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Meta-analysis of the effects of cognitive-behavioral therapy on the core eating disorder maintaining mechanisms: Implications for mechanisms of therapeutic change

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Abstract

The original and enhanced cognitive model of eating disorders proposes that cognitive-behavioral therapy (CBT) “works” through modifying dietary restraint and dysfunctional attitudes towards shape and weight. However, evidence supporting the validity of this cognitive model is limited. This meta-analysis examined whether CBT can indeed effectively modify these proposed maintaining mechanisms. Randomized controlled trials that compared CBT to control conditions or non-CBT interventions, and reported outcomes on dietary restraint and shape and weight concerns were searched. Twenty-nine trials were included. CBT was superior to control conditions in reducing shape (g=0.53) and weight (g=0.63) concerns, and dietary restraint (g=0.36). These effects occurred across all eating disorder presentations and treatment formats. Improvements in shape and weight concerns and restraint were also greater in CBT than non-CBT interventions (g’s=0.25, 0.24, 0.31, respectively) at post-treatment and follow-up. The magnitude of improvement in binge/purge symptoms was related to the magnitude of improvement in these maintaining mechanisms. Findings demonstrate that CBT has a specific effect in targeting the eating disorder maintaining mechanisms, and offers support to the underlying cognitive model. If changes in these variables during the course of treatment are shown to be causal mechanisms, then these findings show that CBT, relative to non-CBT interventions, is better able to modify these mechanisms.

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... In addition, some of the core eating disorder symptoms directly targeted in treatment resemble self-esteem deficits in a specific domain, rather than as an overall negative self-worth (e.g., overvaluation represents low self-esteem specifically in the domain of weight, shape, and their control; Fairburn, 2008). Because of this, the beneficial effects of psychotherapy on such specific symptoms like overvaluation (Linardon, 2018a) may have a "flow-on" effect or generalize to improvements in more general negative self-worth. However, the precise mechanisms underpinning the effects of psychotherapy on self-esteem improvement are unknown. ...
... Linardon, Wade, De la Piedad Garcia, & Brennan, 2017a) and shape/weight concern improvements (g's = 0.53-0.63; Linardon, 2018a). This was somewhat expected, as self-esteem is typically not a direct target for many of the psychological treatments examined in this study, hence resulting in small effects. ...
... There was no evidence that CBT was more effective in improving self-esteem than non-CBT interventions. This finding goes against recent meta-analyses reporting the superiority of CBT over non-CBT interventions in reducing eating disorder psychopathology (Brownley et al., 2016;Linardon, 2018a;Linardon et al., 2017a), quality of life impairment (Linardon & Brennan, 2017), and depressive symptoms (Linardon, Wade, De la Piedad Garcia, & Brennan, 2017b;Vocks et al., 2010) in BN and BED. However, the lack of significant differences between treatments in this study may have been a result of insufficient statistical power. ...
Article
Objectives This meta‐analysis examined the effects of psychotherapy for bulimia nervosa (BN) and binge‐eating disorder (BED) on self‐esteem improvement. Method Randomized controlled trials (RCTs) of psychological treatments that assessed self‐esteem change in eating disorders were included. Thirty‐four RCTs were included; most sampled BED and then BN. Hedge's g effects were entered into random effects models. Results Psychotherapy for BN led to significantly greater post‐treatment improvements in self‐esteem than control conditions (g = 0.45; 95% CI [0.17, 0.73]). This effect was smaller when only analysing low risk of bias trials (g = 0.28; 95% CI [0.05, 0.51]). Psychotherapy for BED also led to significantly greater post‐treatment improvements in self‐esteem than controls (g = 0.20; 95% CI [0.05, 0.35]), with some evidence that guided self‐help was associated with the largest effects. This effect, however, was overestimated after adjustment for publication bias (g = 0.10; 95% CI [−0.05, 0.26]). There was no evidence that cognitive‐behavioural therapy was superior to non‐cognitive‐behavioural therapy interventions in improving self‐esteem. There was no relationship between symptom improvement and self‐esteem improvement in a meta‐regression. Conclusions Psychotherapy may lead to small improvements in self‐esteem in BN and BED. Additional RCTs with follow‐up assessments are required to make more definitive conclusions about the effects of psychotherapy for eating disorders on self‐esteem in the long‐term.
... Treatment effects for CBT relative to other treatments have been established through several meta-analyses of randomized controlled trials (RCTs). CBT has demonstrated effectiveness in reducing eating-disordered cognitions [30] depressive symptoms [31] and increasing quality of life [32]. Furthermore, reduction of ED psychopathology predicted the reduction of behavioral symptoms for BN and BED samples [30], and reduction of binge/purge symptoms have been found to predict greater reduction of depressive symptoms in BN samples receiving CBT, compared to other treatments [31]. ...
... CBT has demonstrated effectiveness in reducing eating-disordered cognitions [30] depressive symptoms [31] and increasing quality of life [32]. Furthermore, reduction of ED psychopathology predicted the reduction of behavioral symptoms for BN and BED samples [30], and reduction of binge/purge symptoms have been found to predict greater reduction of depressive symptoms in BN samples receiving CBT, compared to other treatments [31]. These findings lend preliminary support for the cognitive-behavioral model of EDs, and thus the core behavioral and cognitive symptoms as principal targets of therapeutic interventions. ...
... Inferences as to the effect of other specified therapeutic approaches have, however, been difficult to make from meta-analyses of RCTs, e.g., [30][31][32][33][34][35] because effect sizes have been based on differences between treatment arms containing heterogenous interventions (e.g. different combinations of active experimental treatments, multimodal interventions and different variants of treatment as usual or active psychotherapy control conditions). ...
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Background: Cognitive behavior therapy (CBT) and psychodynamic-interpersonal therapies (PIT) are two widely used and conceptually different outpatient treatments for eating disorders (EDs). To better understand how these treatments works, for whom, and under what circumstances, there is a need for knowledge about how outcomes are affected by diagnosis, comorbidity, changes in psychopathology, and study design. Method: Reports on the effects of CBT and PIT for eating disorders were searched. Rates of remission and changes in ED specific- and general psychopathology were computed. Regression models were made to predict event rates by changes in specific- and general psychopathology, as well as ED diagnosis and study design. Results: The remission rate of CBT for binge eating disorder was 50%, significantly higher than the effect for other diagnostic groups (anorexia = 33%, bulimia: 28%, mixed samples 30%). The number of studies found for PIT was limited. All effect sizes differed from zero (binge eating disorder = 27%, anorexia = 24%, bulimia = 18%, mixed samples = 15%), but the precision of the estimates was low, with some lower-bound confidence intervals close to zero. For CBT, change in ED specific psychopathology predicted remission only when controlling for ED diagnosis, while change in general psychopathology did not predict remission at all. The predictive value of change in psychopathology for PIT, and the potential impact of comorbid personality disorders could not be analyzed due to a lack of studies. There was no difference in effects between randomized controlled trials and observational studies. Conclusions: CBT showed consistent remission rates for all EDs but left a substantial number of patients not in remission. Extant evidence suggest that PIT is not consistently effective in achieving remission for patients with EDs, although this finding is uncertain due to a small number of eligible studies. A group of patients with eating disorders may, however, require therapy aimed at strengthening deficits in self functions not easily ameliorable by cognitive behavioral techniques alone. Further research should be aimed at identifying treatment interventions that helps patients change behavior, while strengthening self-functions to substitute eating-disordered behavior in the long-term.
... The leading evidence-based treatment for BN is cognitive behavioral therapy (CBT), a present-focused, active, skill-oriented treatment. Although CBT can be an effective treatment for BN, a recent meta-analysis found that nearly 70% of patients remain at least partially symptomatic at the end of the treatment [2]. ...
... Acquisition and utilization of therapeutic skills designed to reduce dietary restraint (eg, regular eating) consistently predict treatment outcomes [4][5][6][7]. In addition, numerous studies have demonstrated that reduction of dietary restraint is a key mechanism of action in CBT for BN [2,[8][9][10][11]. Although less well-studied, failure to respond adaptively to cues for binge eating (particularly a failure to regulate negative affect) is also strongly associated with the maintenance of BN symptoms [12,13]. ...
... As described above, CBT for BN strives to help patients acquire and use skills designed to (1) reduce dietary restraint and (2) increase adaptive responses to cues [3]. To reduce dietary restraint, CBT for BN encourages the development of 3 core skills: (1) scheduling eating episodes at regular intervals throughout the day, with the goal of eating 3 meals and 1-2 snacks per day; (2) eating a sufficient number of calories at each meal or snack to prevent acute hunger; and (3) eating a sufficient range of food, including foods the patient may fear eating (eg, desserts and carbohydrates), to reduce or prevent feelings of deprivation. ...
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Background Cognitive behavioral therapy (CBT) for bulimia nervosa (BN) is most effective when patients demonstrate adequate skill utilization (ie, the frequency with which a patient practices or uses therapeutic skills) and skill acquisition (ie, the ability to successfully perform a skill learned in treatment). However, rates of utilization and acquisition of key treatment skills (eg, regular eating, urge management skills, and mood management skills) by the end of the treatment are frequently low; as a result, outcomes from CBT for BN are affected. Just-in-time adaptive interventions (JITAIs) may improve skill acquisition and utilization by delivering real-time interventions during algorithm-identified opportunities for skill practice. Objective In this manuscript, we describe a newly developed JITAI system called CBT+ that is designed to facilitate the acquisition and utilization of CBT for BN treatment skills when used as a treatment augmentation. We also present feasibility, acceptability, and preliminary outcomes data from a small proof-of-concept pilot trial (n=5 patients and n=3 clinicians) designed to identify opportunities for iterative development of CBT+ ahead of a larger ongoing randomized controlled trial. MethodsA total of 5 individuals with BN received 16 sessions of outpatient CBT for BN while using the CBT+ app. Data were collected from patients and clinicians to evaluate the feasibility (eg, app use and user adherence), acceptability (eg, qualitative patient and clinician feedback, including usefulness ratings of CBT+ on a 6-point Likert scale ranging from 1=extremely useless to 6=extremely useful), and preliminary outcomes (eg, improvements in skill utilization and acquisition and BN symptoms) of the CBT+ system. ResultsPatients reported that CBT+ was a relatively low burden (eg, quick and easy-to-use self-monitoring interface), and adherence to in-app self-monitoring was high (mean entries per day 3.13, SD 1.03). JITAIs were perceived as useful by both patients (median rating 5/6) and clinicians (median rating 5/6) for encouraging the use of CBT skills. Large improvements in CBT skills and clinically significant reductions in BN symptoms were observed post treatment. Although preliminary findings indicated that the CBT+ system was acceptable to most patients and clinicians, the overall study dropout was relatively high (ie, 2/5, 40% patients), which could indicate some moderate concerns regarding feasibility. ConclusionsCBT+, the first-ever JITAI system designed to facilitate the acquisition and utilization of CBT for BN treatment skills when used as a treatment augmentation, was shown to be feasible and acceptable. The results indicate that the CBT+ system should be subjected to more rigorous evaluations with larger samples and should be considered for wider implementation if found effective. Areas for iterative improvement of the CBT+ system ahead of a randomized controlled trial are also discussed.
... Secondary outcomes included the severity of overall eating and depressive pathology. Thereby, this study aimed to update and extend previous systematic reviews and meta-analyses (Hughes et al., 1986;Freeman et al., 1988;Agras et al., 1989Agras et al., , 2000Fluoxetine Bulimia Nervosa Collaborative Study Group, 1992;Walsh et al., 1997;Bacaltchuk et al., 2000;Hsu et al., 2001;Bacaltchuk and Hay, 2003;Lundgren et al., 2004;Nickel et al., 2005;Shapiro et al., 2007;Arbaizar et al., 2008;Hay et al., 2009;Linardon et al., 2017a, 2017c, Linardon, 2018aSlade et al., 2018). ...
... In spite of first support for dialectic behavioral therapy in BN, independent replication is desirable, and follow-up data are required to determine its sustainability. Guided CBT-based self-help could be considered as an alternative if CBT cannot be realized, targeting the same mechanisms as clinician-led CBT, i.e. dietary restraint and shapeand weight concerns (Linardon, 2018a). Pharmacotherapy was shown to be moderately effective and may be suited for patients who prefer drug treatment. ...
