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The empirical status of the third-wave behaviour therapies for the treatment of eating disorders: A systematic review
Abstract
Although third-wave behaviour therapies are being increasingly used for the treatment of eating disorders, their efficacy is largely unknown. This systematic review and meta-analysis aimed to examine the empirical status of these therapies. Twenty-seven studies met full inclusion criteria. Only 13 randomized controlled trials (RCT) were identified, most on binge eating disorder (BED). Pooled within- (pre-post change) and between-groups effect sizes were calculated for the meta-analysis. Large pre-post symptom improvements were observed for all third-wave treatments, including dialectical behaviour therapy (DBT), schema therapy (ST), acceptance and commitment therapy (ACT), mindfulness-based interventions (MBI), and compassion-focused therapy (CFT). Third-wave therapies were not superior to active comparisons generally, or to cognitive-behaviour therapy (CBT) in RCTs. Based on our qualitative synthesis, none of the third-wave therapies meet established criteria for an empirically supported treatment for particular eating disorder subgroups. Until further RCTs demonstrate the efficacy of third-wave therapies for particular eating disorder subgroups, the available data suggest that CBT should retain its status as the recommended treatment approach for bulimia nervosa (BN) and BED, and the front running treatment for anorexia nervosa (AN) in adults, with interpersonal psychotherapy (IPT) considered a strong empirically-supported alternative.
... Additionally, the two linked papers and Lyn and Mollie's commentaries (see Additional Files 1 & 2) contribute to the academic dialogue by challenging the controversial concept of terminal anorexia [23] which has caused alarm among patients [24][25][26] and could have been relevant for Lorna at certain times. ...
... Her medication (and reminders), individual therapy, I-CBTE groups, and the MDT helped her find new ways to express her emotions (e.g. writing poems, cathartic painting), problem-solving to deal with situations, and use DBT skills [25] for mood intolerance. ...
... A focus on the role of emotional dysregulation or emotional overcontrol is key to the theoretical understanding of the development, maintenance and treatment of patients with EDs [25]. Similarly, a systematic review of comorbid PTSD with EDs found that maladaptive emotional regulation act as a mediating mechanism where ED behaviours enable the avoidance of trauma-related feelings and thoughts and reduce hyperarousal [36,37] and is linked with higher rates of relapse. ...
Background
This case study examines the application of Integrated Enhanced Cognitive Behavioural Therapy (I-CBTE) for a patient with severe, longstanding anorexia nervosa and multiple comorbidities, including organic hallucinosis, complex post-traumatic stress disorder (CPTSD), and severe self-harm. Such complex presentations often result in patients falling between services, which can lead to high chronicity and increased mortality risk. Commentaries from two additional patients who have recovered from severe and longstanding anorexia nervosa are included.
Case study
The patient developed severe anorexia nervosa and hallucinosis after a traumatic brain injury in 2000. Despite numerous hospitalisations and various psychotropic medications in the UK and France, standard treatments were ineffective for 17 years. However, Integrated Enhanced Cognitive Behaviour Therapy (I-CBTE) using a whole-team approach and intensive, personalised psychological treatment alongside nutritional rehabilitation proved effective.
Methods
In this paper, we describe the application of the I-CBTE model for individuals with severe, longstanding, and complex anorexia nervosa, using lived experience perspectives from three patients to inform clinicians. We also outline the methodology for adapting the model to different presentations of the disorder.
Outcomes
The patient achieved and maintained full remission from her eating disorder over the last 6 years, highlighting the benefit of the I-CBTE approach in patients with complex, longstanding eating disorder histories. Successful treatment also saved in excess of £360 k just by preventing further hospitalisations and not accounting for the improvement in her quality of life. This suggests that this method can improve outcomes and reduce healthcare costs.
Conclusion
This case study, with commentaries from two patients with histories of severe and longstanding anorexia nervosa, provides a detailed description of the practical application of I-CBTE for patients with severe and longstanding eating disorders with complex comorbidities, and extensive treatment histories. This offers hope for patients and a framework for clinicians to enhance existing treatment frameworks, potentially transforming the trajectory of those traditionally deemed treatment resistant.
Recommendations
We advocate the broader integration of CBT for EDs into specialist services across the care pathway to help improve outcomes for patients with complex eating disorders. Systematic training and supervision for multidisciplinary teams in this specialised therapeutic approach is recommended. Future research should investigate the long-term effectiveness of I-CBTE through longitudinal studies. Patient feedback on experiences of integrated models of care such as I-CBTE is also needed. In addition, systematic health economics studies should be conducted.
... Self-harm incidents were extreme acts of aggression for not meeting her own standards, for internalising anger towards her family, and for 'being angry at being angry'. Her medication (and reminders), individual therapy, I-CBTE groups, and the MDT helped her find new ways to [27] for mood intolerance. ...
... A focus on the role of emotional dysregulation or emotional overcontrol is key to the theoretical understanding of the development, maintenance and treatment of patients with EDs [27]. Similarly, a systematic review of comorbid PTSD with EDs found that maladaptive emotional regulation act as a mediating mechanism where ED behaviours enable the avoidance of trauma-related feelings and thoughts and reduce hyperarousal [36,37] and is linked with higher rates of relapse. ...
Background: This case study examines the application of Integrated Enhanced Cognitive Behavioural Therapy (I-CBTE) for a patient with severe, long-standing anorexia nervosa and multiple comorbidities, including organic hallucinosis, complex post-traumatic stress disorder (CPTSD), and severe self-harm. Such complex presentations often result in patients falling between services, which can lead to high chronicity and increased mortality risk.
Case Presentation: The patient developed severe anorexia nervosa and hallucinosis after a traumatic brain injury in 2000. Despite numerous hospitalisations and various psychotropic medications in the UK and France, standard treatments were ineffective for 17 years. However, Integrated Enhanced Cognitive Behaviour Therapy (I-CBTE) using a whole-team approach and intensive, personalised psychological treatment alongside nutritional rehabilitation, proved effective.
Methods: This paper details the personalised application of the I-CBTE model, illustrating the process through a comprehensive case report. The model integrates multidisciplinary treatment to effectively address EDs and comorbid conditions, highlighting the adaptability and potential of I-CBTE for managing severe and long-standing cases.
Outcomes: The patient achieved and maintained full remission from her eating disorder over the last 6 years, highlighting the effectiveness of the I-CBTE approach in patients with complex, long-standing eating disorder histories. Successful treatment also saved in excess of £360k just by preventing further hospitalisations and not accounting for the improvement in her quality of life. This suggests that this method can improve outcomes and reduce healthcare costs.
Conclusion: This case study provides a detailed description of the practical application of I-CBTE for patients with severe and long-standing eating disorders with complex comorbidities, and extensive treatment histories. This offers hope for patients and a framework for clinicians to adopt a similar comprehensive treatment approach, potentially transforming the trajectory of those traditionally deemed treatment resistant.
Recommendations: We advocate the broader integration of the I-CBTE model into clinical services to improve outcomes for patients with complex eating disorders, and recommend systematic training and supervision for multidisciplinary teams in this specialised therapeutic approach.
... In such studies, it is reported that cognitive behavioral therapy interventions play an effective role in the treatment of uncontrolled eating and emotional eating behaviors (Frayn & Knauper 2018). Evidence indicates that structured cognitive behavioral therapy protocols are effective in most of the disordered eating behaviors such as binge eating and uncontrolled eating (Linardon et al., 2017). One of these structured cognitive behavioral protocols for eating behaviors is the Guided Self-Help Program (GSHP) (Carter & Fairburn, 1998). ...
... The comparison of the post-intervention and 6 th -month follow-up TFEQ scores obtained by the Experimental Group with their pre-intervention TFEQ scores demonstrated that their mean scores increased over time. Regulation of the eating behavior in the experimental group may have improved their thoughts about eating, which subsequently may have caused an increase in their cognitive restraint score (Linardon et al., 2017). This situation may be due to the mental deficiencies experienced by individuals with a severe mental disorder. ...
Purpose:
The study was aimed at determining the effectiveness of the Shared Decision Making Model-based Guided Self-Help Program (SDM-GSH) on emotional eating behavior and uncontrolled eating behavior in individuals with a severe mental disorder.
Method:
This randomized controlled experimental study was conducted in the Community Mental Health Center of a university hospital between September 2020 and November 2022. The sample of the study consisted of 64 participants. Of them, 33 were in the Experimental Group and 31 were in the control group. To collect the study data, the Patient Information Form, Emotional Eater Questionnaire, and Three-Factor Eating Questionnaire were administered. The participants in the Experimental Group took part in the SDM-GSH. The study data were collected from the participants in the Experimental and Control Groups before, right after and 6 months after the intervention.
Results:
The comparison of the BMI values of the participants with a severe mental disorder who took part in the SDM-GSH demonstrated that their pre-intervention BMI values significantly decreased at the measurements preformed right after and 6 months after the intervention (p < 0.05). The mean emotional eating (λ = 0.189, η2 = 0.811) and uncontrolled eating (λ = 0.218, η2 = 0.782) scores obtained by the participants in the Experimental Group before the intervention significantly decreased at the measurements preformed right after and 6 months after the intervention (p < 0.05).
Conclusion:
Based on the results of our study, it is concluded that the SDM-GSH positively affected the BMI values, emotional eating behaviors and uncontrolled eating behaviors of the participants with a severe mental disorder.
... CBT is recognised as the first-line treatment for adults with BN [80] (see Section 3.1). In addition to CBT, several other therapeutic approaches have received attention from researchers as potential treatment options [81,82]. This section will first provide an overview of the available evidence regarding the use of interpersonal psychotherapy (IPT), dialectical behaviour therapy (DBT), psychodynamic psychotherapy, and pharmacotherapy in the treatment of BN, followed by a detailed review of the evidence base supporting CBT. ...
... Current empirical evidence indicates that DBT treatments produce significant reductions in disordered eating behaviours at post-treatment in comparison to waitlist control (WLC). However, the evidence base is relatively weak, mainly consisting of small sample sizes and very few studies assessing the maintenance of improvements at follow-up [82,91]. ...
Bulimia nervosa is an eating disorder characterised by marked impairment to one's physical health and social functioning, as well as high rates of chronicity and comorbidity. This literature review aims to summarise existing academic research related to the symptom profile of BN, the costs and burden imposed by the illness, barriers to the receipt of care, and the evidence base for available psychological treatments. As a consequence of well-documented difficulties in accessing evidence-based treatments for eating disorders, efforts have been made towards developing innovative, diverse channels to deliver treatment, with several of these attempting to harness the potential of digital platforms. In response to the increasing number of trials investigating the utility of online treatments, this paper provides a critical review of previous attempts to examine digital interventions in the treatment of eating disorders. The results of a focused literature review are presented, including a detailed synthesis of a knowledgeable selection of high-quality articles with the aim of providing an update on the current state of research in the field. The results of the review highlight the potential for online self-help treatments to produce moderately sized reductions in core behavioural and cognitive symptoms of eating disorders. However, concern is raised regarding the methodological limitations of previous research in the field, as well as the high rates of dropout and poor adherence reported across most studies. The review suggests directions for future research, including the need to replicate previous findings using rigorous study design and methodology, as well as further investigation regarding the utility of clinician support and interactive digital features as potential mechanisms for offsetting low rates of engagement with online treatments.
... Across both groups, 5.8% (n = 15) of participants did not complete the intervention and 5% (n = 14) did not complete all questionnaires. Dropout rates were substantially lower than those reported for other treatments (20%-40%; Linardon et al. 2017) and online interventions (9%-47%; Dölemeyer et al. 2013). Participants rated facilitators as excellent (83%), and 95.6% of participants would recommend EBT-R to a friend. ...
Objective
Current treatments for eating disorders have limited effectiveness, leaving over half of patients unremitted. The evaluation of emerging interventions to support recovery is therefore critical. This study evaluated the efficacy and acceptability of an innovative, virtual intervention for eating disorders (Eat Breathe Thrive; EBT‐R).
Method
Participants recovering from eating disorders from 27 different countries ( N = 277) were randomly allocated to EBT‐R or waitlist conditions. Assessments were completed at baseline, postintervention, and three‐month follow‐up. Primary outcomes were eating disorders and co‐occurring psychopathology; secondary outcomes included measures of positive embodiment.
Results
Compared with controls, participants in EBT‐R demonstrated significant improvements in eating disorders and associated psychopathology (i.e., depression, anxiety) than controls. Participants also reported increased appreciation for the body, interoception, interoceptive attunement, intuitive eating, emotion regulation, mindful self‐care, and integrity.
Discussion
This study evaluated the efficacy of a brief, virtual, embodiment‐focused intervention for eating disorders. The findings suggest that EBT‐R may be an effective intervention to support recovery from eating disorders and development of positive embodiment.
... The leading empirically supported psychotherapeutic treatment for EDs is cognitive behavioural psychotherapy (CBT), which rectifies dysfunctional ED thoughts and reduces ED behaviours (Fairburn et al., 2003;Dahlenburg et al., 2019). However, with less than 50% achieving remission, CBT is associated with high relapse (>30%) and dropout rates (>24%) (Waller, 2016;Södersten, 2017;Linardon, 2017;. While recovery rates are still low, recent meta-analyses and multivariable meta-regression analysis of current treatments confirm that CBT enhanced for EDs, family-based therapy (in adolescents) and psychodynamic therapy (treatments based on an interpretive-supportive continuum) are associated with better outcomes (Leichsenring et al., 2015;Monteleone et al., 2022;Solmi et al., 2024). ...
... Supplementary Materials: The following supporting information can be downloaded at: https: //www.mdpi.com/article/10.3390/adolescents4030023/s1. References[37][38][39][40][41][42][43][44] are cited in the supplementary materials. ...
