediators, and moderators of treatment. The present review focused on personality since its crucial role has been emphasized both by research and practice. Sixteen studies were collected, and data were extracted through a highly operationalized coding system. Overall, personality disorders were the most investigated construct; however, their influence was somewhat contradictory. A more cogent result occurred for Borderline Personality Disorder (BPD) when considered as a moderator (not a predictor, nor a mediator). Patients with a more disturbed borderline personality benefited to a greater extent from treatments including booster modules on affects, interpersonal relationships, and mood intolerance, rather than symptoms exclusively. Nine additional personality dimensions, beyond BPD, were investigated sparsely, and results regarding them were barely indicative in this review. However, some of these dimensions (e.g., affective lability and stimulus‐seeking behaviors) could be traced back to BPD, thereby strengthening evidence of the role of borderline disorder as a moderator. Although research on the relationship between personality and eating disorders needs to be increased and methodologically improved, personality, taken as a whole, emerged as a promising variable for enhancing the efficacy of CBT.
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Eating disorders (ED) are defined as specific and severe alterations in food intake, observed in people who present distorted patterns in the act of eating and are characterized by either overeating or stopping do it. Contextual or third generation therapies are being used to treat eating disorders, their objective is to modify the way in which people relate to their thoughts about weight, their physical appearance and eating, to favor the processes of acceptance and cognitive flexibility. The objective of this study is to review the current panorama of contextual or third generation therapies as therapeutic intervention in eating disorders, selecting for their development of adaptations and specific processes in eating disorders, Dialectical Behavioral Therapy (DBT) and Dialectical Behavioral Therapy (DBT), Acceptance and Commitment (ACT) and also including in the review, the Mindfulness-based Conscious Eating Program (MB EAT). We consider that DBT has shown greater affective stabilization, improvement in levels of depression and anxiety, reduction of binge eating and greater adherence to treatment. ACT has been shown to be effective in binge-eating behavior and body dissatisfaction caused by cognitive inflexibility. MB EAT has achieved utility by creating greater acceptance and flexibility in the act of eating, recognizing signs of hunger and satiety, in addition to demonstrating reduction of compulsive eating and mindfulness in eating. More studies are necessary, especially with ACT and MB-EAT, to achieve a higher level of evidence.
Chapter
In this chapter, two DSM-V eating disorders (EDs) associated with binge eating are reviewed. Both bulimia nervosa (BN) and binge eating disorder (BED) are disorders of overeating and share significant overlap in etiology, presentation, and treatment. The primary focus of this chapter is BED; however, elements of BN and its relevance to overeating are also explored. For treatment, the psychotherapy literature suggests utilizing cognitive behavior therapy (CBT)-informed approaches to challenge the mechanisms and behavior that maintain BED and BN, with a further emphasis on reducing emotion dysregulation and increasing mindfulness. There are several medications with emerging evidence including selective serotonin reuptake inhibitors (SSRIs), other antidepressants, some antiepileptics, and some anti-obesity medications. The nuances associated with treating BED and BN in the context of obesity are further discussed. General treatment recommendations for both disorders are provided.
Article
Accumulating evidence suggests that the presence of shape/weight overvaluation in binge-eating disorder (BED) is associated with more severe psychopathology and impairment. To further inform the role of the overvaluation construct in BED, we examined whether those with and without shape/weight overvaluation differ on four core processes that underpin the contextual behaviour therapies: distress tolerance, self-compassion, mindfulness, and experiential avoidance. These four processes were investigated as each are considered important change mechanisms in contextual behavioural therapies and are either compatible or incompatible with the emotion dysregulation known to precipitate binge eating. Participants were categorized into one of four study groups: probable BED with overvaluation (n = 60); probable BED without overvaluation (n = 108); obese control (n = 59); healthy control (n = 123). Analyses of covariance showed that the probable BED with overvaluation group reported lower levels of self-compassion and distress tolerance, and higher levels of experiential avoidance than the three other groups. The probable BED without overvaluation group did not differ to control groups on these processes, except experiential avoidance levels. Findings highlight potentially important intervention targets and constructs among a subgroup of individuals with BED.