Article
Background Bulimia nervosa (BN), a mental disorder that causes significant impairment, can be treated with psychological, pharmacological, nutrition-based and self-help interventions. We conducted a pre-registered meta-analysis of randomized-controlled trials (RCTs) to assess the efficacy of these interventions in up to 19 different interventions. Methods Database search terms were combined for BN and RCTs from database inception to March 2017. Abstinence from binge eating episodes, compensatory behaviors, the absence of a BN diagnosis and reduction of symptom severity were considered as primary outcome variables, reduction of self-reported eating pathology and depression served as secondary outcome variables. Retrieved RCTs were meta-analyzed using fixed and random effects models. Results RCT (79 trials; 5775 participants) effects post-treatment revealed moderate to large intervention effects for psychotherapy [mostly cognitive-behavioral therapy (CBT)] for primary outcome variables. Slightly reduced effects were obtained for self-help and moderate effects for pharmacotherapy. Similarly, psychotherapy yielded large to very large effects in regard to secondary outcome variables, while moderate to large effects were observed for self-help, Pharmacotherapy and combined therapies. Meta-analyses for the pre to post changes within group confirmed these findings. Additionally, follow-up analyses revealed the sustainability of psychotherapies in terms of large effects in primary outcome criteria, while these effects were moderate for self-help, pharmacotherapy, and combined therapies. Conclusions Most psychological and pharmacological interventions revealed to be effective in BN treatment. Taking effect size, sustainability of the intervention, as well as the consistency of findings and available evidence into consideration, CBT can be recommended as the best intervention for the initial treatment of BN.
... CBT has demonstrated effectiveness in reducing eating-disordered cognitions (28) depressive symptoms (29) and increasing quality of life (30). Furthermore, reduction of ED psychopathology predicted the reduction of behavioral symptoms for BN and BED samples (28), and reduction of binge/purge symptoms have been found to predict greater reduction of depressive symptoms in BN samples receiving CBT, compared to other treatments (29). These ndings lend preliminary support for the cognitive-behavioral model of EDs, and thus the core behavioral and cognitive symptoms as principal targets of therapeutic interventions. ...
... However, inferences as to the effect of different speci ed therapeutic approaches have been di cult to make from meta-analytic inquiries, e.g., (28)(29)(30)(31)(32)(33). This di culty is due to the often multi-modal and methodologically heterogenous nature of the treatments under study and their comparator-treatments (e.g., different combinations of active psychotherapies, treatment as usual, or wait-list conditions). ...
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Background: Cognitive behavior therapy (CBT) and psychodynamic-interpersonal therapies (PIT) are the most used outpatient treatments for eating disorders. Knowledge about the outcomes of these therapies in terms of remission is limited. Also, there is a lack of knowledge about how different therapeutic changes and patient characteristic affects outcomes. Method: Reports on the effects of CBT and PIT for eating disorders were searched. Rates of remission and changes in eating disorder specific and general psychopathology were computed and meta-analytically synthesized. Regression models were made to predict summary event rates by patient characteristics and changes in specific and general psychopathology. Results: Only CBT produced remission rates (34.2%) significantly different from waitlist conditions, and only CBT led to significantly greater change in specific psychopathology than waitlist/nutritional counseling conditions. However, CBT and PIT were equally effective in changing general psychopathology. For CBT, change in specific psychopathology predicted remission only when controlling for differences between diagnostic categories. Change in general psychopathology predicted remission only for PIT. The presence of comorbid personality disorder decreased the effect of CBT. Conclusions: A group of patients with eating disorders may require therapy aimed at strengthening deficits in self functions not easily ameliorable by cognitive behavioral techniques alone. However, although effective in changing specific and general psychopathology, PIT is not effective in producing behavioral change. Further research should be aimed at identifying treatment interventions that effectuate both behavioral change and strengthening self-functions to substitute eating-disordered behavior to meet psychological needs in the long-term.
... Cognitive-behavioral therapy (CBT) is the most thoroughly investigated eating disorder treatment. Numerous meta-analyses have demonstrated that clinician-led and guided forms of CBT are significantly more efficacious than control conditions for bulimia nervosa (BN), binge-eating disorder (BED), and other specified feeding or eating disorders (Hay, Bacaltchuk, Stefano, & Kashyap, 2009;Linardon, 2018;Linardon, Wade, De la Piedad Garcia, & Brennan, 2017a,b;Traviss-Turner, West, & Hill, 2017;Vocks et al., 2010). There is also evidence that CBT for BN and BED is significantly more efficacious than other psychological (e.g., interpersonal psychotherapy) and behavioral (e.g., behavioral weight loss) interventions (Linardon et al., 2017a). ...
Article
Objective: Cognitive-behavioral therapy (CBT) is efficacious for a range of eating disorder presentations, yet premature dropout is one factor that might limit CBTs effectiveness. Improved understanding of dropout from CBT for eating disorders is important. This meta-analysis aimed to study dropout from CBT for eating disorders in randomized controlled trials (RCTs), by (a) identifying the types of dropout definitions applied, (b) providing estimates of dropout, (c) comparing dropout rates from CBT to non-CBT interventions for eating disorders, and (d) testing moderators of dropout. Method: RCTs of CBT for eating disorders that reported rates of dropout were searched. Ninety-nine RCTs (131 CBT conditions) were included. Results: Dropout definitions varied widely across studies. The overall dropout estimate was 24% (95% CI = 22-27%). Diagnostic type, type of dropout definition, baseline symptom severity, study quality, and sample age did not moderate this estimate. Dropout was highest among studies that delivered internet-based CBT and was lowest in studies that delivered transdiagnostic enhanced CBT. There was some evidence that longer treatment protocols were associated with lower dropout. No significant differences in dropout rates were observed between CBT and non-CBT interventions for all eating disorder subtypes. Conclusion: Present study dropout estimates are hampered by the use of disparate dropout definitions applied. This meta-analysis highlights the urgency for RCTs to utilize a standardized dropout definition and to report as much information on patient dropout as possible, so that strategies designed to minimize dropout can be developed, and factors predictive of CBT dropout can be more easily identified.
... Based upon this maintenance model, reductions in dietary restraint and weight/shape concerns have been hypothesized to be key mechanisms by which CBT works . Evidence indicates that CBT does, in fact, target these hypothesized mechanisms (Linardon, 2018b); however, CBT has not demonstrated superior efficacy over other psychotherapy treatments for BED that seek to address alternative hypothesized maintenance factors (Hilbert et al., 2019). For example, interpersonal psychotherapy (Wilfley et al., 2002), which seeks to reduce interpersonal problems while improving interpersonal selfefficacy and self-esteem (Murphy, Cooper, Hollon, & Fairburn, 2009), has been found to perform comparably to CBT for BED (Hilbert et al., 2019). ...
Article
Objective: To examine changes in hypothesized maintenance mechanisms during treatment as predictors of treatment response durability in binge-eating disorder (BED) treatment, using data from a randomized clinical trial comparing the efficacy of Integrative Cognitive-Affective Therapy for BED with cognitive-behavioral therapy delivered using guided self-help. Method: Adults with BED (N = 112) received 17 weeks of treatment. Regression models were conducted to examine the extent to which changes in hypothesized maintenance mechanisms from baseline to end of treatment predicted treatment outcomes at 6-month follow-up, adjusting for demographics, study site, and baseline level of treatment outcome. Results: During-treatment reductions in negative self-directed style and emotion dysregulation predicted reductions in the primary treatment outcome (i.e., binge-eating episode frequency) at follow-up. During-treatment reductions in emotion dysregulation also predicted improvements at follow-up across all three secondary treatment outcomes examined (i.e., global eating disorder [ED] psychopathology, depressive symptoms, and anxiety symptoms), as did during-treatment reductions in actual-ideal self-discrepancy and actual-ought self-discrepancy. Increases in positive self-directed style (e.g., self-affirmation) and reductions in negative self-directed style (e.g., self-blame) during treatment each predicted improvements in anxiety symptoms at follow-up. When predictors were examined simultaneously, the most salient predictors of treatment response durability identified were negative self-directed style for binge-eating episode frequency, actual-ought self-discrepancy and emotion dysregulation for depressive symptoms, and emotion dysregulation for anxiety symptoms. No predictors emerged as most salient for global ED psychopathology. Discussion: Results indicate that negative self-directed style and emotion dysregulation are particularly important treatment targets in relation to behavioral treatment outcomes in BED.
... Fairburn and colleagues provided a useful model for understanding the different "types" of restraint components, why each of these restraint component should be specifically targeted in treatment, and what role each restraint component has in maintaining other eating disorder symptoms (Fairburn, 2008(Fairburn, , 2013Fairburn, Marcus, & Wilson, 1993). This model underpins cognitive-behavioural therapy (CBT), and although CBT is one the leading evidence-based eating disorder treatments (Linardon, Wade, De la Piedad Garcia, & Brennan, 2017b) recent calls have been made to improve its effectiveness (Linardon, 2018). ...
... Fairburn and colleagues provided a useful model for understanding the different "types" of restraint components, why each of these restraint component should be specifically targeted in treatment, and what role each restraint component has in maintaining other eating disorder symptoms (Fairburn, 2008(Fairburn, , 2013Fairburn, Marcus, & Wilson, 1993). This model underpins cognitive-behavioural therapy (CBT), and although CBT is one the leading evidence-based eating disorder treatments (Linardon, Wade, De la Piedad Garcia, & Brennan, 2017b) recent calls have been made to improve its effectiveness (Linardon, 2018). ...
Article
Although empirical evidence identifies dietary restraint as a transdiagnostic eating disorder maintaining mechanism, the distinctiveness and significance of the different behavioural and cognitive components of dietary restraint are poorly understood. The present study examined the relative associations of the purportedly distinct dietary restraint components (intention to restrict, delayed eating, food avoidance, and diet rules) with measures of psychological distress (depression, anxiety, and stress), disability, and core eating disorder symptoms (overvaluation and binge eating) in patients with anorexia nervosa (AN) and bulimia nervosa (BN). Data were analysed from a treatment-seeking sample of individuals with AN (n = 124) and BN (n = 54). Intention to restrict, food avoidance, and diet rules were strongly related to each other (all r's > 0.78), but only weakly-moderately related to delayed eating behaviours (all r's < 0.47). In subsequent moderated ridge regression analyses, delayed eating was the only restraint component to independently predict variance in measures of psychological distress. Patient diagnosis did not moderate these associations. Overall, findings indicate that delayed eating behaviours may be a distinct component from other indices of dietary restraint (e.g., intention to restrict, food avoidance, diet rules). This study highlights the potential importance of ensuring that delayed eating behaviours are screened, assessed, and targeted early in treatment for patients with AN and BN.
... BED is associated with profound psychosocial impairment (Becker & Grilo, 2015), reduced quality of life ( Agh et al., 2015), obesity (Kessler et al., 2013), increased risk of developing Type 2 diabetes (Raevuori et al., 2015), and metabolic syndrome (Hudson et al., 2010). Cognitive-behavioral therapy (CBT) and, to a lesser extent, interpersonal psychotherapy and dialectical behavior therapy have shown empirical support as efficacious psychological treatments for BED, with recent meta-analyses of randomized controlled trials (RCTs) demonstrating that these treatments lead to significantly greater reductions in binge eating and core attitudinal symptoms (e.g., weight and shape concerns) than control conditions and to other active treatments (Brownley et al., 2016;Linardon, 2018;Linardon, Fairburn, Fitzsimmons-Craft, Wilfley, & Brennan, 2017;Vocks et al., 2010). ...