Individuals with eating disorders often face difficulty accessing sufficiently intensive, recovery-focused treatment. Residential treatment may fill a gap in the spectrum of care, offering 24-h support in a more home-like environment than a hospital and using a holistic approach including individual and group psychological therapy, meal support, and lived experience staff. As residential treatment has not previously been examined in Australia, the current study aimed to document the development, treatment components, and structure of this first Australian residential service for eating disorders and provide a pilot of its treatment outcomes. Preliminary outcomes are included from a sample of 19 individuals from the first six months of admissions, including eating disorder symptoms, eating disorder-related impairment, anxiety, and depression. Significant pre- to post-treatment improvement was found in total eating disorder psychopathology, dietary restraint, eating concerns, body mass index, eating disorder-related impairment, and depression, but not from pre-treatment to a six-month follow-up. Pilot outcomes were positive at end-of-treatment but require further clinical evaluation to examine follow-up effects. Clinical insights are discussed from the establishment of this new treatment service, including recommendations for clinicians involved in the current roll-out of residential programs across Australia.
... Furthermore, characterization of how aspects of state mindfulness relate to ED behaviors can lead to the development and optimization of MBIs for EDs. Given that the majority of the research reviewed thus far has focused on the relationship between mindfulness and binge-spectrum disorders, such as bulimia nervosa or binge eating disorder, it may not be surprising that most MBIs for EDs have also been indicated for those with binge-spectrum disorders (Godfrey et al., 2015;Linardon et al., 2017). Research on mindfulness and eating disorder pathology suggests that mindfulness is relevant for those who experience symptoms related to AN, such as body checking . ...
Objectives
Mindfulness has been proposed as a potential intervention for eating disorders (EDs). However, a better understanding of the relationships between state mindfulness and restrictive ED symptoms for those with anorexia nervosa and atypical anorexia nervosa (AN-spectrum) is needed to design effective mindfulness-based interventions. Additionally, individualized longitudinal modeling of state mindfulness and ED behaviors could inform development of personalized mindfulness-based interventions for those with AN-spectrum disorders.
Methods
Participants (n = 18; 784 data points per participant; 14,112 data points) with AN-spectrum disorders completed four daily ecological momentary assessments of ED behaviors, nonjudgment, acceptance, and present-moment awareness for 14 days. Contemporaneous and temporal group-level and idiographic (i.e., one-person, individual) networks were calculated to identify associations among mindfulness variables and ED behaviors.
Results
In contemporaneous networks (i.e., within a single timepoint), present-moment awareness was negatively associated with eating small meals but positively associated with avoiding foods due to anxiety. Acceptance was positively associated with eating small meals. In temporal networks, nonjudgment was negatively associated with following eating rules and avoiding foods due to anxiety, whereas acceptance negatively predicted restriction prospectively. Idiographic networks were heterogenous; state mindfulness facets demonstrated positive and negative associations with ED behaviors depending on the individual.
Conclusions
At the group level, state mindfulness tends to relate to lower engagement in restrictive ED behaviors over time. High heterogeneity in individual networks illustrates the need for personalized assessment of relationships between state mindfulness and ED behaviors. These types of methodologies can lead to the development of personalized mindfulness-based interventions for those with AN-spectrum disorders.
Preregistration
This study is not preregistered.
... A importância atribuída à consciência emocional e à aceitação das emoções, bem como a valorização do contexto e da experiência interna, representam outros pontos de convergência. A abordagem destes aspectos, que são característicos e diferenciadores do transtorno, poderá ser a chave para o desenvolvimento de um tratamento mais eficaz (Le Grange, 2016;Linardon et al., 2017). ...
... Therefore, adding ME to TAU and testing it against TAU without ME, like it has been done before (Mason, Epel, Aschbacher, et al., 2016;Mason, Epel, Kristeller, et al., 2016), seems the recommended way to investigate effects of ME in line with clinical recommendations. Notably, so far MBPs were not found to outperform cognitive behavioral therapies for eating and weight disorders, although the factor of treatment duration should be taken into account when interpreting these findings (Linardon, Fairburn, Fitzsimmons-Craft, Wilfley, & Brennan, 2017;Turgon et al., 2019). ...
Maladaptive eating behaviors such as emotional eating, external eating, and loss-of-control eating are widespread in the general population. Moreover, they are associated to adverse health outcomes and well-known for their role in the development and maintenance of eating disorders and obesity (i.e., eating and weight disorders). Eating and weight disorders are associated with crucial burden for individuals as well as high costs for society in general. At the same time, corresponding treatments yield poor outcomes. Thus, innovative concepts are needed to improve prevention and treatment of these conditions.
The Buddhist concept of mindfulness (i.e., paying attention to the present moment without judgement) and its delivery via mindfulness-based intervention programs (MBPs) has gained wide popularity in the area of maladaptive eating behaviors and associated eating and weight disorders over the last two decades. Though previous findings on their effects seem promising, the current assessment of mindfulness and its mere application via multi-component MBPs hampers to draw conclusions on the extent to which mindfulness-immanent qualities actually account for the effects (e.g., the modification of maladaptive eating behaviors). However, this knowledge is pivotal for interpreting previous effects correctly and for avoiding to cause harm in particularly vulnerable groups such as those with eating and weight disorders.
To address these shortcomings, recent research has focused on the context-specific approach of mindful eating (ME) to investigate underlying mechanisms of action. ME can be considered a subdomain of generic mindfulness describing it specifically in relation to the process of eating and associated feelings, thoughts, and motives, thus including a variety of different attitudes and behaviors. However, there is no universal operationalization and the current assessment of ME suffers from different limitations. Specifically, current measurement instruments are not suited for a comprehensive assessment of the multiple facets of the construct that are currently discussed as important in the literature. This in turn hampers comparisons of different ME facets which would allow to evaluate their particular effect on maladaptive eating behaviors. This knowledge is needed to tailor prevention and treatment of associated eating and weight disorders properly and to explore potential underlying mechanisms of action which have so far been proposed mainly on theoretical grounds.
The dissertation at hand aims to provide evidence-based fundamental research that contributes to our understanding of how mindfulness, more specifically its context-specific form of ME, impacts maladaptive eating behaviors and, consequently, how it could be used appropriately to enrich the current prevention and treatment approaches for eating and weight disorders in the future.
Specifically, in this thesis, three scientific manuscripts applying several qualitative and quantitative techniques in four sequential studies are presented. These manuscripts were published in or submitted to three scientific peer-reviewed journals to shed light on the following questions:
I. How can ME be measured comprehensively and in a reliable and valid way to advance the understanding of how mindfulness works in the context of eating?
II. Does the context-specific construct of ME have an advantage over the generic concept in advancing the understanding of how mindfulness is related to maladaptive eating behaviors?
III. Which ME facets are particularly useful in explaining maladaptive eating behaviors?
IV. Does training a particular ME facet result in changes in maladaptive eating behaviors?
To answer the first research question (Paper 1), a multi-method approach using three subsequent studies was applied to develop and validate a comprehensive self-report instrument to assess the multidimensional construct of ME - the Mindful Eating Inventory (MEI). Study 1 aimed to create an initial version of the MEI by following a three-step approach: First, a comprehensive item pool was compiled by including selected and adapted items of the existing ME questionnaires and supplementing them with items derived from an extensive literature review. Second, the preliminary item pool was complemented and checked for content validity by experts in the field of eating behavior and/or mindfulness (N = 15). Third, the item pool was further refined through qualitative methods: Three focus groups comprising laypersons (N = 16) were used as a check for applicability. Subsequently, think-aloud protocols (N = 10) served as a last check of comprehensibility and elimination of ambiguities.
The resulting initial MEI version was tested in Study 2 in an online convenience sample (N = 828) to explore its factor structure using exploratory factor analysis (EFA). Results were used to shorten the questionnaire in accordance with qualitative and quantitative criteria yielding the final MEI version which encompasses 30 items. These items were assigned to seven ME facets: (1) ‘Accepting and Non-attached Attitude towards one’s own eating experience’ (ANA), (2) ‘Awareness of Senses while Eating’ (ASE), (3) ‘Eating in Response to awareness of Fullness‘ (ERF), (4) ‘Awareness of eating Triggers and Motives’ (ATM), (5) ‘Interconnectedness’ (CON), (6) ‘Non-Reactive Stance’ (NRS) and (7) Focused Attention on Eating’ (FAE).
Study 3 sought to confirm the found facets and the corresponding factor structure in an independent online convenience sample (N = 612) using confirmatory factor analysis (CFA). The study served as further indication of the assumed multidimensionality of ME (the correlational seven-factor model was shown to be superior to a single-factor model). Psychometric properties of the MEI, regarding factorial validity, internal consistency, retest-reliability, and observed criterion validity using a wide range of eating-specific and general health-related outcomes, showed the inventory to be suitable for a comprehensive, reliable and valid assessment of ME. These findings were complemented by demonstrating measurement invariance of the MEI regarding gender. In accordance with the factor structure of the MEI, Paper 1 offers an empirically-derived definition of ME, succeeding in overcoming ambiguities and problems of previous attempts at defining the construct.
To answer the second and third research questions (Paper 2) a subsample of Study 2 from the MEI validation studies (N = 292) was analyzed. Incremental validity of ME beyond generic mindfulness was shown using hierarchical regression models concerning the outcome variables of maladaptive eating behaviors (emotional eating and uncontrolled eating) and nutrition behaviors (consumption of energy-dense food). Multiple regression analyses were applied to investigate the impact of the seven different ME facets (identified in Paper 1) on the same outcome variables. The following ME facets significantly contributed to explaining variance in maladaptive eating and nutrition behaviors: Accepting and Non-attached Attitude towards one`s own eating experience (ANA), Eating in Response to awareness of Fullness (ERF), the Awareness of eating Triggers and Motives (ATM), and a Non-Reactive Stance (NRS, i.e., an observing, non-impulsive attitude towards eating triggers). Results suggest that these ME facets are promising variables to consider when a) investigating potential underlying mechanisms of mindfulness and MBPs in the context of eating and b) addressing maladaptive eating behaviors in general as well as in the prevention and treatment of eating and weight disorders.
To answer the fourth research question (Paper 3), a training on an isolated exercise (‘9 Hunger’) based on the previously identified ME facet ATM was designed to explore its particular association with changes in maladaptive eating behaviors and thus to preliminary explore one possible mechanism of action. The online study was realized using a randomized controlled trial (RCT) design. Latent Change Scores (LCS) across three measurement points (before the training, directly after the training and three months later) were compared between the intervention group (n = 211) and a waitlist control group (n = 188). Short- and longer-term effects of the training could be shown on maladaptive eating behaviors (emotional eating, external eating, loss-of-control eating) and associated outcomes (intuitive eating, ME, self-compassion, well-being). Findings serve as preliminary empirical evidence that MBPs might influence maladaptive eating behaviors through an enhanced non-judgmental awareness of and distinguishment between eating motives and triggers (i.e., ATM). This mechanism of action had previously only been hypothesized from a theoretical perspective. Since maladaptive eating behaviors are associated with eating and weight disorders, the findings can enhance our understanding of the general effects of MBPs on these conditions.
The integration of the different findings leads to several suggestions of how ME might enrich different kinds of future interventions on maladaptive eating behaviors to improve health in general or the prevention and treatment of eating and weight disorders in particular. Strengths of the thesis (e.g., deliberate specific methodology, variety of designs and methods, high number of participants) are emphasized. The main limitations particularly regarding sample characteristics (e.g., higher level of formal education, fewer males, self-selected) are discussed to arrive at an outline for future studies (e.g., including multi-modal-multi-method approaches, clinical eating disorder samples and youth samples) to improve upcoming research on ME and underlying mechanisms of action of MBPs for maladaptive eating behaviors and associated eating and weight disorders.
This thesis enriches current research on mindfulness in the context of eating by providing fundamental research on the core of the ME construct. Thereby it delivers a reliable and valid instrument to comprehensively assess ME in future studies as well as an operational definition of the construct. Findings on ME facet level might inform upcoming research and practice on how to address maladaptive eating behaviors appropriately in interventions. The ME skill ‘Awareness of eating Triggers and Motives (ATM)’ as one particular mechanism of action should be further investigated in representative community and specific clinical samples to examine the validity of the results in these groups and to justify an application of the concept to the general population as well as to subgroups with eating and weight disorders in particular.
In conclusion, findings of the current thesis can be used to set future research on mindfulness, more specifically ME, and its underlying mechanism in the context of eating on a more evidence-based footing. This knowledge can inform upcoming prevention and treatment to tailor MBPs on maladaptive eating behaviors and associated eating and weight disorders appropriately
... We hypothesized that in separate moderation models, the association between body dissatisfaction and disordered eating would be attenuated among those individuals with higher levels of dispositional mindfulness or body image flexibility. Importantly, since dispositional mindfulness and body image flexibility have been proposed as core constructs to target in third-wave behavioral therapies for body dissatisfaction and disordered eating (e.g., Bluett et al., 2016;Fogelkvist et al., 2020;Lee et al., 2018;Linardon et al., 2017Linardon et al., , 2019Merwin et al., 2023), it is also important to understand the relative importance of these two factors to further explain variability in the well-documented association between body dissatisfaction and disordered eating. Thus, in the present study, we also compared the relative importance of the moderating roles of dispositional mindfulness and body image flexibility by entering both moderators in the same regression model. ...