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Anahtar kelimeler: Yeme bozukluğu, aile odaklı terapi, farkındalık terapisi, diyalektik davranış terapisi Keywords: Eating disorders, family-based therapy, mindfulness-based therapy, dialectical behavior therapy Öz Yeme bozuklukları, bireylerin bedenlerine yönelik çarpıtılmış algılarını ve düzensiz yeme alışkanlıklarını içeren bir tanı grubudur. Çeşitli tıbbi sorunları beraberinde getiren yeme bozukluğunda tamamen iyileşmenin güç olduğu ve yüksek oranlarda hastalığın tekrarladığı bilinmektedir. Erken tanı ve tedavinin öneminin sıkça vurgulandığı yeme bozukluklarında uygulanan tedavi yönteminin etkililiği ve tanıya uygunluğu da oldukça önemlidir. Bu nedenle, günümüzde pratikte de yaygınlaşan güncel psikoterapi yaklaşımlarının yeme bozuklukları alt türleri ile nasıl çalışılabileceği, psikolojik sağlık hizmeti veren uzmanlar tarafından buna dair bilgilerin öğrenilmesi ve değerlendirilmesi önemli bir konudur. Bu derleme çalışmasında, yaygın yeme bozukluğu tanılı bireylerle çalışılırken dikkate alınması gereken güncel terapi yaklaşımları aktarılmıştır. Aile odaklı terapi, farkındalık temelli terapiler ve diyalektik davranış terapisinin yeme bozukluğu olgularıyla çalışma yöntemleri, başlıca teknikleri ve terapi hedefleri üzerinde durulmuştur. Ayrıca, bu yaklaşımların etkililiği incelendiğinde alanyazındaki etkililik çalışmalarının hem sayıca hem de yöntemsel kısıtlılıkları göze çarpmıştır. Buna rağmen bu yöntemlerin farklı uygulamalar içermeleri ve yeme bozukluğu belirtilerini azaltmaları yönünden tercih edilebilir yaklaşımlar olduğu düşünülmüştür. Family-Based Therapies, Mindfullnes-Based Therapies and Dialectical Behavior Therapy in Common Eating Disorders Abstract Eating disorders are characterized by individuals' distorted perceptions and irregular eating habits. Evidence obtained from clinical practices shows that eating disorders bring along various medical problems, and complete recovery is difficult; thus, relapse rates are high. In eating disorders, the importance of early diagnosis and treatment is emphasized; however, the effectiveness and suitability of the treatment method are also crucial. Accordingly, increasing knowledge about the contemporary psychotherapy approaches used in the treatment of eating disorders subtypes is significant for those who work in the field of mental health. In this review, contemporary therapy approaches that should be taken into consideration when working with individuals diagnosed with eating disorders are presented. Family-based therapies, mindfulness-based therapies, and dialectical behavioral therapies are emphasized with their underlying assumptions about eating disorders as well as their main techniques and therapy goals. In addition, effectiveness of these approaches was examined, and previous studies are found to be limited based on their amount and methodology. However, these psychotherapies were considered as useful approaches in terms of reducing the symptoms of eating disorders and providing different methods in treatment.
Article
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.