Article
Objective Standardized effect sizes reported in previous meta‐analyses of binge‐eating disorder (BED) treatment are sometimes difficult to interpret and are criticized for not being a useful indicator of the clinical importance of a treatment. Abstinence from binge eating is a clinically relevant component of a definition of a successful treatment outcome. This meta‐analysis estimated the prevalence of patients with BED who achieved binge eating abstinence following psychological or behavioral treatments. Method This meta‐analysis included 39 randomized controlled trials, with 65 treatment conditions and 2,349 patients. Most conditions comprised cognitive‐behavioral therapy (n = 40). Pooled event rates were calculated at posttreatment and follow‐up using random effects models. Results The total weighted percentage of treatment‐completers who achieved abstinence at posttreatment was 50.9% (95% CI = 43.9, 57.8); this estimate was almost identical at follow‐up (50.3%; 95% CI = 43.6, 56.9). The total weighted percentage of patients who achieved abstinence at posttreatment in the intention‐to‐treat analysis (all randomized patients) was 45.1% (95% CI =40.7, 49.5), and at follow‐up it was 42.3% (95% CI =37.5, 47.2). Interpersonal psychotherapy (IPT) produced the highest abstinence rates. Clinician‐led group treatments produced significantly higher posttreatment (but not follow‐up) abstinence estimates than guided self‐help treatments. Neither timeframe for achieving abstinence, assessment type (interview/questionnaire), number of treatment sessions, patient demographics, nor trial quality, moderated the abstinence estimates. Discussion The present findings demonstrate that 50% of patients with BED do not fully respond to treatment. Continued efforts toward improving eating disorder treatments are needed.
... Cognitive-behavioral therapy (CBT) is one of the few empirically supported psychological treatments for a range of eating disorder presentations (Fairburn & Harrison, 2003;Linardon, Fairburn, Fitzsimmons-Craft, Wilfley, & Brennan, 2017). Several recent metaanalyses of randomized controlled trials (RCTs) have demonstrated that CBT is significantly more efficacious in reducing core behavioral and cognitive symptoms than control conditions, alternative psychological interventions, and pharmacological treatments in patients with bulimia nervosa (BN), binge-eating disorder (BED), and other specified feeding and eating disorders (OSFEDs;Brownley et al., 2016;Linardon, 2018a;Linardon, Wade, De la Piedad Garcia, & Brennan, 2017;Slade et al., 2018). Findings from these metaanalyses reinforce existing clinical guidelines, which recommend CBT as the front-running treatment for these eating disorder subtypes (National Institute of Clinical Excellence, 2017). ...
Article
Objective: The efficacy of cognitive‐behavioral therapy (CBT) for eating disorders is well‐established. The extent to which CBT tested in controlled research settings generalizes to real‐world circumstances is unknown. We conducted a meta‐analysis of nonrandomized studies of CBT for eating disorders, with three aims: (a) to estimate the prevalence of patients who achieve binge‐purge abstinence after CBT in routine practice; (b) to compare these estimates with those derived from two recent meta‐analyses of randomized controlled trials (RCTs) of CBT for bulimia nervosa (BN) and binge‐eating disorder (BED); (c) to examine whether the degree of clinical representativeness of studies was associated with effect sizes. Method: Twenty‐seven studies, mainly involving BN, were included. Pooled event rates were calculated using random effects models. Results: The percentage of treatment completers who achieved abstinence at post‐treatment was 42.1% (95% CI = 34.7–50.0). The intention‐to‐treat (ITT) estimate was lower (34.6% [95% CI = 29.3–40.4]). However, abstinence rates varied across diagnoses, such that the completer and ITT analysis abstinence estimates were larger for BED samples (completer = 50.2%, 95% CI = 29.4–70.9; ITT = 47.2%, 95% CI = 29.8–65.2) than for BN (completer = 37.4%, 95% CI = 29.1–46.5; ITT = 29.8%, 95% CI = 24.9–35.3) and atypical eating disorder samples (completer = 37.8%, 95% CI = 20.2–59.3; ITT = 28.8%, 95% CI = 18.2–42.4). No relationship between the degree of clinical representativeness and the effect size was observed, and our estimates were highly comparable to those observed in recent meta‐analyses of RCTs. Discussion: Findings suggest that CBT for eating disorder can be effectively delivered in real‐world settings. This study provides evidence for the generalizability of CBT from controlled research settings to routine clinical services.
... Outcomes from treatments for binge eating spectrum eating disorders (EDs) such as bulimia nervosa (BN) and binge eating disorder (BED) are suboptimal, with up to 60-70% of patients still symptomatic at post-treatment [1,2]. A critical objective to improve existing interventions is to better understand the cognitive and emotional precipitants and reinforcers of binge eating so that intervention components can be designed to target such factors. ...
Article
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Objective Although binge eating is associated with impulsivity, clinical reports suggest that some individuals with bulimia nervosa (BN) and binge eating disorder (BED) plan binge episodes in advance. This study is the first to examine: (1) the frequency of binge planning (BP; defined as both advanced knowledge that a binge episode will occur and taking steps to facilitate the binge episode); (2) associations of BP with ED severity, and (3) whether BP serves a negative reinforcement function. Method Patients with BN- and BED-spectrum eating disorders (EDs; n = 111) were administered semi-structured interview questions regarding BP. Results Results indicate that a substantial minority of patients (27.8%) engage in BP. BP was significantly more common in BN versus BED-spectrum EDs (38.3% versus 20.6%, p = 0.04) and in those who did versus did not endorse self-induced vomiting (50.0% versus 21.3%, p < 0.01). Frequency of BP was positively associated with overall ED psychopathology (r = 0.19, p < 0.05). Exploratory analyses indicated that approximately two-thirds (67.7%) reported that BP served to distract from unpleasant experiences. Discussion BP is present for a significant subset of patients and may play a critical role in the reinforcement cycles of binge eating. Future research should further elucidate the function of BP to inform treatment development.
... Most importantly, however, as opposed to the BN group, bodyrelated attention of our controls was not affected by the emotion induction, suggesting that women without ED are more body image resilient and that effects of sadness and happiness on visual selective attention during mirror exposure are specific to BN. Consistent with findings in underweight patients with AN (Svaldi et al., 2016), our results provide empirical support for cognitive-behavioral models on the maintenance of ED (Linardon, 2018;Pennesi & Wade, 2016;Williamson et al., 2004), which assume that there is a particular emo- ing body image problems (Griffen, Naumann, & Hildebrandt, 2018), it must be mentioned that reported effect sizes often are relatively small and that several contraindications are currently discussed (incl. lack of emotional stability). ...
Article
Objective: Abundant research points to the central role of body image disturbances in the occurrence of eating disorders (ED). While emotional arousal has been identified as a trigger for binge eating in bulimia nervosa (BN), empirical knowledge on the influence of emotions on body image in individuals with BN is scarce. The present study sought to experimentally examine effects of a positive and negative emotion induction on body dissatisfaction and selective attention towards negatively valenced body parts among people with BN. Method: In a randomized-controlled cross-over design, happiness and sadness were induced by film clips one-week apart in women with BN (n = 23) and non-ED controls (n = 26). After the emotion induction, participants looked at their body in a full-length mirror, while their attentional allocation was recorded with the help of a mobile eye tracker. Participants repeatedly rated their momentary body dissatisfaction. Results: Induction of happiness led to a significant decrease in self-reported body dissatisfaction. Furthermore, attentional bias (higher gaze duration and frequency) towards the most disliked body part relative to the most liked body part was significantly greater in the sadness than happiness condition in BN. No significant effects of emotion induction on gaze duration and gaze frequency during mirror exposure were found for controls. Discussion: In line with assumptions of current models on ED, findings support the notion that emotional state influences the body image of patients with BN.
... Like bulimia nervosa, binge-eating disorder is characterized by repeated episodes of hyperphagia but without the repetitive inappropriate compensatory behavior seen in bulimia nervosa [1]. Several meta-analyses of randomized controlled trials (RCTs) that included wait list controls have reported that cognitive behavioral therapy (CBT) is effective for bulimia nervosa and binge-eating disorder [3,[4][5][6][7]. Our research group has recently conducted a single-arm study that confirmed the effectiveness of guided self-help CBT for Japanese patients with bulimia nervosa [8]. ...
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BACKGROUND A major problem in providing mental health services is the lack of access to treatment, especially in remote areas. Thus far, no clinical studies have demonstrated the feasibility of Internet-based cognitive behavioral therapy (ICBT) with real-time therapist support via videoconference for bulimia nervosa (BN) and binge-eating disorder (BED) at the same time in Japan. OBJECTIVE To evaluate the feasibility of ICBT via videoconference for patients with BN or BED. METHODS Five Japanese subjects (mean age 35.4 ± 9.2 years) with BN and BED received 16 weekly sessions of individualized ICBT via videoconference with real-time therapist support. Treatment included CBT tailored specifically to the presenting diagnosis. The primary outcome was a reduction in the Eating Disorder Examination interview-16 (EDE 16) for BN and BED: the combined objective binge and purging episodes; objective binge episodes; purging episodes. The secondary outcomes were the EDE-Q, the Bulimic Investigatory Test, Edinburgh, body mass index for eating symptoms, the Motivational Ruler for motivation to change, the EuroQol-5 Dimension for quality of life, the Patient Health Questionnaire-9 for depression, the Generalized Anxiety Disorder questionnaire-7 for anxiety, and the Working Alliance Inventory-Short Form (WAI-SF). All outcomes were assessed at week 1 (baseline) and at weeks 8 (mid intervention), and 16 (post intervention) during therapy. Patients were asked about adverse events at each session. For the primary analysis, treatment-related changes were assessed by comparing participant scores and the 95% confidence intervals using the paired t-test. RESULTS Although the mean combined objective binge episodes and purging episodes improved from 47.60 to 13.60 (71% reduction) and showed a medium effect size (Cohen’s d, -0.76), there was no significant reduction in the combined these episodes (EDE 16D, -41; 95% confidence interval -2.089, 0.576; P = 0.17). There were no significant treatment-related changes in the secondary outcomes. The WAI-SF scores remained consistently high (64.8–66.0) during treatment. CONCLUSIONS ICBT via videoconference is feasible in Japanese patients with BN and BED. CLINICALTRIAL UMIN000029426
... Like bulimia nervosa, binge-eating disorder is characterized by repeated episodes of hyperphagia but without the repetitive inappropriate compensatory behavior seen in bulimia nervosa [1]. Several meta-analyses of randomized controlled trials (RCTs) that included wait list controls have reported that cognitive behavioral therapy (CBT) is effective for bulimia nervosa and binge-eating disorder [3,[4][5][6][7]. Our research group has recently conducted a single-arm study that confirmed the effectiveness of guided self-help CBT for Japanese patients with bulimia nervosa [8]. ...
Article
Full-text available
Background: A major problem in providing mental health services is the lack of access to treatment, especially in remote areas. Thus far, no clinical studies have demonstrated the feasibility of internet-based cognitive behavioral therapy (ICBT) with real-time therapist support via videoconference for bulimia nervosa and binge-eating disorder in Japan. Objective: The goal of the research was to evaluate the feasibility of ICBT via videoconference for patients with bulimia nervosa or binge-eating disorder. Methods: Seven Japanese subjects (mean age 31.9 [SD 7.9] years) with bulimia nervosa and binge-eating disorder received 16 weekly sessions of individualized ICBT via videoconference with real-time therapist support. Treatment included CBT tailored specifically to the presenting diagnosis. The primary outcome was a reduction in the Eating Disorder Examination Edition 16.0D (EDE 16D) for bulimia nervosa and binge-eating disorder: the combined objective binge and purging episodes, objective binge episodes, and purging episodes. The secondary outcomes were the Eating Disorders Examination Questionnaire, Bulimic Investigatory Test, Edinburgh, body mass index for eating symptoms, Motivational Ruler for motivation to change, EuroQol-5 Dimension for quality of life, 9-item Patient Health Questionnaire for depression, 7-item Generalized Anxiety Disorder scale for anxiety, and Working Alliance Inventory–Short Form (WAI-SF). All outcomes were assessed at week 1 (baseline) and weeks 8 (midintervention) and 16 (postintervention) during therapy. Patients were asked about adverse events at each session. For the primary analysis, treatment-related changes were assessed by comparing participant scores and 95% confidence intervals using the paired t test. Results: Although the mean combined objective binge and purging episodes improved from 47.60 to 13.60 (71% reduction) and showed a medium effect size (Cohen d=–0.76), there was no significant reduction in the combined episodes (EDE 16D –41; 95% CI –2.089 to 0.576; P=.17). There were no significant treatment-related changes in secondary outcomes. The WAI-SF scores remained consistently high (64.8 to 66.0) during treatment. Conclusions: ICBT via videoconference is feasible in Japanese patients with bulimia nervosa and binge-eating disorder. Trial Registration: UMIN Clinical Trials Registry UMIN000029426; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000033419
... Binge eating disorder (BED) is an eating disorder that is associated with a range of psychological and medical comorbidities, impairment, and increased mortality [1][2][3][4]. Despite the clinical severity of this disorder, outcomes of psychological and behavioral treatments for BED remain suboptimal [5], which indicates a need to identify relevant maintenance factors that could inform more effective intervention approaches. Self-discrepancy, the degree to which individuals perceive a difference between their actual self and their personal standards (referred to as self-guides), has been identified as a possible risk and maintenance factor of various types of psychopathology [6], including some eating disorders [7,8]. ...