Objectives: Previous research suggests potential moderating roles of dispositional mindfulness and body image flexibility in the association between body dissatisfaction and disordered eating. However, relevant research is mainly conducted on adult women from Western countries, and limited evidence exists for adolescent samples, especially from non-Western contexts (e.g., China). Thus, this study aimed to examine the moderating roles of dispositional mindfulness and body image flexibility in the relationship between body dissatisfaction and disordered eating in Chinese adolescents. Method: We recruited 545 Chinese adolescents (53.9% boys, aged 12-16 years) who completed measures of body dissatisfaction, dispositional mindfulness, body image flexibility, and disordered eating. Moderation analyses were examined with PROCESS macro on SPSS. Results: In separate models, both higher dispositional mindfulness and body image flexibility weakened relationships between body dissatisfaction and disordered eating. However, when both dispositional mindfulness and body image flexibility were entered into the same moderation model, only body image flexibility showed a significant moderating effect. Discussion: Both dispositional mindfulness and body image flexibility may weaken the association between body dissatisfaction and disordered eating in adolescents. However, body image flexibility might have a stronger effect than dispositional mindfulness. These findings suggest that
interventions aimed at reducing body dissatisfaction to prevent disordered eating in adolescents may pay more attention to adolescents' body image flexibility.
... For adults with BN, third-wave behavioral therapies are feasible attempts, such as dialectical behavior therapy, acceptance and commitment therapy. However, previous evaluations have shown little difference in efficacy between these therapies and cognitive behavioral therapy (Byrne et al., 2017;Linardon et al., 2017). For adolescents with AN and BN, familybased interventions are recommended as first-line treatments by international evidence-based guidelines (Hilbert et al., 2017). ...
Background
Anorexia nervosa (AN) and bulimia nervosa (BN) poses a significant challenge to global public health. Despite extensive research, conclusive evidence regarding the association between gut microbes and the risk of AN and BN remains elusive. Mendelian randomization (MR) methods offer a promising avenue for elucidating potential causal relationships.
Materials and methods
Genome-wide association studies (GWAS) datasets of AN and BN were retrieved from the OpenGWAS database for analysis. Independent single nucleotide polymorphisms closely associated with 196 gut bacterial taxa from the MiBioGen consortium were identified as instrumental variables. MR analysis was conducted utilizing R software, with outlier exclusion performed using the MR-PRESSO method. Causal effect estimation was undertaken employing four methods, including Inverse variance weighted. Sensitivity analysis, heterogeneity analysis, horizontal multivariate analysis, and assessment of causal directionality were carried out to assess the robustness of the findings.
Results
A total of 196 bacterial taxa spanning six taxonomic levels were subjected to analysis. Nine taxa demonstrating potential causal relationships with AN were identified. Among these, five taxa, including Peptostreptococcaceae, were implicated as exerting a causal effect on AN risk, while four taxa, including Gammaproteobacteria, were associated with a reduced risk of AN. Similarly, nine taxa exhibiting potential causal relationships with BN were identified. Of these, six taxa, including Clostridiales, were identified as risk factors for increased BN risk, while three taxa, including Oxalobacteraceae, were deemed protective factors. Lachnospiraceae emerged as a common influence on both AN and BN, albeit with opposing effects. No evidence of heterogeneity or horizontal pleiotropy was detected for significant estimates.
Conclusion
Through MR analysis, we revealed the potential causal role of 18 intestinal bacterial taxa in AN and BN, including Lachnospiraceae. It provides new insights into the mechanistic basis and intervention targets of gut microbiota-mediated AN and BN.
... In line with theoretical models of binge eating as a maladaptive emotion regulation strategy (Leehr et al., 2015), DBT has been specially adapted for the treatment of binge-eating disorder (BED) and bulimia nervosa (Safer et al., 2009). Evidence shows DBT-BED to be effective in treating BED and bulimia nervosa, although it has not been shown to outperform other leading therapies, such as CBT for binge eating (CBT+; see Linardon et al., 2017, for a review). One RCT comparing DBT-BED to CBT+ found that in obese adults (N = 77) with BED, the CBT+ condition had greater improvements in number of binges, global eating disorder pathology, and self-esteem (Lammers et al., 2020). ...
... The focus is on making change despite cognitions and emotions rather than on trying to change them. Acceptance based approaches have demonstrated positive effects when applied to individuals with schizophrenia (e.g., El Ashry et al. 2021), but are not superior to cognitive behavioral therapy for AN (Linardon et al. 2017). But again, these approaches have not been tested specifically in individuals with AN experiencing delusions. ...
Numerous studies of the beliefs of people with anorexia nervosa (AN) suggest that a subset of such individuals may experience delusions. We first describe what makes a belief delusional and conclude that such characteristics can be appropriately applied to some beliefs of people with AN. Next, we outline how delusional beliefs may relate to the broader psychopathological process in AN, including: (1) they may be epiphenomenal; (2) they may be an initial partial cause of AN; (3) they may be caused by aspects of AN; or (4) they may be sustaining causes, possibly involved in reciprocal causal relations with aspects of AN. We argue that there is good reason to believe that delusional beliefs of people with AN are not merely epiphenomenal, but rather that they’re causally connected to AN. Because of this, empirical studies can be designed to test for the presence of causal relations. We describe how these studies should be designed. The results of such studies have important implications for understanding the experience of individuals with AN and for the treatment of AN. We outline these implications.
... Effectiveness studies into these alternative treatment options are promising but they are still relatively limited in number and size compared to the studies on CBT. To date, comparative studies for these alternative treatment options have not shown superiority over CBT (Hayes & Hofmann, 2021;Linardon et al., 2017;Rozakou-Soumalia et al., 2021). Treatment remains difficult especially for patients with BED or BN, who often have comorbidities such as anxiety disorders, major depressive disorder, and personality disorders (Groff, 2015). ...
Binge eating disorder (BED) and bulimia nervosa (BN) are characterized by recurrent binge eating, episodes of consuming large amounts of food in a discrete period of time associated with a loss of control. Implementation intentions are explicit if-then plans that engender goal-directed action, and rely less on cognitive control than standard treatment options. In a sample with BED and BN, we compared two implementation intention conditions to a control condition. In the behavior-focused condition, implementation intentions targeted binge eating behaviors. In the emotion-focused condition, implementation intentions targeted negative affect preceding binge eating. In the control condition, only goal intentions were set. Each condition comprised three sessions. Participants kept food diaries for four weeks. Compared to the control condition both implementation intention conditions showed significant and large reductions of binge eating that persisted for six months. Effects did not differ between the behavior-focused and emotion-focused implementation intention conditions. These results demonstrate that three sessions on implementation intention formation can lead to long-term reductions in binge eating in patients with BED or BN. Learning how to form implementation intentions seems a recommendable addition to the current standard treatment. Future research could investigate the added value of fully personalized implementation intentions. CLINICAL TRIAL REGISTRATION NUMBER: NL52600.068.15.
... Other treatments, such as Dialectical Behavioural Therapy (DBT) are effective in targeting emotion regulation deficits in individuals with eating disorders (Lammers et al., 2022;Linardon et al., 2017;Telch et al., 2001). DBT subscribes more closely to the affect regulation model of binge eating than CBT does, and teaches skills to specifically target emotion dysregulation to facilitate treatment (Telch et al., 2001). ...
Objective:
Emotion dysregulation (i.e., a multi-component term comprising nonacceptance of emotional responses, difficulty engaging in goal-directed behaviour, impulse control difficulties, lack of emotional awareness, limited access to emotion regulation strategies, and lack of emotional clarity) is a well-established transdiagnostic risk and maintenance factor for eating disorders. To date, there is limited information on how varying scores on subdomains of emotion dysregulation may yield distinct profiles in individuals with binge-spectrum eating disorders (B-EDs), and how these emotion dysregulation profiles may inform resultant symptomatology.
Method:
In the current study, treatment-seeking individuals with B-EDs (n = 315) completed the Difficulties in Emotion Regulation Scale (DERS) and Eating Disorder Examination. Latent profile analysis was conducted on the six subscales of the DERS. Identified latent profiles were examined as predictors of eating disorder pathology using linear regression, and a two-class model of emotion dysregulation fit the data.
Results:
Class 1 (n = 113) was low in all of the DERS subscales, while Class 2 (n = 202) was high in all of the DERS subscales. Individuals in Class 2 had a significantly higher frequency of compensatory behaviours in the past month (F(1,313) = 12.97, p < 0.001), and significantly higher restraint scores (F(1,313) = 17.86, p < 0.001). The classes also significantly differed in terms of eating concern (F(1,313) = 20.89, p < 0.001) and shape concern (F(1,313) = 4.59, p = 0.03), with both being higher for Class 2.
Discussion:
We found only two distinct classes of emotion dysregulation in B-ED's such that individuals were simply high or low in emotion dysregulation. These results suggest that it may be more valuable for future research to evaluate emotion dysregulation as a cohesive whole rather than conceptualising the construct as having truly distinct subdomains.
... 11 There is currently little consensus on a first-line therapeutic model for EDs. 12 Treatment typically includes psychosocial interventions and pharmacotherapy, in which the goal is to overcome dysfunctional beliefs and restore healthy eating behaviors and weight. 13,14 However, long-term cessation of ED behaviors is difficult to achieve considering significant rates of avoidance, drop-out, and treatment resistance. ...
Eating disorders (ED) are a group of potentially severe mental disorders characterized by abnormal energy balance, cognitive dysfunction and emotional distress. Cognitive inflexibility is a major challenge to successful ED treatment and dysregulated serotonergic function has been implicated in this symptomatic dimension. Moreover, there are few effective treatment options and long-term remission of ED symptoms is difficult to achieve. There is emerging evidence for the use of psychedelic-assisted psychotherapy for a range of mental disorders. Psilocybin is a serotonergic psychedelic which has demonstrated therapeutic benefit to a variety of psychiatric illnesses characterized by rigid thought patterns and treatment resistance. The current paper presents a narrative review of the hypothesis that psilocybin may be an effective adjunctive treatment for individuals with EDs, based on biological plausibility, transdiagnostic evidence and preliminary results. Limitations of the psychedelic-assisted psychotherapy model and proposed future directions for the application to eating behavior are also discussed. Although the literature to date is not sufficient to propose the incorporation of psilocybin in the treatment of disordered eating behaviors, preliminary evidence supports the need for more rigorous clinical trials as an important avenue for future investigation.
... The main theoretical framework in the literature in cases of AN is Cognitive-Behavioral Therapy (Linardon et al., 2017). Thus, we believe that Narrative Therapy (NT) also conveys very positive results, considering its philosophy and given that it is also contextualized as a recent dimension of the cognitive model (Chimpén-López & Muñoz, 2021). ...
Anorexia is an eating disorder characterized by a morbid fear of gaining weight, excessive restriction of food and intense and exaggerated practice of physical exercise. There are two subtypes of anorexia: restrictive and purgative. Its prevalence is mainly in female adolescents aged 15 to 19 and entails multiple harmful physical, psychological, social, and emotional consequences. Anorexia is portrayed as a multifactorial disorder, requiring a biopsychosocial perspective and a multidisciplinary intervention to address all the affected areas of the individual. In this article, we approach the appliance of Narrative Therapy by White and Epston (1989), which advocates that the psychotherapeutic treatment can be carried out together – psychologist, client and family – with the literature supporting it. Anorexia is an egosyntonic disorder associated with a high mortality rate. It should be noted that the cure for anorexia is not granted since there is an increased number of relapses and treatment dropouts. For this reason, an innovative approach like narrative therapy can be approached with promising results.
... The attenuation of difficulties with emotion regulation is particularly important, as we found that such difficulties have a direct effect on depression and poor mental HRQoL in this population. Taking this into consideration, psychological therapies that focus on training in emotion-regulation skills (e.g., dialectical behavior therapy) are known to be useful to address mental-health complications and eating-disorder symptoms in people with BED and comorbid difficulties with emotion regulation [40], but are under researched [41,42]. Overall, it may be beneficial that clinicians working with treatment models that focus mostly on the reduction of eating-disorder symptoms consider adding skills training on emotion-regulation and stress-management interventions to their treatment plans for clients with BED. ...
Citation: da Luz, F.Q.; Mohsin, M.; Jana, T.A.; Marinho, L.S.; Santos, E.d.; Lobo, I.; Pascoareli, L.; Gaeta, T.; Ferrari, S.; Teixeira, P.C.; et al. An Examination of the Relationships between Eating-Disorder Symptoms, Abstract: Eating disorders, such as binge eating disorder, are commonly associated with difficulties with emotion regulation and mental-health complications. However, the relationship between eating-disorder symptoms, difficulties with emotion regulation, and mental health in people with binge eating disorder is unclear. Thus, we investigated associations between eating-disorder symptoms, difficulties with emotion regulation, and mental health in 119 adults with binge eating disorder. Participants were assessed with the Eating Disorder Examination Questionnaire, Loss of Control over Eating Scale, Difficulties in Emotion Regulation Scale, Depression Anxiety and Stress Scale, and the 12-Item Short Form Survey at the pre-treatment phase of a randomized controlled trial. Structural-equation-modelling path analysis was used to investigate relationships between variables. We found that (1) eating-disorder behaviors had a direct association with depression, anxiety, and stress; (2) depression, psychological stress, difficulties with emotion regulation, and eating-disorder psychopathology had a direct association with mental-health-related quality of life; and (3) eating-disorder psychopathology/behaviors and stress had a direct association with difficulties with emotion regulation. Our findings show that depression, stress, difficulties with emotion regulation, and eating-disorder psychopathology were related in important ways to mental-health complications in people with binge eating disorder.
... It is important to note that there is a difference between the number of studies investigating the efficacy and effectiveness of CBT and thirdwave treatments for EDs in adolescents compared to adults. For example, three MA have analyzed the efficacy of third-wave therapies for EDs among patients over 18 years (Godfrey et al., 2015;Lenz et al., 2014;Linardon et al., 2017) versus one MA in adolescence (Buerger et al., 2021) and the study quality is higher in the adult studies while in adolescence a weak quality is predominant. There is a lack of SRs and MA on the efficacy of third-wave therapies different from DBT, as well as other emerging treatments such as neurocognitive treatments or technology based psychological interventions. ...