Article
Objective Mindfulness-based interventions (MBIs) are being increasingly used as interventions for eating disorders including binge eating. This systematic review and meta-analysis aimed to assess two decades of research on the efficacy of MBIs in reducing binge eating severity. Methods We searched PubMed, Scopus and Cochrane Library for trials assessing the use of MBIs to treat binge eating severity in both clinical and non-clinical samples. The systematic review and meta-analysis was pre-registered at PROSPERO (CRD42020182395). Results Twenty studies involving 21 samples (11 RCT and 10 uncontrolled samples) met inclusion criteria. Random effects meta-analyses on the 11 RCT samples (n = 618: MBIs n = 335, controls n = 283) showed that MBIs significantly reduced binge eating severity (g = −0.39, 95% CI -0.68, −0.11) at end of trial, but was not maintained at follow-up (g = −0.06, 95% CI, −0.31, 0.20, k = 5). No evidence of publication bias was detected. On the Cochrane Risk of Bias Tool 2, trials were rarely rated at high risk of bias and drop-out rates did not differ between MBIs and control groups. MBIs also significantly reduced depression, and improved both emotion regulation and mindfulness ability. Conclusion MBIs reduce binge eating severity at the end of trials. Benefits were not maintained at follow-up; however, only five studies were assessed. Future well-powered trials should focus on assessing diversity better, including more men and people from ethnic minority backgrounds.
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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.
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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.
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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.
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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/.
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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.
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Eating disorders may be viewed from a transdiagnostic perspective and there is evidence supporting a transdiagnostic form of cognitive behaviour therapy (CBT-E). The aim of the present study was to compare CBT-E with interpersonal psychotherapy (IPT), a leading alternative treatment for adults with an eating disorder. One hundred and thirty patients with any form of eating disorder (body mass index >17.5 to <40.0) were randomized to either CBT-E or IPT. Both treatments involved 20 sessions over 20 weeks followed by a 60-week closed follow-up period. Outcome was measured by independent blinded assessors. Twenty-nine participants (22.3%) did not complete treatment or were withdrawn. At post-treatment 65.5% of the CBT-E participants met criteria for remission compared with 33.3% of the IPT participants (p < 0.001). Over follow-up the proportion of participants meeting criteria for remission increased, particularly in the IPT condition, but the CBT-E remission rate remained higher (CBT-E 69.4%, IPT 49.0%; p = 0.028). The response to CBT-E was very similar to that observed in an earlier study. The findings indicate that CBT-E is potent treatment for the majority of outpatients with an eating disorder. IPT remains an alternative to CBT-E, but the response is less pronounced and slower to be expressed. ISRCTN 15562271. Copyright © 2015. Published by Elsevier Ltd.
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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.
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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.
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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.
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Objective: The authors compared psychoanalytic psychotherapy and cognitive-behavioral therapy (CBT) in the treatment of bulimia nervosa. Method: A randomized controlled trial was conducted in which 70 patients with bulimia nervosa received either 2 years of weekly psychoanalytic psychotherapy or 20 sessions of CBT over 5 months. The main outcome measure was the Eating Disorder Examination interview, which was administered blind to treatment condition at baseline, after 5 months, and after 2 years. The primary outcome analyses were conducted using logistic regression analysis. Results: Both treatments resulted in improvement, but a marked difference was observed between CBT and psychoanalytic psychotherapy. After 5 months, 42% of patients in CBT (N=36) and 6% of patients in psychoanalytic psychotherapy (N=34) had stopped binge eating and purging (odds ratio=13.40, 95% confidence interval [CI]=2.45-73.42; p<0.01). At 2 years, 44% in the CBT group and 15% in the psychoanalytic psychotherapy group had stopped binge eating and purging (odds ratio=4.34, 95% CI=1.33-14.21; p=0.02). By the end of both treatments, substantial improvements in eating disorder features and general psychopathology were observed, but in general these changes took place more rapidly in CBT. Conclusions: Despite the marked disparity in the number of treatment sessions and the duration of treatment, CBT was more effective in relieving binging and purging than psychoanalytic psychotherapy and was generally faster in alleviating eating disorder features and general psychopathology. The findings indicate the need to develop and test a more structured and symptom-focused version of psychoanalytic psychotherapy for bulimia nervosa.
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Objective: 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.