Article
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PurposeSelf-discrepancy (i.e., perceived differences between one’s actual self and personal standards) has been associated with binge eating disorder (BED) symptoms. However, little is known about how weight discrepancy (i.e., the difference between one’s actual and ideal weights) interacts with or is distinguished from nonappearance self-discrepancy (discrepancy unrelated to weight or shape) in predicting BED severity. The current study examined how these two forms of discrepancy independently and interactively relate to BED and associated symptoms to elucidate how facets of self-discrepancy may operate to precipitate and maintain BED.Methods Adults with BED (N = 111) completed questionnaires and interviews prior to treatment that assessed self-discrepancy (computerized selves) and weight discrepancy (assessed during the Eating Disorder Examination [EDE]) as predictors of global eating disorder (ED) symptomatology (EDE Global score), depression (Beck Depression Inventory), anxiety (State-Trait Anxiety Inventory), self-esteem (Rosenberg Self-Esteem Scale), and ED-related impairment (Clinical Impairment Assessment).ResultsMultivariate regression models indicated nonappearance self-discrepancy and weight discrepancy were not significantly related to the severity of global ED symptoms, but both independently predicted impairment (ps < 0.05). Nonappearance self-discrepancy, but not weight discrepancy, was also associated with higher depression (p = 0.001), anxiety (p < 0.001), and lower self-esteem (p < 0.001).Conclusion These findings suggest distinct associations of weight discrepancy and nonappearance self-discrepancy with ED and related symptoms, as well as each of these constructs’ relevance to everyday functioning in BED. The results also highlight potential avenues for future research to examine mechanistic pathways by which self-discrepancy influences BED severity.Level of evidenceV, descriptive cross-sectional study.
... FBT highlights the importance of the parents'/caregivers' involvment in therapy as necessary for successful treatment outcomes (Dalle Grave, Eckhardt, Calugi, & Le Grange, 2019), and is therefore difficult to use effectively when parent or caregiver involvement is limited. Enhanced cognitive-behavioural therapy (CBT-E; Fairburn, 2008), based on the transdiagnostic model, has demonstrated efficacy with adults (Linardon, 2018). There is emerging evidence that it is also efficacious with adolescents (e.g., Dalle Grave, Calugi, Doll, & Fairburn, 2013;Dalle Grave, Calugi, Sartirana, & Fairburn, 2015), and has been recommended for adolescents when FBT is not appropriate. ...
Article
Objective The validity of the transdiagnostic cognitive-behavioural model of eating disorders has been examined in adults, however there is limited examination in adolescents with eating disorders. The present study examined the direct and indirect relationships between eating disorder symptoms and the four maintaining processes: perfectionism, low core self-esteem, mood intolerance, and interpersonal difficulties. Method Using a correlational cross-sectional design, adolescents with eating disorders (N = 270; anorexia nervosa [restricting; 35.9%]; anorexia nervosa [binge purge; 8.1%]; bulimia nervosa [9.3%]; atypical anorexia nervosa [27.4%]; bulimia nervosa [of low frequency and/or limited duration; 3%]; purging [1.1%]; and unspecified feeding or eating disorders [15.2%]) completed measures of perfectionism, self-esteem, mood intolerance, interpersonal difficulties, and eating disorder symptoms as part of the intake assessment to an eating disorders program. Results Path analysis revealed that low self-esteem and mood intolerance were directly associated with eating disorder symptoms. Perfectionism was indirectly associated with eating disorder symptoms through self-esteem and mood intolerance. Discussion The findings provide partial support for the transdiagnostic model of eating disorders in an adolescent clinical sample. In particular, core low self-esteem and mood intolerance were found to be pertinent in adolescents with eating disorders. A limitation of the current study was the use of cross-sectional data. Future research should examine the transdiagnostic model with the use of longitudinal data. Furthermore, future research is required to examine potential differences in the way the maintaining mechanisms operate between adolescents and adults with eating disorders and the implications for treatment.
... Growing research indicates that CBT-based prevention and treatment programmes can effectively target dietary restraint, binge eating, and other risk and maintaining factors (Le, Barendregt, Hay, & Mihalopoulos, 2017;Linardon, 2018). However, interventions that have demonstrated efficacy typically rely on face-to-face delivery with a trained professional, which can limit their dissemination. ...
Article
Background Existing internet-based prevention and treatment programmes for binge eating are composed of multiple distinct modules that are designed to target a broad range of risk or maintaining factors. Such multi-modular programmes (1) may be unnecessarily long for those who do not require a full course of intervention and (2) make it difficult to distinguish those techniques that are effective from those that are redundant. Since dietary restraint is a well-replicated risk and maintaining factor for binge eating, we developed an internet- and app-based intervention composed solely of cognitive-behavioural techniques designed to modify dietary restraint as a mechanism to target binge eating. We tested the efficacy of this combined selective and indicated prevention programme in 403 participants, most of whom were highly symptomatic (90% reported binge eating once per week). Method Participants were randomly assigned to the internet intervention ( n = 201) or an informational control group ( n = 202). The primary outcome was objective binge-eating frequency. Secondary outcomes were indices of dietary restraint, shape, weight, and eating concerns, subjective binge eating, disinhibition, and psychological distress. Analyses were intention-to-treat. Results Intervention participants reported greater reductions in objective binge-eating episodes compared to the control group at post-test (small effect size). Significant effects were also observed on each of the secondary outcomes (small to large effect sizes). Improvements were sustained at 8 week follow-up. Conclusions Highly focused digital interventions that target one central risk/maintaining factor may be sufficient to induce meaningful change in core eating disorder symptoms.
... The panel aims at exploring the efficacy and effectiveness of psychological treatments for eating disorders. Despite the growing evidence regarding the benefit of psychotherapy for patients with eating problems, they are still considered as difficult-to treat clients, given their modest rate of recovery and their difficulties in maintaining positive changes (Linardon, 2018;Nazar et al., 2016;Swift & Greenberg, 2014). In this panel, two presentations will report efficacy data from a RCT and meta-analysis, which were conducted in Italy and UK. ...
... En el caso de la psicopatología alimentaria, múltiples estudios han apuntado hacia síntomas que se manifiestan a lo largo del llamado espectro psicopatológico, con diferentes grados de intensidad, tales como la insatisfacción corporal (Amaya, Alvarez y Mancilla, 2010; Contreras-Valdez, Hernández-Guzmán y Freyre, 2016), el atracón (Gómez-Peresmitré et al., 2013;Melioli et al., 2016), el deseo de adelgazar (Mancilla-Díaz et al., 2010), la dieta restrictiva o la preocupación por la comida (Linardon, 2018;Melioli et al., 2016;Moulton, Newman, Power, Swanson y Day, 2015), entre otras. ...
Article
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The purpose of this research was to contrast the categorial and dimensional approaches within the eating disorders area. Research on the eating problems categorical model reveals vast evidence against its validity: excessive comorbidity, inadequate coverage, diagnostic migration, residual categories, false positives and negatives, etc. The dimensional conceptualization of the eating psychopathology study would achieve more accurate findings by considering eating problems according to the degree in which they manifest, avoiding diagnostics based on arbitrary cut-off points and facilitating the analysis of eating psychopathology at early age, as well as following symptom evolution throughout development. Based on the dimensional model, transdiagnostic perspective has received empirical support, which endorses the use of the transdiagnostic treatment aimed to underlying psychological mechanisms, such as negative affect and emotional dysregulation.
... SUD is also commonly comorbid with EDs, occurring in an estimated 17-46% of those with EDs (Harrop & Marlatt, 2010;Hudson et al., 2007). Cognitive-behavioral therapy has a strong evidence base in the treatment of EDs (Atwood and Friedman, 2020;Dahlenburg, Gleaves, & Hutchinson, 2019;Linardon, 2018), as well as comorbid MDD and SUD (Hides, Samet, & Lubman, 2010;Vujanovic et al., 2017). While review of meta-analyses suggests CBT is generally effective in the treatment of these disorders, no published studies provide explicit guidance on how to prioritize targets or stage treatment for those with EDs in the context of these comorbidities. ...
Article
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Longitudinal associations between eating disorders (EDs) and comorbid psychiatric disorders are poorly understood but important to examine as comorbidities are common and can impede ED recovery. We examined two common comorbidities, major depressive disorder (MDD)and substance use disorder (SUD), in adult women with intake diagnoses of anorexia nervosa(AN) and bulimia nervosa (BN) who participated in a longitudinal study. To test the longitudinal reciprocal relations among ED, MDD, and SUD, we conducted a multi-group autoregressive cross-lagged path analysis. We tested whether ED, MDD, and SUD in a given three-month period (t — 1)each predicted ED, MDD, and SUD during the subsequent three-month period (t) over 5 years. We examined the moderating effect of intake diagnosis (AN vs. BN). Among AN (but not BN)participants, having MDD at t — 1 predicted having an ED at time t, OR = 1.98, B = .68, z = 2.49,p = .01. Among BN (but not AN) participants, having a SUD at t — 1 predicted having an ED at time t, OR = 5.16, B = 1.64, z = 2.34, p = .01. In contrast, having an ED at t — 1 did not predict MDD or SUD at time t for AN or BN participants. These results suggest for individuals with AN and MDD, treating MDD may facilitate ED recovery. For individuals with BN and SUD, treating SUD may facilitate ED recovery. These identified temporal associations between ED and comorbid disorders may guide cognitive behavioral researchers and therapists in prioritizing treatment targets given the high rate of comorbidity in EDs.
... Although there are no (to the best of our knowledge) evidenced-based (EB) or empirically supported (ES) treatments for social physique anxiety, clinicians may find value in using one of many different validated treatments for generalized anxiety to address body image concerns and associated anxiety symptomatology. For example, cognitive-behavioral therapy (CBT) is a long established EB and ES treatment for anxiety symptoms (Springer, Levy, & Tolin, 2018) and eating disorders (Linardon, 2018). Specifically, CBT could be used to address maladaptive thoughts and beliefs that others are continually judging the individual based upon their physique (Beck, 2011). ...
Article
Researchers disagree on which types of anxiety influence body dissatisfaction and how gender (cisgender men vs. cisgender women) may impact these associations. Specifically, little is known about how generalized anxiety and social physique anxiety combine to predict body dissatisfaction in men and women. The purpose of the present study was to explore a moderated mediation model in which the relationships between generalized anxiety and body dissatisfaction (drive for thinness and drive for muscularity) were mediated by social physique anxiety and moderated by gender. Data from 423 U.S. college students (n = 259 women) were analyzed using multigroup structural equation modeling. Generalized anxiety was positively associated with social physique anxiety, and this association was significantly stronger for men than for women. Neither social physique anxiety nor generalized anxiety were associated with drive for muscularity. Social physique anxiety was positively and significantly associated with drive for thinness equally for men and women and emerged as a significant mediator. These results highlight gender differences/similarities in body image and suggest drive for thinness and social physique anxiety may have a common factor of generalized anxiety. When helping clients who suffer with body dissatisfaction, clinicians and researchers may wish to focus on generalized anxiety (and not just social physique anxiety).