Eating disorders (EDs) are high prevalent among adolescents with serious consequences. Evidence of effectiveness of psychological interventions for eating disorders in adolescents lacks a systematic synthesis of systematic reviews. The goal of this umbrella review is to summarize evidence from systematic reviews examining effects of psychological interventions for eating disorders targeting adolescents. Web of Science, PsycINFO and Cochrane Database of Systematic Reviews were searched for systematic reviews on effectiveness and/or efficacy of any psychological intervention aiming to treat eating disorders in terms of outcomes in adolescents (improvement of eating-disorder symptoms, weight restoration and treatment retention). The methodological quality of each study was assessed using AMSTAR 2. The original search identified 831 reviews, 9 of which were included in the overview of systematic reviews rated as having a low methodological quality. Predominant psychological interventions for EDs in adolescents are family-based interventions. The efficacy of cognitive behavioral therapy and third-wave treatments has been less researched. Anorexia nervosa and bulimia nervosa are the EDs that have been studied the most. This study provides evidence supporting the positive impact of psychological interventions on eating disorders in adolescents. Family based treatment is the most evidence-based psychological intervention. There is a need for high-quality systematic reviews as well as systematic reviews to examine if psychological interventions are effective for different eating disorders.
... Clinical trials using schema therapy to treat adults with EDs were sought out on the Australian New Zealand Clinical Trials Registry and the US National Library of Medicine Clinical Trials database. References included in reviews on the applications of schema therapy (Taylor et al., 2017) and schema theory in EDs (Linardon et al., 2017;Maher et al., 2022;Pugh, 2015) were also searched to ensure all relevant studies were included. Secondary searches were conducted on the 6 th of May and 17 th of August 2022, both of which identified no further relevant studies. ...
Commonly developing in adolescence and following a chronic course, eating disorders are life-threatening psychological disorders and typically very difficult to treat despite the body of research exploring treatment options. Due to the high levels of severity and the enduring nature of eating disorders, schema therapy has been proposed as a more effective treatment than cognitive behaviour therapy. To assess the effectiveness of schema therapy in adults with eating disorders, the present systematic review was designed in accordance with PRISMA guidelines. A structured search of electronic databases and grey literature was conducted, and the Mixed Methods Assessment Tool was used to assess the quality of each article. Four articles including 151 participants were found which demonstrated that schema therapy is effective at reducing eating disorder symptoms and behaviour and general psychopathology. Despite the limitations of this study, including the scarcity of research available and varying methodologies used, the present systematic review found evidence supporting the use of schema therapy in patients with eating disorders, particularly those experiencing severe and enduring forms.
... O terceiro artigo que apresenta evidências científicas da eficácia do tratamento comportamental dialético de transtornos alimentares é o "Dialectical Behavior Therapy for Bulimia Nervosa", de Safer et al. (2001), selecionado nas referências da Meta-Análise "The empirical status of the third-wave behaviour therapies for the treatment of eating disorders: A systematic review" de Linardon et al. (2017). É necessário reforçar a compreensão de que, ainda que não tenhamos encontrado artigos que apresentem estas evidências, isto não significa que estes artigos não existam, apenas que o procedimento seguido e citado acima não foi suficiente para encontrar estes documentos. ...
Este trabalho teve o objetivo de apresentar práticas que demonstrem tratamentos psicológicos dos transtornos alimentares em quatro abordagens psicológicas, apresentadas em artigos científicos, e que sirvam de suporte empírico da eficácia destas terapias. Para isto, abordou-se a definição e etiologia dos transtornos alimentares e a concepção teórica destes transtornos para a Análise do Comportamento, Gestalt-Terapia, Terapia Cognitivo-Comportamental e Psicanálise, assim como a definição da Prática Baseada em Evidências no contexto da Psicologia. Foram apresentados o processo de intervenção destes transtornos para estas abordagens, um estudo de caso de cada uma delas e ensaios randomizados de tais tratamentos. O procedimento da pesquisa da monografia ocorreu a partir da seleção de meta-análises e revisões bibliográficas que abordam o processo terapêutico pelo qual os psicólogos das abordagens podem atuar no tratamento da Anorexia e/ou Bulimia Nervosas. Estes documentos foram encontrados na Língua Inglesa e traduzidos para o Português. Por fim, buscou-se sistematizar as técnicas, os resultados e as diferenças encontradas, além da discussão da PPBE nas quatro abordagens.
Introduction: Interoception, the perception of internal bodily sensations , is increasingly acknowledged as a pivotal construct in the understanding of psychiatric disorders. This is particularly relevant for Eating Disorders (EDs)1-4 where a problematic relationship with one's own body is well-documented5,6 Previous research has explored interocep-tive awareness using the Multidimensional Assessment of Interoceptive Awareness (MAIA)7. In our study, we specifically focus on hospitalized ED patients using the Italian version of the MAIA8. To our knowledge, this is the first study that offers a comprehensive comparison across multiple MAIA studies involving ED patients. Aim of the study: We aim to explore the facets of interoceptive awareness in hospitalized ED patients and offer a unique comparative lens by including four major studies.: Brown et al. (2017), Perry et al. (2021), Monteleone et al. (2021), and Phillipou et al. (2022) [9-12]. Materials and methods: We evaluated 69 inpatients diagnosed with EDs at Maria Luigia Hospital in Monticelli Terme, Parma, using the MAIA at admission. All statistical evaluations were executed using R version 4.2.1. Results: Based on the provided statistical data, our findings indicate significant deficits in multiple MAIA subscales among ED patients. The most pronounced impairments are seen in the Self-Regulation (t = − 12.79, p < 0.001, Cohen's d = − 1.54) and Trusting (t = − 13.32, p < 0.001, Cohen's d = − 1.32) subscales. Additionally, substantial deficits were also found in the Attention Regulation (t = − 9.13, p < 0.001, Cohen's d = − 1.1), Emotional Awareness (t = − 4.45, p < 0.001, Cohen's d = − 0.5), and Body Listening (t = − 7.23, p < 0.001, Cohen's d = − 0.87) subscales. In contrast, the Noticing, Not Distracting, and Not Worrying subscales did not display statistically significant differences. These numerical insights are further contextualized when compared to other studies, offering a nuanced understanding of varying severity levels in ED patients assessed with MAIA.
Mindfulness is the practice of focusing one's attention and energy on the present moment with an accepting attitude and an open mindset. Its adoption is increasingly utilized in addressing health concerns, particularly in the realm of nutrition. Mindful eating seeks to adjust disordered eating patterns by cultivating intentional awareness of the physical, mental, and emotional aspects of eating. Mindfulness techniques may involve meditation, breathing exercises, and simply being more attentive in daily activities. Integrating mindfulness into a nutrition strategy may improve digestion, foster a healthier relationship with food, and lead to making better choices aligned with overall well-being. This critical review aims to examine recent prevailing studies on the effects of mindfulness-based interventions (MBI) on weight regulation, eating disorders related to obesity, emotional eating, and diabetes management. For the methods section, the study utilized the Google Scholar and PubMed databases, employing the Medical Subject Headings (MeSH) descriptors. The search included articles published up to September 2024, resulting in a total of 122 articles gathered using various keyword combinations. Results show that out of the 122 studies, 28 articles were common, leaving a total of 94 articles. They included 33 randomized controlled trials (RCTs), 17 systematic reviews and meta-analyses, 11 observational studies, 14 reviews, and 19 others. The findings from these studies demonstrate the positive impact of MBI on conditions such as binge eating disorder, weight loss, emotional eating, and diabetes-related issues. In conclusion, the review supports the growing evidence suggesting that the incorporation of mindfulness can play a crucial role in managing obesity, eating disorders, and their associated consequences. However, further research is necessary to establish a definitive understanding of its effectiveness and how to integrate it into healthcare practices.
Introduction
Difficulties in emotion regulation (ER) are transdiagnostic in eating disorders (EDs). Self-compassion impacts ED-related outcomes by either preventing their initial establishment or interrupting/modifying their ongoing detrimental impact. Studies conducted in mixed samples found significantly lower levels of self-compassion in ED clinical samples. The main goal in this study was to explore the clinical profile presentation (in terms of transdiagnostic psychological processes) of participants within a continuum of eating psychopathology levels, through a two-step cluster analysis.
Methods
The ED clinical sample comprised 94 women aged between 18 and 60 years old (M = 29.5, SD = 10.2). The college sample included 274 female students aged between 18 and 56 years old (M = 21.2, SD = 4.7).
Results
Self-compassion facets significantly predicted overall difficulties in ER in both samples (clinical, F(6, 81) = 20.57, p < 0.001; R2 = 0.60; college, F(6, 267) = 22.64, p < 0.001; R2 = 0.34). The two-step cluster analysis resulted in an optimal solution of three clusters: low profile – C1; intermediate profile – C2; and severe profile – C3. Self-criticism and self-compassion were the strongest predictor variables, contributing 100% and 98%, respectively, to clustering membership. Self-compassion was a significant moderator on the relationship between difficulties in ER and eating psychopathology (b = −0.02, t(357) = 3.38, p < 0.001; R2 = 0.43).
Discussion
Fostering self-compassionate skills and addressing self-criticism and experiential avoidance (including experiential therapeutic components) as they become prominent during the therapeutic process, may be influential to successfully implement specific ER skills and enhance therapeutic gains.
Os Transtornos Alimentares (TA) são condições psiquiátricas complexas que afetam predominantemente adolescentes e adultos jovens do sexo feminino, causando danos biológicos e psicológicos significativos. Dentre eles, a anorexia nervosa (AN) e a bulimia nervosa (BN) se caracterizam como os tipos principais, compartilhando sintomas como obsessão pelo peso e distorção da imagem corporal. Sendo assim, utilizando o método bibliográfico e revisando fontes escritas em português e inglês que apresentam palavras-chave como “transtornos alimentares”, “psicoterapia” e “Terapia Cognitivo-Comportamental (TCC)” e foram produzidas ao longo dos últimos 5 anos, este artigo se propõe a investigar a eficácia da TCC no tratamento de TA, centrando-se em AN e BN. Durante seu desenvolvimento, foi evidenciado que apesar do padrão de beleza cultural ser um fator importante para o estabelecimento desses transtornos, não é o único, dividindo espaço com a predisposição genética e alterações de ordem psicológica e que, embora a terapia comportamental e a terapia familiar demonstrem eficácia no tratamento dos TA, a TCC figura como a abordagem mais amplamente reconhecida e respaldada em evidências científicas, atuando no sentido de modificar os padrões de pensamento e comportamento disfuncionais utilizando enfoque flexível e colaboração ativa. Destarte, ainda que sejam necessárias novas pesquisas no sentido de atualizar aspectos comprobatórios, seu papel crucial no autogerenciamento do comportamento, modificação de cognições desadaptadas, redução da ansiedade e na própria compreensão da dinâmica dos transtornos alimentares a torna uma ferramenta essencial na promoção da recuperação e bem-estar psicológico em indivíduos afetados pelos TA.
Purpose of Review
The present review describes the recent literature on treatment for binge-eating disorder (BED) in adults and youth, with a particular focus on research gaps, emerging treatments, and future research directions.
Recent Findings
Evidence supports the efficacy of several treatment modalities in adults, including self-help treatment, clinician-led psychotherapy, and pharmacotherapy; the largest effect sizes have been found for psychotherapies, most of which were cognitive-behavioral in orientation. Adapted psychotherapies for youth also show promise but lack a robust body of evidence. Predictors, moderators, and mediators of treatment outcome remain poorly understood; individuals with BED continue to experience significant barriers to treatment; and research is needed to address suboptimal treatment response. Recent work has highlighted the potential of adaptive interventions and investigation of novel mechanisms to address these gaps.
Summary
Research on BED treatment continues to grow, though critical questions must be answered to improve treatment efficacy across the lifespan.
Objective
Interpersonal psychotherapy (IPT) has been proposed as a treatment strategy for eating disorders (EDs). However, cognitive behavioural therapy (CBT) is the treatment more widely used than IPT.
Method
Our study aimed to conduct a systematic review and meta‐analysis of randomized controlled trials (RCTs) in order to compare the effectiveness of IPT with CBT in treating eating disorders (EDs). To achieve this goal, we conducted a comprehensive search on PubMed, Embase, Medline, Cochrane, Web of Science, and the Clinical Trials Database for RCTs that compared the effectiveness of IPT with CBT in treating EDs.
Results
After reviewing 468 potential studies, we selected 10 suitable for our meta‐analysis, which included 833 participants. Results showed that both IPT and CBT had similar effects on the primary outcome measure (i.e., ED score) (SMD = 0.08). However, IPT had a more significant effect on the secondary outcome measure (i.e., Inventory of Interpersonal Problems) (SMD = 0.32) compared to CBT. Additionally, IPT had a better treatment effect for individuals with EDs who had a lower body mass index (SMD = 0.27) and were younger (SMD = 0.43) than those receiving CBT. Both IPT and CBT demonstrated follow‐up effects at pretest and after follow‐up periods of less than 6 months (SMD = 1.61, 1.83), between 6 and 12 months (SMD = 1.48, 1.65), and greater than 12 months (SMD = 1.29, 1.33). However, only CBT demonstrated a dose–response relationship trend ( β = 0.017, p = 0.067).
Conclusions
The meta‐analysis yielded compelling evidence that IPT is an effective treatment for individuals with EDs. However, the review highlights the need for future research to further elucidate the effects of IPT on ED treatment.