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Background: The purpose of this investigation was to compare a new psychotherapy for bulimia nervosa (BN), integrative cognitive-affective therapy (ICAT), with an established treatment, 'enhanced' cognitive-behavioral therapy (CBT-E). Method: Eighty adults with symptoms of BN were randomized to ICAT or CBT-E for 21 sessions over 19 weeks. Bulimic symptoms, measured by the Eating Disorder Examination (EDE), were assessed at baseline, at the end of treatment (EOT) and at the 4-month follow-up. Treatment outcome, measured by binge eating frequency, purging frequency, global eating disorder severity, emotion regulation, self-oriented cognition, depression, anxiety and self-esteem, was determined using generalized estimating equations (GEEs), logistic regression and a general linear model (intent-to-treat). Results: Both treatments were associated with significant improvement in bulimic symptoms and in all measures of outcome, and no statistically significant differences were observed between the two conditions at EOT or follow-up. Intent-to-treat abstinence rates for ICAT (37.5% at EOT, 32.5% at follow-up) and CBT-E (22.5% at both EOT and follow-up) were not significantly different. Conclusions: ICAT was associated with significant improvements in bulimic and associated symptoms that did not differ from those obtained with CBT-E. This initial randomized controlled trial of a new individual psychotherapy for BN suggests that targeting emotion and self-oriented cognition in the context of nutritional rehabilitation may be efficacious and worthy of further study.
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Background: There are no evidence-based treatments for severe and enduring anorexia nervosa (SE-AN). This study evaluated the relative efficacy of cognitive behavioral therapy (CBT-AN) and specialist supportive clinical management (SSCM) for adults with SE-AN. Method: Sixty-three participants with a diagnosis of AN, who had at least a 7-year illness history, were treated in a multi-site randomized controlled trial (RCT). During 30 out-patient visits spread over 8 months, they received either CBT-AN or SSCM, both modified for SE-AN. Participants were assessed at baseline, end of treatment (EOT), and at 6- and 12-month post-treatment follow-ups. The main outcome measures were quality of life, mood disorder symptoms and social adjustment. Weight, eating disorder (ED) psychopathology, motivation for change and health-care burden were secondary outcomes. Results: Thirty-one participants were randomized to CBT-AN and 32 to SSCM with a retention rate of 85% achieved at the end of the study. At EOT and follow-up, both groups showed significant improvement. There were no differences between treatment groups at EOT. At the 6-month follow-up, CBT-AN participants had higher scores on the Weissman Social Adjustment Scale (WSAS; p = 0.038) and at 12 months they had lower Eating Disorder Examination (EDE) global scores (p = 0.004) and higher readiness for recovery (p = 0.013) compared to SSCM. Conclusions: Patients with SE-AN can make meaningful improvements with both therapies. Both treatments were acceptable and high retention rates at follow-up were achieved. Between-group differences at follow-up were consistent with the nature of the treatments given.
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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.
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Objective: Depressive symptoms are an important risk factor and consequence of binge eating and purging behavior in bulimia nervosa (BN). Although psychotherapy is effective in reducing symptoms of BN in the short- and long-term, it is unclear whether psychotherapy for BN is also effective in reducing depressive symptoms. This meta-analysis examined the efficacy of psychotherapy for BN on depressive symptoms in the short- and long-term. Method: Randomized controlled trials (RCTs) on BN that assessed depressive symptoms as an outcome were identified. Twenty-six RCTs were included. Results: Psychotherapy was more efficacious at reducing symptoms of depression at post-treatment (g = 0.47) than wait-lists. This effect was strongest when studies delivered therapist-led, rather than guided self-help, treatment. No significant differences were observed between psychotherapy and antidepressants. There was no significant post-treatment difference between CBT and other active psychological comparisons at reducing symptoms of depression. However, when only therapist-led CBT was analyzed, therapist-led CBT was significantly more efficacious (g = 0.25) than active comparisons at reducing depressive symptoms. The magnitude of the improvement in depressive symptoms was predicted by the magnitude of the improvement in BN symptoms. Discussion: These findings suggest that psychotherapy is effective for reducing depressive symptoms in BN in the short-term. Whether these effects are sustained in the long-term is yet to be determined, as too few studies conducted follow-up assessments. Moreover, findings demonstrate that, in addition to being the front-running treatment for BN symptoms, CBT might also be the most effective psychotherapy for improving the symptoms of depression that commonly co-occur in BN.