... 21 Meta-analyses of Randomised Controlled Trials (RCTs) that include waitlist controls report that CBT is particularly effective for BN and BED. [22][23][24][25][26] In Japan, there are two reports on the effectiveness and feasibility of CBT for BN or BED, 27 28 and the national health insurance has covered CBT in Japan since 2018. However, according to a meta-analysis of RCTs, the dropout rate for CBT is approximately 24%, 29 and there are large individual differences in treatment responsiveness. ...
Article
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Introduction Anorexia nervosa is a refractory psychiatric disorder with a mortality rate of 5.9% and standardised mortality ratio of 5.35, which is much higher than other psychiatric disorders. The standardised mortality ratio of bulimia nervosa is 1.49; however, it is characterised by suicidality resulting in a shorter time to death. While there is no current validated drug treatment for eating disorders in Japan, cognitive–behavioural therapy (CBT) is a well-established and commonly used treatment. CBT is also recommended in the Japanese Guidelines for the Treatment of Eating Disorders (2012) and has been covered by insurance since 2018. However, the neural mechanisms responsible for the effect of CBT have not been elucidated, and the use of biomarkers such as neuroimaging data would be beneficial. Methods and analysis The Eating Disorder Neuroimaging Initiative is a multisite prospective cohort study. We will longitudinally collect data from 72 patients with eating disorders (anorexia nervosa and bulimia nervosa) and 70 controls. Data will be collected at baseline, after 21–41 sessions of CBT and 12 months later. We will assess longitudinal changes in neural circuit function, clinical data, gene expression and psychological measures by therapeutic intervention and analyse the relationship among them using machine learning methods. Ethics and dissemination The study was approved by The Ethical Committee of the National Center of Neurology and Psychiatry (A2019-072). We will obtain written informed consent from all patients who participate in the study after they had been fully informed about the study protocol. All imaging, demographic and clinical data are shared between the participating sites and will be made publicly available in 2024. Trial registration number UMIN000039841
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Outcomes from cognitive behavioral therapy for binge‐eating spectrum disorders are suboptimal, possibly due in part to deficits in self‐regulation (i.e., the ability to control behavior in pursuit of long‐term goals despite internal challenges). Mindfulness and acceptance‐based treatments (MABTs) integrate behavioral treatment with psychological strategies designed to enhance self‐regulation, yet little is known about how and for whom they are effective. The present study will utilize the multiphase optimization strategy to identify which of four MABT components (mindful awareness, distress tolerance, emotion modulation, values‐based decision making) to include in a fully powered clinical trial. Participants (n = 256) will be randomized to 16 sessions in one of 16 conditions, each a different combination of MABT components being included or excluded from a base behavioral treatment. Our primary aim is to evaluate each component's independent efficacy on disordered eating symptoms. Our secondary aims are to confirm each component's target engagement (i.e., whether each component improves the targeted variable and outcomes), and test that each component's efficacy is moderated by baseline weaknesses in the same component (e.g., that participants with poor distress tolerance at baseline benefit most from the distress tolerance component). Our exploratory aim is to quantify the component interaction effects.
Article
The Inflexible Eating Questionnaire (IEQ) is a recently developed measure that assesses an individual's inflexible adherence to rigid eating rules, along with the tendency to respectively feel empowered or distressed when such rules are or are not followed. At present, evidence supporting the unidimensional structure and psychometric properties of the IEQ is limited to one specific sample of Portuguese adults. Establishing whether the IEQ is a valid and reliable measure in a different sample and by an independent research team is needed. We sought to examine the factor structure and psychometric properties of the IEQ in large sample (n = 1000) of Australian female adults. A unidimensional structure was replicated and evidence of internal consistency (α = .89) was found. IEQ scores were significantly and moderately correlated with various eating restraint measures and intuitive eating, providing evidence of convergent validity. IEQ scores also predicted incremental variance in global eating disorder symptomatology and psychosocial impairment after controlling for intuitive eating, flexible control, and rigid dietary control. Present findings offer further support for the validity and reliability of the IEQ in a non-clinical sample of women. A brief measure that assesses the inflexible adherence to eating rules may be valuable for validating current models of eating disorder psychopathology. Furthermore, incorporating the IEQ into the assessment of future randomized trials of eating disorder prevention or treatment programs may be beneficial for elucidating these interventions mechanisms of change.
Article
Introduction: Homework assignments are considered key components of behavioral treatments for bulimia nervosa (BN), but little is known about whether homework compliance predicts BN symptom improvement. The present study is the first to examine whether session-by-session change in homework compliance predicts session-by-session changes in BN symptoms during behavioral treatment. Method: Patients with BN-spectrum eating disorders (n = 42) received 20 sessions of behavioral treatment. Each session, their clinicians completed surveys assessing compliance with self-monitoring, behavioral, and written homework assignments and BN symptom frequency during the previous week. Results: Significant between-persons effects of self-monitoring and behavioral homework compliance were identified, such that patients with greater compliance in the past week experienced greater reductions in binge eating and purging the following week. There were significant within-persons effects of self-monitoring compliance on binge eating and behavioral homework compliance on restrictive eating, binge eating, and purging, such that greater than one's usual compliance predicted greater improvements in BN symptoms the following week. No significant effects of written homework compliance were identified. Conclusion: Compliance with self-monitoring and behavioral homework predict improvements in BN symptoms during behavioral treatment. These findings reinforce the importance of self-monitoring and behavioral homework compliance as drivers of change during treatment for BN.
Article
Bulimia nervosa (BN) is characterized by a pattern of binge eating and compensatory behaviors as well as an overemphasis on body weight and shape in self-evaluation. Although cognitive behavioral therapy (CBT) is efficacious, recent reviews suggest that only 30% of patients reach abstinence at posttreatment. One potential reason for these poor outcomes is that CBT fails to adequately reduce elevated negative affect (NA) and shape and weight concern, which have been shown to be correlated with poorer treatment outcomes in BN. Therefore, novel treatment components that focus on improving NA and shape and weight concern are needed in order to enhance outcomes. Promoting physical activity (PA) is a promising avenue through which to reduce NA and improve body image in healthy individuals, other clinical populations (e.g., individuals with depression or anxiety), and individuals with eating disorders. While prescribing PA for individuals with BN has been controversial (due to concerns that exercise maybe be used to compensate for binge episodes or become driven or compulsive), this approach may have many benefits, including promoting healthy lifetime exercise habits that reduce likelihood of relapse through the improvement of emotion regulation skills and weight regulation. Given the promise of PA for targeting key maintenance factors of BN, we developed a 12-session healthy PA promotion intervention for BN and tested initial feasibility, acceptability, and preliminary target engagement in an iterative case series design (n = 3). The treatment provided cognitive-behavioral skills designed to identify, practice, and achieve behavioral goals while asking patients to engage in up to 150 minutes of moderate-to-vigorous PA per week, which was preplanned during each session with the client’s therapist. Results suggested that the healthy PA promotion intervention was both feasible and acceptable to deliver. In addition, the intervention resulted in a clinically significant decrease in BN symptom frequency in each participant. Further, participants showed clinically significant decreases in NA and shape and weight concern. The current study demonstrates that healthy PA interventions can have beneficial effects on BN symptoms, NA, and shape and weight concern. However, due to the small sample size, conclusions must be treated with caution. Future research should investigate additional approaches for promoting healthy PA and include a larger sample in order to further test initial efficacy of this treatment approach.
Article
Introduction: The purpose of this study was to examine mental health status by gender identity among undergraduate and graduate students. Methods: Data came from the 2015-2017 Healthy Minds Study, a mobile survey of randomly selected students (N=65,213 at 71 U.S. campuses, including 1,237 gender minority [GM] students); data were analyzed in 2018. Outcomes were symptoms of depression, anxiety, eating disorders, self-injury, and suicidality based on widely used, clinically validated screening instruments. Bivariable and multivariable analyses explored differences between GM and cisgender (non-GM) students as well as by assigned sex at birth. Results: Across mental health measures, a significantly higher prevalence of symptoms was observed in GM students than cisgender students. Compared with 45% of cisgender students, 78% of GM students met the criteria for 1 or more of the aforementioned mental health outcomes. GM status was associated with 4.3 times higher odds of having at least 1 mental health problem (95% CI=3.61, 5.12). Conclusions: Findings from this largest campus-based study of its kind using representative data with both gender identity and mental health measures underscore the importance of recognizing and addressing GM mental health burdens, such as by screening for mental health and providing gender-affirming services. There is broad urgency to identify protective factors and reduce mental health inequities for this vulnerable population.
Article
Accumulating evidence suggests that the presence of shape/weight overvaluation in binge-eating disorder (BED) is associated with more severe psychopathology and impairment. To further inform the role of the overvaluation construct in BED, we examined whether those with and without shape/weight overvaluation differ on four core processes that underpin the contextual behaviour therapies: distress tolerance, self-compassion, mindfulness, and experiential avoidance. These four processes were investigated as each are considered important change mechanisms in contextual behavioural therapies and are either compatible or incompatible with the emotion dysregulation known to precipitate binge eating. Participants were categorized into one of four study groups: probable BED with overvaluation (n = 60); probable BED without overvaluation (n = 108); obese control (n = 59); healthy control (n = 123). Analyses of covariance showed that the probable BED with overvaluation group reported lower levels of self-compassion and distress tolerance, and higher levels of experiential avoidance than the three other groups. The probable BED without overvaluation group did not differ to control groups on these processes, except experiential avoidance levels. Findings highlight potentially important intervention targets and constructs among a subgroup of individuals with BED.
Chapter
Übergewicht ist Folge einer Energieimbalance, an deren Entstehung sowohl Umwelt- als auch genetische Faktoren beteiligt sind. Psychische Faktoren spielen vor allem bei der Aufrechterhaltung eine wichtige Rolle und sind zentraler Baustein der Behandlung (Lebensstilinterventionen, Ernährungs- und Psychotherapie sowie chirurgische Maßnahmen). Lebensstilprogramme basieren auf kognitiv-behavioralen Methoden, wie u. a. Psychoedukation, Selbst- und Verhaltensbeobachtung, Selbstbewertung und -verstärkung. Zur Gewichtsreduktion liegen zahlreiche gut kontrollierte Studien wie auch eine Reihe von Meta-Analysen vor. Die größte Herausforderung besteht darin, nach einer Gewichtsreduktion eine Gewichtsstabilisierung zu erzielen. Daher ist es von enormer Bedeutung, schon während der intensiven Behandlungsphase die Gestaltung der Nachsorge zu planen.
Article
Purpose The present study examined racial differences in associations among body dissatisfaction, body checking, and dietary restraint relative to overeating, loss of control eating, and binge eating outcomes among college women. Method: Young adult women (N = 903) at three Mid-Atlantic US institutions completed measures assessing negative body image and eating pathology via an online survey. Structural equation modeling was used to test a model examining associations among body dissatisfaction, body checking, dietary restraint, and disinhibited eating behaviors. Multigroup analyses examined whether these associations differed for women who identified as White (n = 432) versus Black (n = 359). Results: More frequent body checking explained associations between elevated body dissatisfaction and more frequent use of all three disinhibited eating outcomes for White and Black women, whereas restraint solely mediated an association between body dissatisfaction and overeating. The assessed constructs generally operated in a similar manner across racial groups. However, stronger associations among body dissatisfaction, restraint, and overeating, and between body checking and loss of control eating were identified for women who identified as White versus Black. Conclusions: Eating disorder programming efforts targeting body checking behavior may prove useful in decreasing White and Black women's disinhibited eating.
Article
Objectives To evaluate the efficacy of CBT in relation to weight loss and related psychological components and to analyze the relationship between alleged cognitive mechanisms of change and weight loss. Methods The studies we considered eligible were the randomized clinical trials which included and reported a quantitative assessment of change in weight and of potential cognitive mechanisms of successful change in weight and comparing at least one active CBT intervention with a control for adults. Results We included 16 studies (18 contrasts) with a total of 1.663 participants. The pooled ESs in which a CBT-intervention was compared to a control condition for weight loss, was Hedges' g= 0.31 (95% CI 0.04 to 0.58) favoring CBT and for cognitive factors was g = 0.37 (95% CI 0.22 to 0.45). Results indicated a significant association between motivation outcomes ESs (slope= 0.992, 95% CI 0.13 to 1.85, p =0.02) and selfefficacy ESs (slope= 1.59, 95% CI 0.24 to 2.94, p =0.02) and weight outcomes. Discussion Current evidence suggests that CBT is effective in weight loss. Clinicians will be more effective if they add to their weight loss interventions components for increasing the motivation and self-efficacy of their patients.