Objectives Psychological support is one of the basic aspects of care for patients with cancer. It has been emphasized in literature and clinical practice for many years. This study aims to explore the experiences and perceptions of healthcare providers in Ardabil, Iran, about psychological support to patients with cancer. Methods The research was conducted using conventional qualitative content analysis in cancer treatment centers in Ardabil, Iran, in 2021. Participants were 19 healthcare providers who were purposefully selected and interviewed to explore their experiences. After transcribing the recorded data, analysis was carried out based on Graneheim and Lundman’s content analysis method. Results Based on the content analysis results, four main themes, including “highlighting positive mental connection with oneself and others”, “positive awareness”, “positive change in the patient’s point of view,” and “strengthening the perceived value” were extracted. These categories reflected the healthcare providers’ efforts to “strengthen the positive mindsets” of patients and showed the formation of psychological support for patients with cancer. Conclusion Strengthening of the positive mentality in patients with cancer is needed for their psychological support, and should be used as a strategic plan in the development of training programs for healthcare providers. It can be an indicator for evaluating psychological support to these patients and be a step towards providing quality care to them. The findings can be useful for designing a tool to measure the status of psychological support for patients with cancer in Iran or assess the care quality and performance of healthcare providers in giving psychological support to these patients.
Third generation cognitive-behavioral therapies (CBTs) have presented evidence of their efficacy for several clinical cases, mainly in international studies. In the Brazilian scenario, this ascension is also observed, although more recently and on a smaller scale. The objective of this study was to investigate the current panorama of research on third generation CBTs in Brazil. A scoping review was conducted in Scielo, Lilacs and Pepsic databases, according to the Joana Briggs Institute guidelines and PRISMA protocol. 598 studies were located and 16 were selected and submitted to bibliometric and content analysis. The clinical practices had a wide application in diverse clinical settings, with individual and group practices. Results point to efficacy of third generation therapies interventions with reduction or elimination of dysfunctional symptoms, and clinically relevant behavioral changes.
Background:
Psychotherapy is considered central to the effective treatment of eating disorders-focusing on behavioural, psychological, and social factors that contribute to the illness. Research indicates psychotherapeutic interventions out-perform placebo, waitlist, and/or other treatments; but, outcomes vary with room for major improvement. Thus, this review aims to (1) establish and consolidate knowledge on efficacious eating disorder psychotherapies; (2) highlight select emerging psychotherapeutic interventions; and (3) identify knowledge gaps to better inform future treatment research and development.
Methods:
The current review forms part of a series of Rapid Reviews published in a special issue in the Journal of Eating Disorders to inform the development of the Australian-government-funded National Eating Disorder Research and Translation Strategy 2021-2031. Three databases were searched for studies published between 2009 and 2023, published in English, and comprising high-level evidence studies (meta-analyses, systematic reviews, moderately sized randomised controlled studies, moderately sized controlled-cohort studies, and population studies). Data pertaining to psychotherapies for eating disorders were synthesised and outlined in the current paper.
Results:
281 studies met inclusion criteria. Behavioural therapies were most commonly studied, with cognitive-behavioural and family-based therapies being the most researched; and thus, having the largest evidence-base for treating anorexia nervosa, bulimia nervosa, and binge eating disorder. Other therapies, such as interpersonal and dialectical behaviour therapies also demonstrated positive treatment outcomes. Emerging evidence supports specific use of Acceptance and Commitment; Integrative Cognitive Affective; Exposure; Mindfulness; and Emotionally-Focused therapies; however further research is needed to determine their efficacy. Similarly, growing support for self-help, group, and computer/internet-based therapeutic modalities was noted. Psychotherapies for avoidant/restrictive food intake disorder; other, and unspecified feeding and eating disorders were lacking evidence.
Conclusions:
Currently, clinical practice is largely supported by research indicating that behavioural and cognitive-behavioural psychotherapies are most effective for the treatment of eating disorders. However, the efficacy of psychotherapeutic interventions varies across studies, highlighting the need for investment and expansion of research into enhanced variants and novel psychotherapies to improve illness outcomes. There is also a pressing need for investigation into the whole range of eating disorder presentations and populations, to determine the most effective interventions.
Objective:
Emotion regulation, perfectionism, and rumination are perpetuating factors in anorexia nervosa (AN). Mindfulness can be protective and therapeutic. We aimed to understand the relationship between these factors and mindfulness in AN.
Methods:
20 adolescent girls in the acute phase of the AN, 16 in remission, and 40 in the control group were evaluated.
Results:
Mindfulness was lowest in the acute AN group. The difference in the acute AN group regarding body dissatisfaction, emotion dysregulation, perfectionism, and mindfulness disappeared after controlling for the effects of depression and anxiety. The predictors of disordered eating in the entire study population were body dissatisfaction and depressive symptoms. Emotion regulation and perfectionism were the predictors of mindfulness in the acute AN group and the entire study population. When mindfulness decreased, concerns about body shape increased in both acute AN and remission groups, while dietary restriction and disordered eating behaviors increased only in the remission group.
Discussion:
Emotion regulation difficulties in acute AN could be related to depression and anxiety. Mindfulness interventions for emotion regulation could be used for depression during the acute phase while for perfectionism in remission. Early intervention for depression and body dissatisfaction seems protective, and mindfulness could be an appropriate intervention.
Objective:
To assess the associations of binge eating, compensatory behaviors, and dietary restraint with the composition and diversity of the intestinal microbiota among participants with binge-eating disorder (BED) or bulimia nervosa (BN).
Methods:
We analyzed data from 265 participants aged 18-45 years with current BED or BN enrolled in the Binge Eating Genetics Initiative (BEGIN) study. We evaluated the associations of binge-eating frequency, presence/absence and frequency of vomiting, laxative use, and compulsive exercise, and dietary restraint with abundances of gut microbial genera, species, and diversity (Shannon diversity, Faith phylogenetic diversity, and Peilou's evenness). General linear models adjusted for potential confounders, including age and current BMI, modeled associations; p-values were corrected for the false discovery rate.
Results:
The normalized abundance of four genus- and species-level gut microbes and three diversity indices were lower among BEGIN participants who reported any laxative use compared to those who reported no laxative use. Vomiting frequency was positively associated with the normalized abundance of genus Escherichia-Shigella, a potential pathobiont, although the association was attenuated to non-significance after adjustment for age, BMI, and binge-eating episodes.
Conclusions:
Laxative use was highly and uniformly predictive of a reduced gut microbial diversity including of potential commensals and pathobionts and should be assessed and accounted for in all future microbial studies of eating disorders. Future studies should collect data on specific medications-especially laxatives-and dietary intake to obtain unbiased estimates of the effect of eating disorders on the gut microbiota and identify potential downstream clinical implications.Registration: ClinicalTrials.gov identifier: NCT04162574.
Binge-eating disorder (BED), characterized by recurrent binge eating in the absence of regular weight-compensatory behaviors, is the most common eating disorder, associated with pronounced mental and physical sequelae. An increasing body of research documents the efficacy of diverse approaches to the treatment of this disorder, summarized in meta-analyses. This research update narratively reviewed randomized-controlled trials (RCTs) on the psychological and medical treatment of BED published between January 2018 to November 2022, identified through a systematic literature search. A total of 16 new RCTs and 3 studies on previous RCTs providing efficacy- and safety-related data were included. Regarding psychotherapy, confirmatory evidence supported the use of integrative-cognitive therapy and, with lower effects, brief emotion regulation skills training for binge eating and associated psychopathology. Behavioral weight loss treatment was revealed to be efficacious for binge eating, weight loss, and psychopathology, but its combination with naltrexone-bupropion did not augment efficacy. New treatment approaches were explored, including e-mental-health and brain-directed treatments, mostly targeting emotion and self-regulation. Additionally, different therapeutic approaches were evaluated in complex stepped-care models. In light of these advances, future research is necessary to further optimize effects of evidence-based treatments for BED, through improvement of existing or development of new treatments, based on mechanistic and/or interventional research, and/or tailoring treatments to personal characteristics in a precision medicine approach.
Psychiatric comorbidity is the norm in the assessment and treatment of eating disorders (EDs), and traumatic events and lifetime PTSD are often major drivers of these challenging complexities. Given that trauma, PTSD, and psychiatric comorbidity significantly influence ED outcomes, it is imperative that these problems be appropriately addressed in ED practice guidelines. The presence of associated psychiatric comorbidity is noted in some but not all sets of existing guidelines, but they mostly do little to address the problem other than referring to independent guidelines for other disorders. This disconnect perpetuates a “silo effect,” in which each set of guidelines do not address the complexity of the other comorbidities. Although there are several published practice guidelines for the treatment of EDs, and likewise, there are several published practice guidelines for the treatment of PTSD, none of them specifically address ED + PTSD. The result is a lack of integration between ED and PTSD treatment providers, which often leads to fragmented, incomplete, uncoordinated and ineffective care of severely ill patients with ED + PTSD. This situation can inadvertently promote chronicity and multimorbidity and may be particularly relevant for patients treated in higher levels of care, where prevalence rates of concurrent PTSD reach as high as 50% with many more having subthreshold PTSD. Although there has been some progress in the recognition and treatment of ED + PTSD, recommendations for treating this common comorbidity remain undeveloped, particularly when there are other co-occurring psychiatric disorders, such as mood, anxiety, dissociative, substance use, impulse control, obsessive–compulsive, attention-deficit hyperactivity, and personality disorders, all of which may also be trauma-related. In this commentary, guidelines for assessing and treating patients with ED + PTSD and related comorbidity are critically reviewed. An integrated set of principles used in treatment planning of PTSD and trauma-related disorders is recommended in the context of intensive ED therapy. These principles and strategies are borrowed from several relevant evidence-based approaches. Evidence suggests that continuing with traditional single-disorder focused, sequential treatment models that do not prioritize integrated, trauma-focused treatment approaches are short-sighted and often inadvertently perpetuate this dangerous multimorbidity. Future ED practice guidelines would do well to address concurrent illness in more depth.
Clinical psychology and psychotherapy are disciplines that have made significant contributions to the treatment of mental health disorders. Evidence-based treatments should be available to people who suffer from mental health problems. In this regard, cognitive behavioral therapy (CBT) for adults, groups, and couples, the third-wave CBT, metacognitive therapies, and rehabilitation and recovery programs are presented and discussed. A psychotherapeutic relationship and alliance in combination with the implementation of cognitive and behavioral interventions such as CBT contributes to a dynamic context, which leads to recovery and reintegration with society. The importance of the training in CBT is mentioned. CBT focuses on the content of thoughts and beliefs and how they can change. Metacognitive therapies focus on the thoughts about thoughts and beliefs. Rehabilitation focuses on the improvement of cognitive functions, social skills, and problem-solving. Recovery programs provide better insights into the disorder and the coping mechanisms. In this regard, third-wave CBT contributes to a better understanding and acceptance of and process of coping with the disorders. Clinical and research implications are discussed. This chapter shares a very positive message about the possibilities of coping with mental health disorders.KeywordsClinical psychologyCognitive behavioral psychotherapyMetacognitive therapiesRecoveryRehabilitation
In this chapter, the authors discuss the role that self-concept plays as a modulator in disordered eating. While there are many models for self-concept, all models recognize that the development of positive self-esteem is multidimensional, and an individual’s perception of self can be affected by the environment in both positive and negative ways. Effective prevention and intervention programs must recognize the importance of this concept and integrate self-esteem in their programs. Numerous theoretical frameworks have been proposed to explain and predict the process of health behavior change. The Transtheoretical Model (TTM) developed by Prochaska and DiClemente as a model of intentional behavior change is highlighted in this chapter. Targeted educational programs to prevent disordered eating for female athletes are presented and contact information for more details for research-based effective programs are provided in a summary format. Lastly, a concept called mindfulness has been introduced specifically as it relates to eating disorders.
Anorexia nervosa (AN) is a chronic and debilitating psychiatric disorder. Unfortunately, current treatments are lacking, with only 30-50% of individuals with AN recovering after treatment. We developed a beta-version of a digital mindfulness-based intervention for AN called Mindful Courage-Beta, which includes: (a) one foundational multimedia module; (b) 10 daily meditation mini-modules; (c) emphasis on a core skill set called the BOAT (Breathe, Observe, Accept, Take a Moment); and (d) brief phone coaching for both technical and motivational support. In this open trial, we aimed to evaluate (1) acceptability and feasibility; (2) intervention skill use and its association with state mindfulness in daily life; and (3) pre-to-post changes in target mechanisms and outcomes. Eighteen individuals with past-year AN or past-year atypical AN completed Mindful Courage-Beta over 2 weeks. Participants completed measures of acceptability, trait mindfulness, emotion regulation, eating disorder symptoms, and body dissatisfaction. Participants also completed ecological momentary assessment of skill use and state mindfulness. Acceptability ratings were good (ease-of-use: 8.2/10, helpfulness: 7.6/10). Adherence was excellent (100% completion for foundational module and 96% for mini-modules). Use of the BOAT in daily life was high (1.8 times/day) and was significantly associated with higher state mindfulness at the within-person level. We also found significant, large improvements in the target mechanisms of trait mindfulness (d = .96) and emotion regulation (d = .76), as well as significant, small-medium to medium-large reductions in eating disorder symptoms (ds = .36-.67) and body dissatisfaction (d = .60). Changes in trait mindfulness and emotion regulation had medium-large size correlations with changes in global ED symptoms and body dissatisfaction (rs = .43 - .56). Mindful Courage-Beta appears to be promising and further research on a longer, refined version is warranted.