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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.
Article
Objective: Meta-analyses have documented the efficacy of cognitive-behavioral therapy (CBT) for reducing symptoms of eating disorders. However, it is not known whether CBT for eating disorders can also improve quality of life (QoL). This meta-analysis therefore examined the effects of CBT for eating disorders on subjective QoL and health-related quality of life (QoL). Method: Studies that assessed QoL before and after CBT for eating disorders were searched in the PsycInfo and Medline database. Thirty-four articles met inclusion criteria. Pooled within and between-groups Hedge's g were calculated at post-treatment and follow-up for treatment changes on both subjective and HRQoL using a random effects model. Results: CBT led to significant and modest improvements in subjective QoL and HRQoL from pre to post-treatment and follow-up. CBT led to greater subjective QoL improvements than inactive (i.e., wait-list) and active (i.e., a combination of bona fide therapies, psychoeducation) comparisons. CBT also led to greater HRQoL improvements than inactive, but not active, comparisons. Prepost QoL improvements were larger in studies that delivered CBT individually and by a therapist or according to the cognitive maintenance model of eating disorders (CBT-BN or CBT-E); though this was not replicated at follow-up CONCLUSIONS: Findings provide preliminary evidence that CBT for eating disorders is associated with modest improvements in QOL, and that CBT may be associated with greater improvements in QOL relative to comparison conditions.
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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.
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This systematic review synthesised the literature on predictors, moderators, and mediators of outcome following Fairburn's CBT for eating disorders. Sixty-five articles were included. The relationship between individual variables and outcome was synthesised separately across diagnoses and treatment format. Early change was found to be a consistent mediator of better outcomes across all eating disorders. Moderators were mostly tested in binge eating disorder, and most moderators did not affect cognitive-behavioural treatment outcome relative to other treatments. No consistent predictors emerged. Findings suggest that it is unclear how and for whom this treatment works. More research testing mediators and moderators is needed, and variables selected for analyses need to be empirically and theoretically driven. Future recommendations include the need for authors to (i) interpret the clinical and statistical significance of findings; (ii) use a consistent definition of outcome so that studies can be directly compared; and (iii) report null and statistically significant findings.
Article
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.
Article
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.
Article
Objective: This review aimed to (a) examine the effects of rapid response on behavioral, cognitive, and weight-gain outcomes across the eating disorders, (b) determine whether diagnosis, treatment modality, the type of rapid response (changes in disordered eating cognitions or behaviors), or the type of behavioral outcome moderated this effect, and (c) identify factors that predict a rapid response. Method: Thirty-four articles met inclusion criteria from six databases. End of treatment and follow-up outcomes were divided into three categories: Behavioral (binge eating/purging), cognitive (EDE global scores), and weight gain. Average weighted effect sizes(r) were calculated. Results: Rapid response strongly predicted better end of treatment and follow-up cognitive and behavioral outcomes. Moderator analyses showed that the effect size for rapid response on behavioral outcomes was larger when studies included both binge eating and purging (as opposed to just binge eating) as a behavioral outcome. Diagnosis, treatment modality, and the type of rapid response experienced did not moderate the relationship between early response and outcome. The evidence for weight gain was mixed. None of the baseline variables analyzed (eating disorder psychopathology, demographics, BMI, and depression scores) predicted a rapid response. Discussion: As there is a solid evidence base supporting the prognostic importance of rapid response, the focus should shift toward identifying the within-treatment mechanisms that predict a rapid response so that the effectiveness of eating disorder treatment can be improved. There is a need for future research to use theories of eating disorders as a guide to assess within-treatment predictors of rapid response. © 2016 Wiley Periodicals, Inc.
Article
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.
Article
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.
Article
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.