Article
Objective: Hedonic hunger (i.e., the motivation to consume palatable foods in the absence of an energy deficit) has been associated with the onset and maintenance of loss of control (LOC) eating. However, it remains underexplored as a mechanism of action in outpatient cognitive behavioral therapy (CBT) for bulimia nervosa (BN). In the present study, we hypothesized that reductions in hedonic hunger would significantly mediate reductions in overall eating pathology and LOC episodes in two samples (N 1 = 28, N 2 = 23) of 20 and 16 sessions, respectively. Method: Participants completed the Eating Disorder Examination (EDE) and Power of Food Scale (PFS) at pre‐ and post‐treatment. Results: In both samples, EDE Global scores, LOC episodes, and PFS Total scores significantly improved over the course of treatment. In Sample 1, significant indirect effects of PFS Total scores on EDE Global scores and LOC episodes were observed. In Sample 2, the indirect effect of PFS Total scores was significant on EDE Global scores and nonsignificant on LOC episodes though it followed a similar pattern of change. Discussion: Results suggest that reductions in hedonic hunger are associated with better outcomes in CBT for BN. Replication and further research is needed to elucidate the treatment components driving these reductions.
Article
Objective: Fear of weight gain (FOWG) is increasingly implicated in the maintenance of binge-spectrum eating disorders (EDs; e.g., bulimia nervosa [BN], binge-eating disorder [BED]) through the pathway of increased dietary restriction. However, particularly in binge-spectrum EDs, research is nascent and based on retrospective self-report. To improve treatment outcomes, it is critical to better understand the momentary relations between FOWG and dietary restriction. Method: Sixty-seven adults with binge spectrum EDs completed a 7-14-day ecological momentary assessment protocol that included items regarding FOWG, ED behaviors, and types of dietary restriction (e.g., attempted restraint vs. actual restriction) several times per day. Multilevel models were used to evaluate reciprocal associations between FOWG and dietary restriction, and to evaluate the indirect of effects of dietary restriction on the relation between FOWG and binge eating. Results: While main effects were not statistically significant, ED presentation significantly moderated the association between increases in FOWG at time1 and both attempted and actual avoidance of enjoyable foods at time2 such that those with BN-spectrum EDs were more likely to avoid enjoyable foods following increased FOWG compared to those with BED-spectrum EDs. Engagement in restriction at time1 was not associated with decreased FOWG at time2. Discussion: Prospective associations between FOWG and restriction suggest that individuals with BN may be more likely to restrict their eating following increased FOWG. These findings suggest FOWG may be an important target for future treatments.
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Background: There is a lack of evidence pointing to the efficacy of any specific psychotherapy for adults with anorexia nervosa (AN). The aim of this study was to compare three psychological treatments for AN: Specialist Supportive Clinical Management, Maudsley Model Anorexia Nervosa Treatment for Adults and Enhanced Cognitive Behavioural Therapy. Method: A multi-centre randomised controlled trial was conducted with outcomes assessed at pre-, mid- and post-treatment, and 6- and 12-month follow-up by researchers blind to treatment allocation. All analyses were intention-to-treat. One hundred and twenty individuals meeting diagnostic criteria for AN were recruited from outpatient treatment settings in three Australian cities and offered 25-40 sessions over a 10-month period. Primary outcomes were body mass index (BMI) and eating disorder psychopathology. Secondary outcomes included depression, anxiety, stress and psychosocial impairment. Results: Treatment was completed by 60% of participants and 52.5% of the total sample completed 12-month follow-up. Completion rates did not differ between treatments. There were no significant differences between treatments on continuous outcomes; all resulted in clinically significant improvements in BMI, eating disorder psychopathology, general psychopathology and psychosocial impairment that were maintained over follow-up. There were no significant differences between treatments with regard to the achievement of a healthy weight (mean = 50%) or remission (mean = 28.3%) at 12-month follow-up. Conclusion: The findings add to the evidence base for these three psychological treatments for adults with AN, but the results underscore the need for continued efforts to improve outpatient treatments for this disorder. Trial Registration Australian New Zealand Clinical Trials Registry (ACTRN 12611000725965) http://www.anzctr.org.au/.
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Eating disorders may be viewed from a transdiagnostic perspective and there is evidence supporting a transdiagnostic form of cognitive behaviour therapy (CBT-E). The aim of the present study was to compare CBT-E with interpersonal psychotherapy (IPT), a leading alternative treatment for adults with an eating disorder. One hundred and thirty patients with any form of eating disorder (body mass index >17.5 to <40.0) were randomized to either CBT-E or IPT. Both treatments involved 20 sessions over 20 weeks followed by a 60-week closed follow-up period. Outcome was measured by independent blinded assessors. Twenty-nine participants (22.3%) did not complete treatment or were withdrawn. At post-treatment 65.5% of the CBT-E participants met criteria for remission compared with 33.3% of the IPT participants (p < 0.001). Over follow-up the proportion of participants meeting criteria for remission increased, particularly in the IPT condition, but the CBT-E remission rate remained higher (CBT-E 69.4%, IPT 49.0%; p = 0.028). The response to CBT-E was very similar to that observed in an earlier study. The findings indicate that CBT-E is potent treatment for the majority of outpatients with an eating disorder. IPT remains an alternative to CBT-E, but the response is less pronounced and slower to be expressed. ISRCTN 15562271. Copyright © 2015. Published by Elsevier Ltd.
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Objective: The authors compared psychoanalytic psychotherapy and cognitive-behavioral therapy (CBT) in the treatment of bulimia nervosa. Method: A randomized controlled trial was conducted in which 70 patients with bulimia nervosa received either 2 years of weekly psychoanalytic psychotherapy or 20 sessions of CBT over 5 months. The main outcome measure was the Eating Disorder Examination interview, which was administered blind to treatment condition at baseline, after 5 months, and after 2 years. The primary outcome analyses were conducted using logistic regression analysis. Results: Both treatments resulted in improvement, but a marked difference was observed between CBT and psychoanalytic psychotherapy. After 5 months, 42% of patients in CBT (N=36) and 6% of patients in psychoanalytic psychotherapy (N=34) had stopped binge eating and purging (odds ratio=13.40, 95% confidence interval [CI]=2.45-73.42; p<0.01). At 2 years, 44% in the CBT group and 15% in the psychoanalytic psychotherapy group had stopped binge eating and purging (odds ratio=4.34, 95% CI=1.33-14.21; p=0.02). By the end of both treatments, substantial improvements in eating disorder features and general psychopathology were observed, but in general these changes took place more rapidly in CBT. Conclusions: Despite the marked disparity in the number of treatment sessions and the duration of treatment, CBT was more effective in relieving binging and purging than psychoanalytic psychotherapy and was generally faster in alleviating eating disorder features and general psychopathology. The findings indicate the need to develop and test a more structured and symptom-focused version of psychoanalytic psychotherapy for bulimia nervosa.
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Background: The purpose of this investigation was to compare a new psychotherapy for bulimia nervosa (BN), integrative cognitive-affective therapy (ICAT), with an established treatment, 'enhanced' cognitive-behavioral therapy (CBT-E). Method: Eighty adults with symptoms of BN were randomized to ICAT or CBT-E for 21 sessions over 19 weeks. Bulimic symptoms, measured by the Eating Disorder Examination (EDE), were assessed at baseline, at the end of treatment (EOT) and at the 4-month follow-up. Treatment outcome, measured by binge eating frequency, purging frequency, global eating disorder severity, emotion regulation, self-oriented cognition, depression, anxiety and self-esteem, was determined using generalized estimating equations (GEEs), logistic regression and a general linear model (intent-to-treat). Results: Both treatments were associated with significant improvement in bulimic symptoms and in all measures of outcome, and no statistically significant differences were observed between the two conditions at EOT or follow-up. Intent-to-treat abstinence rates for ICAT (37.5% at EOT, 32.5% at follow-up) and CBT-E (22.5% at both EOT and follow-up) were not significantly different. Conclusions: ICAT was associated with significant improvements in bulimic and associated symptoms that did not differ from those obtained with CBT-E. This initial randomized controlled trial of a new individual psychotherapy for BN suggests that targeting emotion and self-oriented cognition in the context of nutritional rehabilitation may be efficacious and worthy of further study.
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Background: There are no evidence-based treatments for severe and enduring anorexia nervosa (SE-AN). This study evaluated the relative efficacy of cognitive behavioral therapy (CBT-AN) and specialist supportive clinical management (SSCM) for adults with SE-AN. Method: Sixty-three participants with a diagnosis of AN, who had at least a 7-year illness history, were treated in a multi-site randomized controlled trial (RCT). During 30 out-patient visits spread over 8 months, they received either CBT-AN or SSCM, both modified for SE-AN. Participants were assessed at baseline, end of treatment (EOT), and at 6- and 12-month post-treatment follow-ups. The main outcome measures were quality of life, mood disorder symptoms and social adjustment. Weight, eating disorder (ED) psychopathology, motivation for change and health-care burden were secondary outcomes. Results: Thirty-one participants were randomized to CBT-AN and 32 to SSCM with a retention rate of 85% achieved at the end of the study. At EOT and follow-up, both groups showed significant improvement. There were no differences between treatment groups at EOT. At the 6-month follow-up, CBT-AN participants had higher scores on the Weissman Social Adjustment Scale (WSAS; p = 0.038) and at 12 months they had lower Eating Disorder Examination (EDE) global scores (p = 0.004) and higher readiness for recovery (p = 0.013) compared to SSCM. Conclusions: Patients with SE-AN can make meaningful improvements with both therapies. Both treatments were acceptable and high retention rates at follow-up were achieved. Between-group differences at follow-up were consistent with the nature of the treatments given.
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There is a need to improve treatment for individuals with bulimic disorders. It was hypothesised that a focus in treatment on broader emotional and social/interpersonal issues underlying eating disorders would increase treatment efficacy. This study tested a novel treatment based on the above hypothesis, an Emotional and Social Mind Training Group (ESM), against a Cognitive Behavioural Therapy Group (CBT) treatment. 74 participants were randomised to either ESM or CBT Group treatment programmes. All participants were offered 13 group and 4 individual sessions. The primary outcome measure was the Eating Disorder Examination (EDE) Global score. Assessments were carried out at baseline, end of treatment (four months) and follow-up (six months). There were no differences in outcome between the two treatments. No moderators of treatment outcome were identified. Adherence rates were higher for participants in the ESM group. This suggests that ESM may be a viable alternative to CBT for some individuals. Further research will be required to identify and preferentially allocate suitable individuals accordingly. ISRCTN61115988.
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This study evaluated the cognitive-behavioral (CB) model of bulimia nervosa and an extension that included two additional maintaining factors - thin-ideal internalization and impulsiveness - in 327 undergraduate women. Participants completed measures of demographics, self-esteem, concern about shape and weight, dieting, bulimic symptoms, thin-ideal internalization, and impulsiveness. Both the original CB model and the extended model provided good fits to the data. Although structural equation modeling analyses suggested that the original CB model was most parsimonious, hierarchical regression analyses indicated that the additional variables accounted for significantly more variance. Additional analyses showed that the model fit could be improved by adding a path from concern about shape and weight, and deleting the path from dieting, to bulimic symptoms. Expanding upon the factors considered in the model may better capture the scope of variables maintaining bulimic symptoms in young women with a range of severity of bulimic symptoms.