Tıkınırcasına yeme bozukluğu, obezite ile güçlü bir şekilde ilişkilidir ve obez bireylerde en sık karşılaşılan yeme bozukluklarından biridir. Tıkınırcasına yeme bozukluğu; telafi edici davranışlar olmaksızın, tekrarlayan aşırı yeme epizodları ile karakterize bir bozukluktur. Aynı zamanda; depresyon, düşük benlik saygısı ve dürtüsellik gibi çeşitli yeme bozukluğu semptomları ile de ilişkilendirilmektedir. Bu yeme bozukluğunun tedavisinde; bilişsel davranışçı terapi, davranışçı vücut ağırlık kaybı terapisi ve kişilerarası ilişkiler terapisi gibi yaklaşımlar kullanılmaktadır. Son yıllarda, üçüncü dalga bilişsel davranışçı terapiler; özellikle farkındalık temelli müdahaleler tıkınırcasına yeme bozukluğu tedavisinde dikkat çekici şekilde öne çıkmaktadır. Bilinçli farkındalık ve özellikle yeme farkındalığı; sağlıklı beslenmeyi desteklemek için yeni yaklaşımlar olarak ortaya çıkmıştır. Bilinçli farkındalık kavramı; kasıtlı olarak, yargılamadan şimdiki zamanda kalma ve dikkat göstermeyi ifade etmektedir. Bu uygulama; anksiyete ve depresyon için başarılı bir birincil ve yardımcı tedavi yöntemi olarak kullanılmasının yanı sıra, yeme bozukluklarında yoğun olarak hissedilen dürtüselliği tersine çevirebilmektedir. Yeme farkındalığı ise bireyin aç ve tok olma durumunun, duygularının ve tükettiği besinlerin farkına varmasına odaklanır. Bu derleme; tıkınırcasına yeme bozukluğunun ve klinik sonuçlarının daha iyi anlaşılması ile birlikte, tıkınırcasına yeme bozukluğu olan farklı popülasyonlarda bilinçli farkındalık uygulamalarının sonuçlarını inceleyen güncel literatür verilerini sunmayı amaçlamaktadır.
Recent studies have found increasing rates of overweight and obesity in bulimia nervosa (BN). However, the relationships between body mass index (BMI) and BN symptoms and other clinically relevant constructs are unknown. Participants (N = 152 adults with BN) were assigned to three groups by BMI: group with no overweight or obesity (NOW-BN; BMI <25; N = 32), group with overweight (OW-BN; BMI ≥25 and <30; N = 66), and group with obesity (O-BN; BMI ≥30; N = 54). We compared the groups on demographics, diet and weight histories, body esteem, BN symptoms, and depression using chi square, analysis of variance, analysis of covariance, and Poisson regression models. The O-BN group was older (d = 0.57) and OW-BN and O-BN groups had greater proportions of race/ethnic minorities than NOW-BN group. The O-BN group was significantly younger at first diet (d = 0.41) and demonstrated significantly higher cognitive dietary restraint (d = 0.31). Compared to NOW-BN, O-BN participants had lower incidence of objective binge eating (incidence rate ratio [IRR] = 4.86) and driven exercise (IRR = 7.13), and greater incidence of vomiting (IRR = 9.30), laxative misuse (IRR = 4.01), and diuretic misuse (d = 2.08). O-BN participants also experienced higher shape (d = 0.41) and weight (d = 0.42) concerns than NOW-BN and OW-BN, although NOW-BN experienced higher shape (d = 0.44) and weight (d = 0.39) concerns than OW-BN. Groups did not differ on depression scores. These results were replicated when examining BMI as a continuous predictor across the full sample, with the exception of objective binge eating and driven exercise, which were not significantly associated with BMI. Individuals with BN and comorbid obesity have distinct clinical characteristics. Existing interventions may need to be adapted to meet clinical needs of these individuals.
Objective:
This meta-analysis examined the efficacy of cognitive-behavioral therapy (CBT) for eating disorders.
Method:
Randomized controlled trials of CBT were searched. Seventy-nine trials were included.
Results:
Therapist-led CBT was more efficacious than inactive (wait-lists) and active (any psychotherapy) comparisons in individuals with bulimia nervosa and binge eating disorder. Therapist-led CBT was most efficacious when manualized CBT-BN or its enhanced version was delivered. No significant differences were observed between therapist-led CBT for bulimia nervosa and binge eating disorder and antidepressants at posttreatment. CBT was also directly compared to other specific psychological interventions, and therapist-led CBT resulted in greater reductions in behavioral and cognitive symptoms than interpersonal psychotherapy at posttreatment. At follow-up, CBT outperformed interpersonal psychotherapy only on cognitive symptoms. CBT for binge eating disorder also resulted in greater reductions in behavioral symptoms than behavioral weight loss interventions. There was no evidence that CBT was more efficacious than behavior therapy or nonspecific supportive therapies.
Conclusions:
CBT is efficacious for eating disorders. Although CBT was equally efficacious to certain psychological treatments, the fact that CBT outperformed all active psychological comparisons and interpersonal psychotherapy specifically, offers some support for the specificity of psychological treatments for eating disorders. Conclusions from this study are hampered by the fact that many trials were of poor quality. Higher quality RCTs are essential. (PsycINFO Database Record
Background
One of the major barriers to the dissemination and implementation of psychological treatments is the scarcity of suitably trained therapists. The currently accepted method of training is not scalable. Recently, a scalable form of training, Web-centered training, has been shown to have promise.
Objective
The goal of our research was to conduct a randomized comparison of the relative effects of independent and supported Web-centered training on therapist competence and investigate the persistence of the effects.
Methods
Eligible therapists were recruited from across the United States and Canada. They were randomly assigned to 1 of 2 forms of training in enhanced cognitive behavior therapy (CBT-E), a multicomponent evidence-based psychological treatment for any form of eating disorder. Independent training was undertaken autonomously, while supported training was accompanied by support from a nonspecialist worker. Therapist competence was assessed using a validated competence measure before training, after 20 weeks of training, and 6 months after the completion of training.
Results
A total of 160 therapists expressed interest in the study, and 156 (97.5%) were randomized to the 2 forms of training (81 to supported training and 75 to independent training). Mixed effects analysis showed an increase in competence scores in both groups. There was no difference between the 2 forms of training, with mean difference for the supported versus independent group being –0.06 (95% Cl –1.29 to 1.16, P=.92). A total of 58 participants (58/114, 50.9%) scored above the competence threshold; three-quarters (43/58, 74%) had not met this threshold before training. There was no difference between the 2 groups in the odds of scoring over the competence threshold (odds ratio [OR] 1.02, 95% CI 0.52 to 1.99; P=.96). At follow-up, there was no significant difference between the 2 training groups (mean difference 0.19, 95% Cl –1.27 to 1.66, P=.80). Overall, change in competence score from end of training to follow-up was not significant (mean difference –0.70, 95% CI –1.52 to 0.11, P=.09). There was also no difference at follow-up between the training groups in the odds of scoring over the competence threshold (OR 0.95, 95% Cl 0.34 to 2.62; P=.92).
Conclusions
Web-centered training was equally effective whether undertaken independently or accompanied by support, and its effects were sustained. The independent form of Web-centered training is particularly attractive as it provides a means of training large numbers of geographically dispersed therapists at low cost, thereby overcoming several obstacles to the widespread dissemination of psychological treatments.
Purpose of review:
The current systematic review sought to compare available evidence-based clinical treatment guidelines for all specific eating disorders.
Recent findings:
Nine evidence-based clinical treatment guidelines for eating disorders were located through a systematic search. The international comparison demonstrated notable commonalities and differences among these current clinical guidelines. Consistency across guidelines was greatest for treatments with a larger evidence base, while those with a lower evidence base had recommendations that varied considerably.
Summary:
Evidence-based clinical guidelines represent an important step toward the dissemination and implementation of evidence-based treatments into clinical practice. Despite advances in clinical research on eating disorders, a growing body of literature demonstrates that individuals with eating disorders often do not receive an evidence-based treatment for their disorder. Regarding the dissemination and implementation of evidence-based treatments, current guidelines do endorse the main empirically validated treatment approaches with considerable agreement, but additional recommendations are largely inconsistent. An increased evidence base is critical in offering clinically useful and reliable guidance for the treatment of eating disorders. Because developing and updating clinical guidelines is time-consuming and complex, an international coordination of guideline development, for example, across the European Union, would be desirable.
Background
A major barrier to the widespread dissemination of psychological treatments is the way that therapists are trained. The current method is not scalable.
Objective
Our objective was to conduct a proof-of-concept study of Web-centered training, a scalable online method for training therapists.
Methods
The Irish Health Service Executive identified mental health professionals across the country whom it wanted to be trained in a specific psychological treatment for eating disorders. These therapists were given access to a Web-centered training program in transdiagnostic cognitive behavior therapy for eating disorders. The training was accompanied by a scalable form of support consisting of brief encouraging telephone calls from a nonspecialist. The trainee therapists completed a validated measure of therapist competence before and after the training.
Results
Of 102 therapists who embarked upon the training program, 86 (84.3%) completed it. There was a substantial increase in their competence scores following the training (mean difference 5.84, 95% Cl –6.62 to –5.05; P<.001) with 42.5% (34/80) scoring above a predetermined cut-point indicative of a good level of competence.
Conclusions
Web-centered training proved feasible and acceptable and resulted in a marked increase in therapist competence scores. If these findings are replicated, Web-centered training would provide a means of simultaneously training large numbers of geographically dispersed trainees at low cost, thereby overcoming a major obstacle to the widespread dissemination of psychological treatments.
Background:
There is a lack of evidence pointing to the efficacy of any specific psychotherapy for adults with anorexia nervosa (AN). The aim of this study was to compare three psychological treatments for AN: Specialist Supportive Clinical Management, Maudsley Model Anorexia Nervosa Treatment for Adults and Enhanced Cognitive Behavioural Therapy.
Method:
A multi-centre randomised controlled trial was conducted with outcomes assessed at pre-, mid- and post-treatment, and 6- and 12-month follow-up by researchers blind to treatment allocation. All analyses were intention-to-treat. One hundred and twenty individuals meeting diagnostic criteria for AN were recruited from outpatient treatment settings in three Australian cities and offered 25-40 sessions over a 10-month period. Primary outcomes were body mass index (BMI) and eating disorder psychopathology. Secondary outcomes included depression, anxiety, stress and psychosocial impairment.
Results:
Treatment was completed by 60% of participants and 52.5% of the total sample completed 12-month follow-up. Completion rates did not differ between treatments. There were no significant differences between treatments on continuous outcomes; all resulted in clinically significant improvements in BMI, eating disorder psychopathology, general psychopathology and psychosocial impairment that were maintained over follow-up. There were no significant differences between treatments with regard to the achievement of a healthy weight (mean = 50%) or remission (mean = 28.3%) at 12-month follow-up.
Conclusion:
The findings add to the evidence base for these three psychological treatments for adults with AN, but the results underscore the need for continued efforts to improve outpatient treatments for this disorder. Trial Registration Australian New Zealand Clinical Trials Registry (ACTRN 12611000725965) http://www.anzctr.org.au/.
Background:
No specific psychotherapy for adult anorexia nervosa (AN) has shown superior effect. Maintenance factors in AN (over-evaluation of control over eating, weight and shape) were addressed via Acceptance and Commitment Therapy (ACT). The study aimed to compare 19 sessions of ACT with treatment as usual (TAU), after 9 to 12 weeks of daycare, regarding recovery and risk of relapse up to five years.
Methods:
Patients with a full, sub-threshold or partial AN diagnosis from an adult eating disorder unit at a hospital were randomized to ACT (n = 24) and TAU (n = 19). The staff at the hospital, as well as the participants, were unaware of the allocation until the last week of daycare. Primary outcome measures were body mass index (BMI) and specific eating psychopathology. Analyses included mixed model repeated measures and odds ratios.
Results:
Groups did not differ regarding recovery and relapse using a metric of BMI and the Eating Disorder Examination Questionnaire (EDE-Q). There were only significant time effects. However, odds ratio indicated that ACT participants were more likely to reach good outcome. The study was underpowered due to unexpected low inflow of patients and high attrition.
Conclusion:
Longer treatment, more focus on established perpetuating factors and weight restoration integrated with ACT might improve outcome. Potential pitfalls regarding future trials on AN are discussed. Trial registration number ISRCTN 12106530. Retrospectively registered 08/06/2016.
The author applauds the plan proposed by Tolin, McKay, Forman, Klonsky, and Thombs (2015) for bringing the methodology for identifying empirically supported treatments (ESTs) into the 21st century. She suggests that further attention is required to operationalize (a) what sorts of designs for effectiveness studies will be acceptable to the Committee on Science and Practice, (b) how data on improvement in functioning will be incorporated in the context of brief treatments, and (c) how complications in obtaining clean follow-up data for long-term outcomes will be addressed, and to specify (d) whether noninferiority to an existing EST is acceptable evidence of efficacy. She further cautions that meta-analyses can mask poorly designed studies and bias in their implementation that will require the Committee's careful scrutiny.
Eating disorders may be viewed from a transdiagnostic perspective and there is evidence supporting a transdiagnostic form of cognitive behaviour therapy (CBT-E). The aim of the present study was to compare CBT-E with interpersonal psychotherapy (IPT), a leading alternative treatment for adults with an eating disorder. One hundred and thirty patients with any form of eating disorder (body mass index >17.5 to <40.0) were randomized to either CBT-E or IPT. Both treatments involved 20 sessions over 20 weeks followed by a 60-week closed follow-up period. Outcome was measured by independent blinded assessors. Twenty-nine participants (22.3%) did not complete treatment or were withdrawn. At post-treatment 65.5% of the CBT-E participants met criteria for remission compared with 33.3% of the IPT participants (p < 0.001). Over follow-up the proportion of participants meeting criteria for remission increased, particularly in the IPT condition, but the CBT-E remission rate remained higher (CBT-E 69.4%, IPT 49.0%; p = 0.028). The response to CBT-E was very similar to that observed in an earlier study. The findings indicate that CBT-E is potent treatment for the majority of outpatients with an eating disorder. IPT remains an alternative to CBT-E, but the response is less pronounced and slower to be expressed.
ISRCTN 15562271.
Copyright © 2015. Published by Elsevier Ltd.
Mindfulness-based interventions are increasingly used to treat binge eating. The effects of these interventions have not been reviewed comprehensively. This systematic review and meta-analysis sought to summarize the literature on mindfulness-based interventions and determine their impact on binge eating behavior. PubMED, Web of Science, and PsycINFO were searched using keywords binge eating, overeating, objective bulimic episodes, acceptance and commitment therapy, dialectical behavior therapy, mindfulness, meditation, mindful eating. Of 151 records screened, 19 studies met inclusion criteria. Most studies showed effects of large magnitude. Results of random effects meta-analyses supported large or medium-large effects of these interventions on binge eating (within-group random effects mean Hedge’s g = −1.12, 95 % CI −1.67, −0.80, k = 18; between-group mean Hedge’s g = −0.70, 95 % CI −1.16, −0.24, k = 7). However, there was high statistical heterogeneity among the studies (within-group I
2 = 93 %; between-group I
2 = 90 %). Limitations and future research directions are discussed.
Background: The current study presents the results of a meta-analysis of 39 randomized controlled trials on the efficacy of ACT, including 1,821 patients with mental disorders or somatic health problems.
Methods: We searched PsycINFO, MEDLINE, and the Cochrane Central Register of Controlled Trials. Information provided by the Association of Contextual Behavioral Science (ACBS) community was also included. Statistical calculations were conducted using Comprehensive Meta-Analysis software. Study quality was rated using a methodology rating form.
Results: ACT outperformed control conditions (Hedges’s g = 0.57) at post-treatment and follow-up, in completer and intent-to-treat analyses for primary outcomes. ACT was superior to waitlist (Hedges’s g = 0.82), to psychological placebo (Hedges’s g = 0.51) and to TAU (Hedges’ g = 0.64). ACT was also superior on secondary outcomes (Hedges’s g = 0.30), life satisfaction/quality measures (Hedges’s g = 0.37) and process measures (Hedges’s g = 0. 56) when compared to control conditions. The comparison between ACT and established treatments (i.e., CBT) did not reveal any significant differences between these treatments (p = .140).
Conclusions: Our findings indicate that ACT is more effective than treatment as usual or placebo and that ACT may be as effective in treating anxiety disorders, depression, addiction, and somatic health problems as established psychological interventions. More research that focuses on quality of life and processes of change is needed to understand the added value of ACT and its trans diagnostic nature.
This study evaluated the effectiveness of dialectical behavior therapy (DBT) for treating eating disorder episodes and co-occurring depression symptoms among individuals diagnosed with eating disorders. Separate meta-analytic procedures for between-groups and single-group studies were conducted and yielded large effect sizes, indicating that DBT may be efficacious for decreasing disordered episodes among women diagnosed with eating disorders; medium to large effect sizes were noted for treating depression symptoms. Implications for evidence-supported practice and study limitations are discussed.
The current study examined two condensed adaptations of dialectical behavior therapy (DBT) for binge eating. Women with full- or sub-threshold variants of either binge eating disorder or bulimia nervosa were randomly assigned to individually supported self-monitoring using adapted DBT diary cards (DC) or group-based DBT, each 15 sessions over 16 weeks. DC sessions focused on problem-solving diary card completion issues, praising diary card completion, and supporting nonjudgmental awareness of eating-related habits and urges, but not formally teaching DBT skills. Group-based DBT included eating mindfulness, progressing through graded exposure; mindfulness, emotion regulation, and distress tolerance skills; and coaching calls between sessions. Both treatments evidenced large and significant improvements in binge eating, bulimic symptoms, and interoceptive awareness. For group-based DBT, ineffectiveness, drive for thinness, body dissatisfaction, and perfectionism also decreased significantly, with medium to large effect sizes. For DC, results were not significant but large in effect size for body dissatisfaction and medium in effect size for ineffectiveness and drive for thinness. Retention for both treatments was higher than recent trends for eating disorder treatment in fee-for-service practice and for similar clinic settings, but favored DC, with the greater attrition of group-based DBT primarily attributed to its more intensive and time-consuming nature, and dropout overall associated with less pretreatment impairment and greater interoceptive awareness. This preliminary investigation suggests that with both abbreviated DBT-based treatments, substantial improvement in core binge eating symptoms is possible, enhancing potential avenues for implementation beyond more time-intensive DBT. (PsycINFO Database Record (c) 2013 APA, all rights reserved).
Objective:
The authors compared psychoanalytic psychotherapy and cognitive-behavioral therapy (CBT) in the treatment of bulimia nervosa.
Method:
A randomized controlled trial was conducted in which 70 patients with bulimia nervosa received either 2 years of weekly psychoanalytic psychotherapy or 20 sessions of CBT over 5 months. The main outcome measure was the Eating Disorder Examination interview, which was administered blind to treatment condition at baseline, after 5 months, and after 2 years. The primary outcome analyses were conducted using logistic regression analysis.
Results:
Both treatments resulted in improvement, but a marked difference was observed between CBT and psychoanalytic psychotherapy. After 5 months, 42% of patients in CBT (N=36) and 6% of patients in psychoanalytic psychotherapy (N=34) had stopped binge eating and purging (odds ratio=13.40, 95% confidence interval [CI]=2.45-73.42; p<0.01). At 2 years, 44% in the CBT group and 15% in the psychoanalytic psychotherapy group had stopped binge eating and purging (odds ratio=4.34, 95% CI=1.33-14.21; p=0.02). By the end of both treatments, substantial improvements in eating disorder features and general psychopathology were observed, but in general these changes took place more rapidly in CBT.
Conclusions:
Despite the marked disparity in the number of treatment sessions and the duration of treatment, CBT was more effective in relieving binging and purging than psychoanalytic psychotherapy and was generally faster in alleviating eating disorder features and general psychopathology. The findings indicate the need to develop and test a more structured and symptom-focused version of psychoanalytic psychotherapy for bulimia nervosa.
Objective:
Negative affect precedes binge eating and purging in bulimia nervosa (BN), but little is known about factors that precipitate negative affect in relation to these behaviors. We aimed to assess the temporal relation among stressful events, negative affect, and bulimic events in the natural environment using ecological momentary assessment.
Method:
A total of 133 women with current BN recorded their mood, eating behavior, and the occurrence of stressful events every day for 2 weeks. Multilevel structural equation mediation models evaluated the relations among Time 1 stress measures (i.e., interpersonal stressors, work/environment stressors, general daily hassles, and stress appraisal), Time 2 negative affect, and Time 2 binge eating and purging, controlling for Time 1 negative affect.
Results:
Increases in negative affect from Time 1 to Time 2 significantly mediated the relations between Time 1 interpersonal stressors, work/environment stressors, general daily hassles, and stress appraisal and Time 2 binge eating and purging. When modeled simultaneously, confidence intervals for interpersonal stressors, general daily hassles, and stress appraisal did not overlap, suggesting that each had a distinct impact on negative affect in relation to binge eating and purging.
Conclusions:
Our findings indicate that stress precedes the occurrence of bulimic behaviors and that increases in negative affect following stressful events mediate this relation. Results suggest that stress and subsequent negative affect may function as maintenance factors for bulimic behaviors and should be targeted in treatment.
Objective:
This study aimed to determine whether cognitive-behavioral therapy (CBT) for eating disorders can be effective in a routine, primary care clinical setting, and to assess dose response.
Method:
The participants were 47 patients who commenced treatment with a publicly-funded primary care eating disorder service. They attended 7-33 sessions of individual CBT (mean = 17), using an evidence-based approach. Routine measures were collected pre- and post-therapy.
Results:
Three-quarters of the patients completed treatment. Using intention to treat analysis (multiple imputation), the patients showed substantial improvements in eating attitudes, bulimic behaviors, and depression. However, there was no association between the level of improvement and the length of therapy past the 8th to 12th session.
Discussion:
The level of effectiveness shown here is comparable to that previously demonstrated by more specialist services in secondary and tertiary care. The nonlinear association between number of sessions and recovery highlights the importance of early change, across the eating disorders.
Objective:
Depressive symptoms are an important risk factor and consequence of binge eating and purging behavior in bulimia nervosa (BN). Although psychotherapy is effective in reducing symptoms of BN in the short- and long-term, it is unclear whether psychotherapy for BN is also effective in reducing depressive symptoms. This meta-analysis examined the efficacy of psychotherapy for BN on depressive symptoms in the short- and long-term.
Method:
Randomized controlled trials (RCTs) on BN that assessed depressive symptoms as an outcome were identified. Twenty-six RCTs were included.
Results:
Psychotherapy was more efficacious at reducing symptoms of depression at post-treatment (g = 0.47) than wait-lists. This effect was strongest when studies delivered therapist-led, rather than guided self-help, treatment. No significant differences were observed between psychotherapy and antidepressants. There was no significant post-treatment difference between CBT and other active psychological comparisons at reducing symptoms of depression. However, when only therapist-led CBT was analyzed, therapist-led CBT was significantly more efficacious (g = 0.25) than active comparisons at reducing depressive symptoms. The magnitude of the improvement in depressive symptoms was predicted by the magnitude of the improvement in BN symptoms.
Discussion:
These findings suggest that psychotherapy is effective for reducing depressive symptoms in BN in the short-term. Whether these effects are sustained in the long-term is yet to be determined, as too few studies conducted follow-up assessments. Moreover, findings demonstrate that, in addition to being the front-running treatment for BN symptoms, CBT might also be the most effective psychotherapy for improving the symptoms of depression that commonly co-occur in BN.
Objective:
Pharmacotherapy, cognitive-behavioral therapy (CBT), and psychodynamic therapy are most frequently applied to treat mental disorders. However, whether psychodynamic therapy is as efficacious as other empirically supported treatments is not yet clear. Thus, for the first time the equivalence of psychodynamic therapy to treatments established in efficacy was formally tested. The authors controlled for researcher allegiance effects by including representatives of psychodynamic therapy and CBT, the main rival psychotherapeutic treatments (adversarial collaboration).
Method:
The authors applied the formal criteria for testing equivalence, implying a particularly strict test: a priori defining a margin compatible with equivalence (g=0.25), using the two one-sided test procedure, and ensuring the efficacy of the comparator. Independent raters assessed effect sizes, study quality, and allegiance. A systematic literature search used the following criteria: randomized controlled trial of manual-guided psychodynamic therapy in adults, testing psychodynamic therapy against a treatment with efficacy established for the disorder under study, and applying reliable and valid outcome measures. The primary outcome was "target symptoms" (e.g., depressive symptoms in depressive disorders).
Results:
Twenty-three randomized controlled trials with 2,751 patients were included. The mean study quality was good as demonstrated by reliable rating methods. Statistical analyses showed equivalence of psychodynamic therapy to comparison conditions for target symptoms at posttreatment (g=-0.153, 90% equivalence CI=-0.227 to -0.079) and at follow-up (g=-0.049, 90% equivalence CI=-0.137 to -0.038) because both CIs were included in the equivalence interval (-0.25 to 0.25).
Conclusions:
Results suggest equivalence of psychodynamic therapy to treatments established in efficacy. Further research should examine who benefits most from which treatment.
Objective:
Meta-analyses have documented the efficacy of cognitive-behavioral therapy (CBT) for reducing symptoms of eating disorders. However, it is not known whether CBT for eating disorders can also improve quality of life (QoL). This meta-analysis therefore examined the effects of CBT for eating disorders on subjective QoL and health-related quality of life (QoL).
Method:
Studies that assessed QoL before and after CBT for eating disorders were searched in the PsycInfo and Medline database. Thirty-four articles met inclusion criteria. Pooled within and between-groups Hedge's g were calculated at post-treatment and follow-up for treatment changes on both subjective and HRQoL using a random effects model.
Results:
CBT led to significant and modest improvements in subjective QoL and HRQoL from pre to post-treatment and follow-up. CBT led to greater subjective QoL improvements than inactive (i.e., wait-list) and active (i.e., a combination of bona fide therapies, psychoeducation) comparisons. CBT also led to greater HRQoL improvements than inactive, but not active, comparisons. Prepost QoL improvements were larger in studies that delivered CBT individually and by a therapist or according to the cognitive maintenance model of eating disorders (CBT-BN or CBT-E); though this was not replicated at follow-up CONCLUSIONS: Findings provide preliminary evidence that CBT for eating disorders is associated with modest improvements in QOL, and that CBT may be associated with greater improvements in QOL relative to comparison conditions.
Remarkable progress has been made in developing psychosocial interventions for eating disorders and other mental disorders. Two priorities in providing treatment consist of addressing the research-practice gap and the treatment gap. The research-practice gap pertains to the dissemination of evidence-based treatments from controlled settings to routine clinical care. Closing the gap between what is known about effective treatment and what is actually provided to patients who receive care is crucial in improving mental health care, particularly for conditions such as eating disorders. The treatment gap pertains to extending treatments in ways that will reach the large number of people in need of clinical care who currently receive nothing. Currently, in the United States (and worldwide), the vast majority of individuals in need of mental health services for eating disorders and other mental health problems do not receive treatment. This article discusses the approaches required to better ensure: (1) that more people who are receiving treatment obtain high-quality, evidence-based care, using such strategies as train-the-trainer, web-centered training, best-buy interventions, electronic support tools, higher-level support and policy; and (2) that a higher proportion of those who are currently underserved receive treatment, using such strategies as task shifting and disruptive innovations, including treatment delivery via telemedicine, the Internet, and mobile apps.