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Despite proven efficacy of cognitive behavioral therapy (CBT) for treating eating disorders with binge eating as the core symptom, few patients receive CBT in clinical practice. Our blended efficacy-effectiveness study sought to evaluate whether a manual-based guided self-help form of CBT (CBT-GSH), delivered in 8 sessions in a health maintenance organization setting over a 12-week period by master's-level interventionists, is more effective than treatment as usual (TAU). In all, 123 individuals (mean age = 37.2; 91.9% female, 96.7% non-Hispanic White) were randomized, including 10.6% with bulimia nervosa (BN), 48% with binge eating disorder (BED), and 41.4% with recurrent binge eating in the absence of BN or BED. Baseline, posttreatment, and 6- and 12-month follow-up data were used in intent-to-treat analyses. At 12-month follow-up, CBT-GSH resulted in greater abstinence from binge eating (64.2%) than TAU (44.6%; number needed to treat = 5), as measured by the Eating Disorder Examination (EDE). Secondary outcomes reflected greater improvements in the CBT-GSH group in dietary restraint (d = 0.30); eating, shape, and weight concern (ds = 0.54, 1.01, 0.49, respectively; measured by the EDE Questionnaire); depression (d = 0.56; Beck Depression Inventory); and social adjustment (d = 0.58; Work and Social Adjustment Scale), but not weight change. CBT-GSH is a viable first-line treatment option for the majority of patients with recurrent binge eating who do not meet diagnostic criteria for BN or anorexia nervosa.
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Although guided self-help for depression and anxiety disorders has been examined in many studies, it is not clear whether it is equally effective as face-to-face treatments.MethodWe conducted a meta-analysis of randomized controlled trials in which the effects of guided self-help on depression and anxiety were compared directly with face-to-face psychotherapies for depression and anxiety disorders. A systematic search in bibliographical databases (PubMed, PsycINFO, EMBASE, Cochrane) resulted in 21 studies with 810 participants. The overall effect size indicating the difference between guided self-help and face-to-face psychotherapy at post-test was d=-0.02, in favour of guided self-help. At follow-up (up to 1 year) no significant difference was found either. No significant difference was found between the drop-out rates in the two treatments formats. It seems safe to conclude that guided self-help and face-to-face treatments can have comparable effects. It is time to start thinking about implementation in routine care.
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The aim of this study was to compare two cognitive-behavioral treatments for outpatients with eating disorders, one focusing solely on eating disorder features and the other a more complex treatment that also addresses mood intolerance, clinical perfectionism, low self-esteem, or interpersonal difficulties. A total of 154 patients who had a DSM-IV eating disorder but were not markedly underweight (body mass index over 17.5), were enrolled in a two-site randomized controlled trial involving 20 weeks of treatment and a 60-week closed period of follow-up. The control condition was an 8-week waiting list period preceding treatment. Outcomes were measured by independent assessors who were blind to treatment condition. Patients in the waiting list control condition exhibited little change in symptom severity, whereas those in the two treatment conditions exhibited substantial and equivalent change, which was well maintained during follow-up. At the 60-week follow-up assessment, 51.3% of the sample had a level of eating disorder features less than one standard deviation above the community mean. Treatment outcome did not depend on eating disorder diagnosis. Patients with marked mood intolerance, clinical perfectionism, low self-esteem, or interpersonal difficulties appeared to respond better to the more complex treatment, with the reverse pattern evident among the remaining patients. These two transdiagnostic treatments appear to be suitable for the majority of outpatients with an eating disorder. The simpler treatment may best be viewed as the default version, with the more complex treatment reserved for patients with marked additional psychopathology of the type targeted by the treatment.
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The authors compared the effectiveness of 4 months (18 sessions) of cognitive-behavioral and supportive-expressive therapy for bulimia. Sixty patients obtained from clinical referrals to an eating disorders program who met modified DSM-III-R criteria for bulimia nervosa were randomly assigned to the two conditions. Treatments were delivered in an individual format, on an outpatient basis, by experienced therapists using treatment manuals. The primary outcome measures were self-induced vomiting, binge eating, and attitudes toward body weight and shape, which were assessed by self-report and structured interview. Fifty patients completed treatment, 25 in each condition. Both treatments led to significant improvements in specific eating disorder symptoms and in psychosocial disturbances. Supportive-expressive therapy was just as effective as cognitive-behavioral therapy in reducing binge eating. Where treatment differences were found, they favored cognitive-behavioral therapy. Cognitive-behavioral therapy was marginally superior in reducing the frequency of self-induced vomiting; 36% of the patients who received cognitive-behavioral therapy and 12% of those who received supportive-expressive therapy abstained from vomiting in the last month of treatment. Cognitive-behavioral therapy was significantly more effective in ameloriating disturbed attitudes toward eating and weight, depression, poor self-esteem, general psychological distress, and certain personality traits. These results moderately favor cognitive-behavioral therapy over supportive-expressive therapy for bulimia nervosa, but follow-up is required to determine the durability of outcome with both modalities. The findings must be interpreted with caution since the selected clinical sample in this study may not represent the bulimia nervosa population.
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Two treatments for bulimia nervosa have emerged as having established efficacy: cognitive-behavioral therapy and antidepressant medication. This study sought to address 1) how the efficacy of a psychodynamically oriented supportive psychotherapy compared to that of cognitive-behavioral therapy; 2) whether a two-stage medication intervention, in which a second antidepressant (fluoxetine) was employed if the first (desipramine) was either ineffective or poorly tolerated, added to the benefit of psychological treatment; and 3) if the combination of medication and psychological treatment was superior to a course of medication alone. A total of 120 women with bulimia nervosa participated in a randomized, placebo-controlled trial. Cognitive-behavioral therapy was superior to supportive psychotherapy in reducing behavioral symptoms of bulimia nervosa (binge eating and vomiting). Patients receiving medication in combination with psychological treatment experienced greater improvement in binge eating and depression than did patients receiving placebo and psychological treatment. In addition, cognitive-behavioral therapy plus medication was superior to medication alone, but supportive psychotherapy plus medication was not. At present, cognitive-behavioral therapy is the psychological treatment of choice for bulimia nervosa. A two-stage medication intervention using fluoxetine adds modestly to the benefit of psychological treatment.
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We study recently developed nonparametric methods for estimating the number of missing studies that might exist in a meta-analysis and the effect that these studies might have had on its outcome. These are simple rank-based data augmentation techniques, which formalize the use of funnel plots. We show that they provide effective and relatively powerful tests for evaluating the existence of such publication bias. After adjusting for missing studies, we find that the point estimate of the overall effect size is approximately correct and coverage of the effect size confidence intervals is substantially improved, in many cases recovering the nominal confidence levels entirely. We illustrate the trim and fill method on existing meta-analyses of studies in clinical trials and psychometrics.
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The authors examined the effectiveness of unguided self-help as a first step in the treatment of bulimia nervosa. A total of 85 women with bulimia nervosa who were on a waiting list for treatment at a hospital-based clinic participated. The patients were randomly assigned to receive one of two self-help manuals or to a waiting list control condition for 8 weeks. One of the self-help manuals addressed the specific symptoms of bulimia nervosa (cognitive behavior self-help), while the other focused on self-assertion skills (nonspecific self-help). Twenty patients (23.5%) dropped out of the study. The data were analyzed with intention-to-treat analysis. Although the group-by-time interaction for binge eating and purging was not statistically significant, simple effects showed that there was a significant reduction in symptom frequency in both self-help conditions at posttreatment but not in the waiting list condition. There were no statistically significant changes in levels of dietary restraint, eating concerns, concerns about shape and weight, or general psychopathology. A greater proportion of patients in the cognitive behavior self-help (53.6%) and nonspecific self-help (50.0%) conditions reported at least a 50% reduction in binge eating or purging at posttreatment, compared with the waiting list condition (31.0%). A lower baseline knowledge about eating disorders, more problems with intimacy, and higher compulsivity scores predicted a better response. The findings suggest that a subgroup of patients with bulimia nervosa may benefit from unguided self-help as a first step in their treatment. Cognitive behavior self-help and nonspecific self-help had equivalent effects.
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Little is known about general practice management of patients with eating disorders. To compare the effectiveness of a general practice-based, self-help approach to the treatment of bulimia nervosa with that of specialist outpatient treatment. A prospective, parallel group, randomised controlled trial. General practices and specialist eating disorder clinics in London. Patients were recruited from general practitioner (GP) referrals to specialist eating disorder clinics. Thirty-four patients were randomised to receive the self-help intervention in general practice and thirty-four were randomised to the clinic intervention. Patients randomised to the self-help arm of the trial worked through a manual based on cognitive behaviour principles, while keeping in contact with their GPs. Those randomised to receive specialist treatment were managed in the specialist clinic to which they had been referred. The main outcome measure was the Bulimic Investigatory Test Edinburgh score, assessed at baseline and at six and nine months. Secondary measures were eating pathology, depression, and social adjustment. A total of 74% and 80% of patients were followed up at six and nine months respectively. An intention-to-treat analysis revealed that, while bulimic symptoms declined in both groups over time, there was no significant difference in outcome between the two groups. The findings lend support to the idea that patients with bulimia nervosa can be treated in general practice and that this approach warrants further investigation.
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Few randomized, controlled trials have examined the efficacy of treatments for anorexia nervosa. Cognitive behavior therapy and interpersonal psychotherapy are effective in a related disorder, bulimia nervosa. There are theoretical and treatment indications for these therapies in anorexia nervosa. Fifty-six women with anorexia nervosa diagnosed by using strict and lenient weight criteria were randomly assigned to three treatments. Two were specialized psychotherapies (cognitive behavior therapy and interpersonal psychotherapy), and one was a control treatment combining clinical management and supportive psychotherapy (nonspecific supportive clinical management). Therapy consisted of 20 sessions over a minimum of 20 weeks. For the total study group (intent-to-treat group), there were significant differences among therapies in the primary global outcome measure. Nonspecific supportive clinical management was superior to interpersonal psychotherapy, while cognitive behavior therapy was intermediate, neither worse than nonspecific supportive clinical management nor better than interpersonal psychotherapy. For the women completing therapy, nonspecific supportive clinical management was superior to the two specialized therapies. The finding that nonspecific supportive clinical management was superior to more specialized psychotherapies was opposite to the primary hypothesis and challenges assumptions about the effective ingredients of successful treatments for anorexia nervosa.
Article
Objective: This meta-analysis examined the efficacy of cognitive-behavioral therapy (CBT) for eating disorders. Method: Randomized controlled trials of CBT were searched. Seventy-nine trials were included. Results: Therapist-led CBT was more efficacious than inactive (wait-lists) and active (any psychotherapy) comparisons in individuals with bulimia nervosa and binge eating disorder. Therapist-led CBT was most efficacious when manualized CBT-BN or its enhanced version was delivered. No significant differences were observed between therapist-led CBT for bulimia nervosa and binge eating disorder and antidepressants at posttreatment. CBT was also directly compared to other specific psychological interventions, and therapist-led CBT resulted in greater reductions in behavioral and cognitive symptoms than interpersonal psychotherapy at posttreatment. At follow-up, CBT outperformed interpersonal psychotherapy only on cognitive symptoms. CBT for binge eating disorder also resulted in greater reductions in behavioral symptoms than behavioral weight loss interventions. There was no evidence that CBT was more efficacious than behavior therapy or nonspecific supportive therapies. Conclusions: CBT is efficacious for eating disorders. Although CBT was equally efficacious to certain psychological treatments, the fact that CBT outperformed all active psychological comparisons and interpersonal psychotherapy specifically, offers some support for the specificity of psychological treatments for eating disorders. Conclusions from this study are hampered by the fact that many trials were of poor quality. Higher quality RCTs are essential. (PsycINFO Database Record
Article
Objective: Rapid response to cognitive behavior therapy (CBT) for eating disorders (i.e., rapid and substantial change to key eating disorder behaviors in the initial weeks of treatment) robustly predicts good outcome at end-of-treatment and in follow up. The objective of this study was to determine whether rapid response to day hospital (DH) eating disorder treatment could be facilitated using a brief adjunctive CBT intervention focused on early change. Method: 44 women (average age 27.3 [8.4]; 75% White, 6.3% Black, 6.9% Asian) were randomly assigned to 1 of 2 4-session adjunctive interventions: CBT focused on early change, or motivational interviewing (MI). DH was administered as usual. Outcomes included binge/purge frequency, Eating Disorder Examination-Questionnaire and Difficulties in Emotion Regulation Scale. Intent-to-treat analyses were used. Results: The CBT group had a higher rate of rapid response (95.7%) compared to MI (71.4%; p = .04, V = .33). Those who received CBT also had fewer binge/purge episodes (p = .02) in the first 4 weeks of DH. By end-of-DH, CBT participants made greater improvements on overvaluation of weight and shape (p = .008), and emotion regulation (ps < .008). Across conditions, there were no significant baseline differences between rapid and nonrapid responders (ps > .05). Conclusions: The results of this study demonstrate that rapid response can be clinically facilitated using a CBT intervention that explicitly encourages early change. This provides the foundation for future research investigating whether enhancing rates of rapid response using such an intervention results in improved longer term outcomes. (PsycINFO Database Record
Article
Objective The authors compared cognitive-behavioral therapy (CBT) and psychodynamic therapy (PDT) for the treatment of bulimia nervosa (BN) in female adolescents. Method In this randomized controlled trial, 81 female adolescents with BN or partial BN according to the DSM-IV received a mean of 36.6 sessions of manualized disorder−oriented PDT or CBT. Trained psychologists blinded to treatment condition administered the outcome measures at baseline, during treatment, at the end of treatment, and 12 months after treatment. The primary outcome was the rate of remission, defined as a lack of DSM-IV diagnosis for BN or partial BN at the end of therapy. Several secondary outcome measures were evaluated. Results The remission rates for CBT and PDT were 33.3% and 31.0%, respectively, with no significant differences between them (odds ratio [OR] = 0.90, 95% CI = 0.35−2.28, p = .82). The within-group effect sizes were h = 1.22 for CBT and h = 1.18 for PDT. Significant improvements in all secondary outcome measures were found for both CBT (d = 0.51−0.82) and PDT (d = 0.24−1.10). The improvements remained stable at the 12-month follow-up in both groups. There were small between-group effect sizes for binge eating (d = 0.23) and purging (d = 0.26) in favor of CBT and for eating concern (d = −0.35) in favor of PDT. Conclusion CBT and PDT were effective in promoting recovery from BN in female adolescents. The rates of remission for both therapies were similar to those in other studies evaluating CBT. This trial identified differences with small effects in binge eating, purging, and eating concern. Clinical trial registration information—Treating Bulimia Nervosa in Female Adolescents With Either Cognitive-Behavioral Therapy (CBT) or Psychodynamic Therapy (PDT). http://isrctn.com/; ISRCTN14806095.