This systematic review synthesised the literature on predictors, moderators, and mediators of outcome following Fairburn's CBT for eating disorders. Sixty-five articles were included. The relationship between individual variables and outcome was synthesised separately across diagnoses and treatment format. Early change was found to be a consistent mediator of better outcomes across all eating disorders. Moderators were mostly tested in binge eating disorder, and most moderators did not affect cognitive-behavioural treatment outcome relative to other treatments. No consistent predictors emerged. Findings suggest that it is unclear how and for whom this treatment works. More research testing mediators and moderators is needed, and variables selected for analyses need to be empirically and theoretically driven. Future recommendations include the need for authors to (i) interpret the clinical and statistical significance of findings; (ii) use a consistent definition of outcome so that studies can be directly compared; and (iii) report null and statistically significant findings.
Background. Early weak treatment response is one of the few trans-diagnostic, treatment-agnostic predictors of poor outcome following a full treatment course. We sought to improve the outcome of clients with weak initial response to guided self-help cognitive behavior therapy (GSH).
Method. One hundred and nine women with binge-eating disorder (BED) or bulimia nervosa (BN) (DSM-IV-TR)
received 4 weeks of GSH. Based on their response, they were grouped into: (1) early strong responders who continued
GSH (cGSH), and early weak responders randomized to (2) dialectical behavior therapy (DBT), or (3) individual and
additional group cognitive behavior therapy (CBT+).
Results. Baseline objective binge-eating-day (OBD) frequency was similar between DBT, CBT+ and cGSH. During treatment,
OBD frequency reduction was significantly slower in DBT and CBT+ relative to cGSH. Relative to cGSH, OBD frequency was significantly greater at the end of DBT (d = 0.27) and CBT+ (d = 0.31) although these effects were small and within-treatment effects from baseline were large (d = 1.41, 0.95, 1.11, respectively). OBD improvements significantly
diminished in all groups during 12 months follow-up but were significantly better sustained in DBT relative to cGSH (d = −0.43). At 6- and 12-month follow-up assessments, DBT, CBT and cGSH did not differ in OBD.
Conclusions. Early weak response to GSH may be overcome by additional intensive treatment. Evidence was insufficient to support superiority of either DBT or CBT+ for early weak responders relative to early strong responders in cGSH; both were helpful. Future studies using adaptive designs are needed to assess the use of early response to efficiently deliver care to large heterogeneous client groups.
Aims
The standardised mean difference (SMD) is one of the most used effect sizes to indicate the effects of treatments. It indicates the difference between a treatment and comparison group after treatment has ended, in terms of standard deviations. Some meta-analyses, including several highly cited and influential ones, use the pre-post SMD, indicating the difference between baseline and post-test within one (treatment group).
Methods
In this paper, we argue that these pre-post SMDs should be avoided in meta-analyses and we describe the arguments why pre-post SMDs can result in biased outcomes.
Results
One important reason why pre-post SMDs should be avoided is that the scores on baseline and post-test are not independent of each other. The value for the correlation should be used in the calculation of the SMD, while this value is typically not known. We used data from an ‘individual patient data’ meta-analysis of trials comparing cognitive behaviour therapy and anti-depressive medication, to show that this problem can lead to considerable errors in the estimation of the SMDs. Another even more important reason why pre-post SMDs should be avoided in meta-analyses is that they are influenced by natural processes and characteristics of the patients and settings, and these cannot be discerned from the effects of the intervention. Between-group SMDs are much better because they control for such variables and these variables only affect the between group SMD when they are related to the effects of the intervention.
Conclusions
We conclude that pre-post SMDs should be avoided in meta-analyses as using them probably results in biased outcomes.
Objective:
This review aimed to (a) examine the effects of rapid response on behavioral, cognitive, and weight-gain outcomes across the eating disorders, (b) determine whether diagnosis, treatment modality, the type of rapid response (changes in disordered eating cognitions or behaviors), or the type of behavioral outcome moderated this effect, and (c) identify factors that predict a rapid response.
Method:
Thirty-four articles met inclusion criteria from six databases. End of treatment and follow-up outcomes were divided into three categories: Behavioral (binge eating/purging), cognitive (EDE global scores), and weight gain. Average weighted effect sizes(r) were calculated.
Results:
Rapid response strongly predicted better end of treatment and follow-up cognitive and behavioral outcomes. Moderator analyses showed that the effect size for rapid response on behavioral outcomes was larger when studies included both binge eating and purging (as opposed to just binge eating) as a behavioral outcome. Diagnosis, treatment modality, and the type of rapid response experienced did not moderate the relationship between early response and outcome. The evidence for weight gain was mixed. None of the baseline variables analyzed (eating disorder psychopathology, demographics, BMI, and depression scores) predicted a rapid response.
Discussion:
As there is a solid evidence base supporting the prognostic importance of rapid response, the focus should shift toward identifying the within-treatment mechanisms that predict a rapid response so that the effectiveness of eating disorder treatment can be improved. There is a need for future research to use theories of eating disorders as a guide to assess within-treatment predictors of rapid response. © 2016 Wiley Periodicals, Inc.
In this review, we examine common usage of the term third wave in the scientific literature, systematically review published meta-analyses of identified third wave therapies, and consider the implications and options for the use of third wave as a metaphor to describe the nature of and relationships among cognitive and behavioral therapies. We demonstrate that the third wave term has grown in its use over time, that it is commonly linked with specific therapies, and that the majority of such therapies have amassed a compelling evidence base attesting to their clinical and public health value. We also consider the extent to which the third wave designation is an effective guide for the future, and we encourage scientific inquiry and self-reflection among those concerned with cognitive and behavioral therapies and the scientific basis of psychotherapy more broadly.
Background:
The best treatment options for binge-eating disorder are unclear.
Purpose:
To summarize evidence about the benefits and harms of psychological and pharmacologic therapies for adults with binge-eating disorder.
Data sources:
English-language publications in EMBASE, the Cochrane Library, Academic OneFile, CINAHL, and ClinicalTrials.gov through 18 November 2015, and in MEDLINE through 12 May 2016.
Study selection:
9 waitlist-controlled psychological trials and 25 placebo-controlled trials that evaluated pharmacologic (n = 19) or combination (n = 6) treatment. All were randomized trials with low or medium risk of bias.
Data extraction:
2 reviewers independently extracted trial data, assessed risk of bias, and graded strength of evidence.
Data synthesis:
Therapist-led cognitive behavioral therapy, lisdexamfetamine, and second-generation antidepressants (SGAs) decreased binge-eating frequency and increased binge-eating abstinence (relative risk, 4.95 [95% CI, 3.06 to 8.00], 2.61 [CI, 2.04 to 3.33], and 1.67 [CI, 1.24 to 2.26], respectively). Lisdexamfetamine (mean difference [MD], -6.50 [CI, -8.82 to -4.18]) and SGAs (MD, -3.84 [CI, -6.55 to -1.13]) reduced binge-eating-related obsessions and compulsions, and SGAs reduced symptoms of depression (MD, -1.97 [CI, -3.67 to -0.28]). Headache, gastrointestinal upset, sleep disturbance, and sympathetic nervous system arousal occurred more frequently with lisdexamfetamine than placebo (relative risk range, 1.63 to 4.28). Other forms of cognitive behavioral therapy and topiramate also increased abstinence and reduced binge-eating frequency and related psychopathology. Topiramate reduced weight and increased sympathetic nervous system arousal, and lisdexamfetamine reduced weight and appetite.
Limitations:
Most study participants were overweight or obese white women aged 20 to 40 years. Many treatments were examined only in single studies. Outcomes were measured inconsistently across trials and rarely assessed beyond end of treatment.
Conclusion:
Cognitive behavioral therapy, lisdexamfetamine, SGAs, and topiramate reduced binge eating and related psychopathology, and lisdexamfetamine and topiramate reduced weight in adults with binge-eating disorder.
Primary funding source:
Agency for Healthcare Research and Quality.
The current study sought to assess the acceptability and feasibility of a compassion-focused therapy (CFT) group as an adjunct to evidence-based outpatient treatment for eating disorders, and to examine its preliminary efficacy relative to treatment as usual (TAU). Twenty-two outpatients with various types of eating disorders were randomly assigned to 12 weeks of TAU (n = 11) or TAU plus weekly CFT groups adapted for an eating disorder population (CFT + TAU; n = 11). Participants in both conditions completed measures of self-compassion, fears of compassion, shame and eating disorder pathology at baseline, week 4, week 8 and week 12. Additionally, participants receiving the CFT group completed measures assessing acceptability and feasibility of the group. Results indicated that the CFT group demonstrated strong acceptability; attendance was high and the group retained over 80% of participants. Participants rated the group positively and indicated they would be very likely to recommend it to peers with similar symptoms. Intention-to-treat analyses revealed that compared to the TAU condition, the CFT + TAU condition yielded greater improvements in self-compassion, fears of self-compassion, fears of receiving compassion, shame and eating disorder pathology over the 12 weeks. Results suggest that group-based CFT, offered in conjunction with evidence-based outpatient TAU for eating disorders, may be an acceptable, feasible and efficacious intervention. Furthermore, eating disorder patients appear to see benefit in, and observe gains from, working on the CFT goals of overcoming fears of compassion, developing more self-compassion and accessing more compassion from others. Copyright © 2016 John Wiley & Sons, Ltd.
Cognitive-behavioural therapy (CBT) is the recommended treatment for binge eating, yet many individuals do not recover, and innovative new treatments have been called for. The current study compares traditional CBT with two augmented versions of CBT; schema therapy, which focuses on early life experiences as pivotal in the history of the eating disorder; and appetite-focused CBT, which emphasises the role of recognising and responding to appetite in binge eating. 112 women with transdiagnostic DSM-IV binge eating were randomized to the three therapies. Therapy consisted of weekly sessions for six months, followed by monthly sessions for six months. Primary outcome was the frequency of binge eating. Secondary and tertiary outcomes were other behavioural and psychological aspects of the eating disorder, and other areas of functioning. No differences among the three therapy groups were found on primary or other outcomes. Across groups, large effect sizes were found for improvement in binge eating, other eating disorder symptoms and overall functioning. Schema therapy and appetite-focused CBT are likely to be suitable alternative treatments to traditional CBT for binge eating.
Objective:
Interpersonal psychotherapy (IPT) has been developed for the treatment of depression but has been examined for several other mental disorders. A comprehensive meta-analysis of all randomized trials examining the effects of IPT for all mental health problems was conducted.
Method:
Searches in PubMed, PsycInfo, Embase, and Cochrane were conducted to identify all trials examining IPT for any mental health problem.
Results:
Ninety studies with 11,434 participants were included. IPT for acute-phase depression had moderate-to-large effects compared with control groups (g=0.60; 95% CI=0.45-0.75). No significant difference was found with other therapies (differential g=0.06) and pharmacotherapy (g=-0.13). Combined treatment was more effective than IPT alone (g=0.24). IPT in subthreshold depression significantly prevented the onset of major depression, and maintenance IPT significantly reduced relapse. IPT had significant effects on eating disorders, but the effects are probably slightly smaller than those of cognitive-behavioral therapy (CBT) in the acute phase of treatment. In anxiety disorders, IPT had large effects compared with control groups, and there is no evidence that IPT was less effective than CBT. There was risk of bias as defined by the Cochrane Collaboration in the majority of studies. There was little indication that the presence of bias influenced outcome.
Conclusions:
IPT is effective in the acute treatment of depression and may be effective in the prevention of new depressive disorders and in preventing relapse. IPT may also be effective in the treatment of eating disorders and anxiety disorders and has shown promising effects in some other mental health disorders.
Binge eating disorder (BED), characterized by recurrent eating episodes in which individuals eat an objectively large amount of food within a short time period accompanied by a sense of loss of control, is the most common eating disorder. While existing treatments, such as cognitive behavioral therapy (CBT), produce remission in a large percentage of individuals with BED, room for improvement in outcomes remains. Two reasons some patients may continue to experience binge eating after a course of treatment are: (a) Difficulty complying with the prescribed behavioral components of CBT due to the discomfort of implementing such strategies; and (b) a lack of focus in current treatments on strategies for coping with high levels of negative affect that often drive binge eating. To optimize treatment outcomes, it is therefore crucial to provide patients with strategies to overcome these issues. A small but growing body of research suggests that acceptance-based treatment approaches may be effective for the treatment of binge eating. The goal of the current paper is to describe the development of an acceptance-based group treatment for BED, discuss the structure of the manual and the rationale and challenges associated with integrating acceptance-based strategies into a CBT protocol, and to discuss clinical strategies for successfully implementing the intervention.
Over the 20 years since the criteria for empirically supported treatments (ESTs) were published, standards for synthesizing evidence have evolved and more systematic approaches to reviewing the findings from intervention trials have emerged. Currently, the APA is planning the development of treatment guidelines, a process that will likely take many years. As an intermediate step, we recommend a revised set of criteria for ESTs that will utilize existing systematic reviews of all of the available literature, and recommendations that address the methodological quality, outcomes, populations, and treatment settings included in the literature.
Psychotherapists report routinely not practising evidence-based treatments. However, there is little research examining the content of therapy from the patient perspective. This study examined the self-reported treatment experiences of individuals who had been told that they had received cognitive-behavior therapy (CBT) for their eating disorder. One hundred and fifty-seven such sufferers (mean age = 25.69 years) were recruited from self-help organisations. Participants completed an online survey assessing demographics, clinical characteristics, and therapy components. The use of evidence-based CBT techniques varied widely, with core elements for the eating disorders (e.g., weighing and food monitoring) used at well below the optimum level, while a number of unevidenced techniques were reported as being used commonly. Cluster analysis showed that participants received different patterns of intervention under the therapist label of 'CBT', with evidence-based CBT being the least common. Therapist age and patient diagnosis were related to the pattern of intervention delivered. It appears that clinicians are not subscribing to a transdiagnostic approach to the treatment of eating disorders. Patient recollections in this study suppo