Article
This systematic review synthesised the literature on predictors, moderators, and mediators of outcome following Fairburn's CBT for eating disorders. Sixty-five articles were included. The relationship between individual variables and outcome was synthesised separately across diagnoses and treatment format. Early change was found to be a consistent mediator of better outcomes across all eating disorders. Moderators were mostly tested in binge eating disorder, and most moderators did not affect cognitive-behavioural treatment outcome relative to other treatments. No consistent predictors emerged. Findings suggest that it is unclear how and for whom this treatment works. More research testing mediators and moderators is needed, and variables selected for analyses need to be empirically and theoretically driven. Future recommendations include the need for authors to (i) interpret the clinical and statistical significance of findings; (ii) use a consistent definition of outcome so that studies can be directly compared; and (iii) report null and statistically significant findings.
Article
Objective: This review aimed to (a) examine the effects of rapid response on behavioral, cognitive, and weight-gain outcomes across the eating disorders, (b) determine whether diagnosis, treatment modality, the type of rapid response (changes in disordered eating cognitions or behaviors), or the type of behavioral outcome moderated this effect, and (c) identify factors that predict a rapid response. Method: Thirty-four articles met inclusion criteria from six databases. End of treatment and follow-up outcomes were divided into three categories: Behavioral (binge eating/purging), cognitive (EDE global scores), and weight gain. Average weighted effect sizes(r) were calculated. Results: Rapid response strongly predicted better end of treatment and follow-up cognitive and behavioral outcomes. Moderator analyses showed that the effect size for rapid response on behavioral outcomes was larger when studies included both binge eating and purging (as opposed to just binge eating) as a behavioral outcome. Diagnosis, treatment modality, and the type of rapid response experienced did not moderate the relationship between early response and outcome. The evidence for weight gain was mixed. None of the baseline variables analyzed (eating disorder psychopathology, demographics, BMI, and depression scores) predicted a rapid response. Discussion: As there is a solid evidence base supporting the prognostic importance of rapid response, the focus should shift toward identifying the within-treatment mechanisms that predict a rapid response so that the effectiveness of eating disorder treatment can be improved. There is a need for future research to use theories of eating disorders as a guide to assess within-treatment predictors of rapid response. © 2016 Wiley Periodicals, Inc.
Article
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.
Article
Binge-eating disorder (BED) is a prevalent health condition associated with obesity. Few people with BED receive appropriate treatment. Personal barriers include shame, fear of stigma, geographic distance to mental health services, and long wait lists. The aims of this study were to examine the efficacy of an Internet-based cognitive-behavioral intervention for adults with threshold BED (DSM-IV) and to examine the stability of treatment effects over 12 months. Participants were randomly assigned to a 16-week Internet-based cognitive-behavioral intervention (n = 69) or a waiting list condition (n = 70). Binge eating frequency and eating disorder psychopathology were measured with the Eating Disorder Examination-Questionnaire and the Eating Disorder Examination administered over the telephone. Additionally, body weight and body mass index, depression, and anxiety were assessed before and immediately after treatment. Three-, six-, and twelve-month follow-up data were recorded in the treatment group. Immediately after the treatment the number of binge-eating episodes showed significant improvement (d = 1.02, between group) in the treatment group relative to the waiting list condition. The treatment group had also significantly reduced symptoms of all eating psychopathology outcomes relative to the waiting list condition (0.82 ≤ d ≤ 1.11). In the treatment group, significant improvement was still observed for all measures one the year after the intervention to relative to pretreatment levels. The Internet-based intervention proved to be efficacious significantly reducing the number of binge-eating episodes and eating disorder pathology long-term. Low-threshold e-health interventions should be further evaluated to improve treatment access for patients suffering from BED.
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IntroductionIndividual studiesThe summary effectHeterogeneity of effect sizesSummary points
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Psychotherapy is the treatment of choice for patients with anorexia nervosa, although evidence of efficacy is weak. The Anorexia Nervosa Treatment of OutPatients (ANTOP) study aimed to assess the efficacy and safety of two manual-based outpatient treatments for anorexia nervosa-focal psychodynamic therapy and enhanced cognitive behaviour therapy-versus optimised treatment as usual. The ANTOP study is a multicentre, randomised controlled efficacy trial in adults with anorexia nervosa. We recruited patients from ten university hospitals in Germany. Participants were randomly allocated to 10 months of treatment with either focal psychodynamic therapy, enhanced cognitive behaviour therapy, or optimised treatment as usual (including outpatient psychotherapy and structured care from a family doctor). The primary outcome was weight gain, measured as increased body-mass index (BMI) at the end of treatment. A key secondary outcome was rate of recovery (based on a combination of weight gain and eating disorder-specific psychopathology). Analysis was by intention to treat. This trial is registered at http://isrctn.org, number ISRCTN72809357. Of 727 adults screened for inclusion, 242 underwent randomisation: 80 to focal psychodynamic therapy, 80 to enhanced cognitive behaviour therapy, and 82 to optimised treatment as usual. At the end of treatment, 54 patients (22%) were lost to follow-up, and at 12-month follow-up a total of 73 (30%) had dropped out. At the end of treatment, BMI had increased in all study groups (focal psychodynamic therapy 0·73 kg/m(2), enhanced cognitive behaviour therapy 0·93 kg/m(2), optimised treatment as usual 0·69 kg/m(2)); no differences were noted between groups (mean difference between focal psychodynamic therapy and enhanced cognitive behaviour therapy -0·45, 95% CI -0·96 to 0·07; focal psychodynamic therapy vs optimised treatment as usual -0·14, -0·68 to 0·39; enhanced cognitive behaviour therapy vs optimised treatment as usual -0·30, -0·22 to 0·83). At 12-month follow-up, the mean gain in BMI had risen further (1·64 kg/m(2), 1·30 kg/m(2), and 1·22 kg/m(2), respectively), but no differences between groups were recorded (0·10, -0·56 to 0·76; 0·25, -0·45 to 0·95; 0·15, -0·54 to 0·83, respectively). No serious adverse events attributable to weight loss or trial participation were recorded. Optimised treatment as usual, combining psychotherapy and structured care from a family doctor, should be regarded as solid baseline treatment for adult outpatients with anorexia nervosa. Focal psychodynamic therapy proved advantageous in terms of recovery at 12-month follow-up, and enhanced cognitive behaviour therapy was more effective with respect to speed of weight gain and improvements in eating disorder psychopathology. Long-term outcome data will be helpful to further adapt and improve these novel manual-based treatment approaches. German Federal Ministry of Education and Research (Bundesministerium für Bildung und Forschung, BMBF), German Eating Disorders Diagnostic and Treatment Network (EDNET).
Article
There is a need for treatment interventions to address the high prevalence of disordered eating throughout adolescence and early adulthood. We developed an adolescent-specific manualized CBT protocol to treat female adolescents with recurrent binge eating and tested its efficacy in a small, pilot randomized controlled trial. We present lessons learned in recruiting adolescents, a description of our treatment approach, acceptability of the treatment for teens and parents, as well as results from the pilot trial. Participants in the CBT group had significantly fewer posttreatment eating binges than those in a treatment as usual/delayed treatment (TAU-DT) control group; 100% of CBT participants were abstinent at follow-up. Our results provide preliminary support for the efficacy of this adolescent adaptation of evidence-based CBT for recurrent binge eating. The large, robust effect size estimate observed for the main outcome (NNT=2) places this among the larger effects observed for any mental health intervention.
Article
The aim of this study was to compare the effects of weight loss treatment, cognitive-behavioral treatment, and desipramine on binge eating and weight in a three group additive design involving 108 overweight participants with binge eating disorder. Subjects were allocated at random to either 9-months weight-loss-only treatment; 3-months of cognitive-behavioral treatment followed by weight loss treatment for 6-months; or the combination treatment with desipramine added for the last 6-months. After 3-months of treatment, those receiving cognitive-behavioral therapy had reduced binge eating significantly more than participants receiving weight loss therapy only, and the weight loss only group had lost significantly more weight than those in the cognitive-behavioral groups. The addition of medication did not lead to greater reductions in the frequency of binge eating. Hence, there was no evidence that either cognitive-behavioral therapy or desipramine added to the effectiveness of weight loss therapy. However, those receiving medication lost significantly more weight than the comparable group without medication at follow-up. Abstinence from binge eating was associated with significantly greater weight losses. Overall, however, the achieved weight losses were small and the abstinence rates low. Moreover, there were no differences between the three groups either at the end of treatment or at follow-up. Suggestions for further research aimed at improving the therapeutic results for this difficult clinical problem are discussed.
Article
The study examined the validity of the transdiagnostic cognitive behavioural theory of eating disorders. The aim was to determine if the maintaining mechanisms of clinical perfectionism, core low self esteem, mood intolerance and interpersonal difficulties have a direct impact on dietary restraint or an indirect impact via eating, shape and weight concerns. The model was tested in a community sample of 224 females recruited via the internet. The structural equation model provided a good fit for the data. The relationship between maintaining mechanisms and dietary restraint was due to maintaining mechanisms impacting indirectly on dietary restraint via eating disorder psychopathology. The results lend support for the validity of the transdiagnostic model of eating disorders as the maintaining mechanisms lead to restraint via the core psychopathology of eating concerns, weight concerns and shape concerns. The findings suggest the four maintaining mechanisms alone are not enough to lead to dietary restraint, the core psychopathology of eating disorders needs to be present, which supports the predictions of the theory. These results help establish the validity of the transdiagnostic cognitive behavioural theory of eating disorders.
Article
Cognitive-behavioral therapy (CBT) is the best established treatment for binge-eating disorder (BED) but does not produce weight loss. The efficacy of behavioral weight loss (BWL) in obese patients with BED is uncertain. This study compared CBT, BWL, and a sequential approach in which CBT is delivered first, followed by BWL (CBT + BWL). 125 obese patients with BED were randomly assigned to 1 of the 3 manualized treatments delivered in groups. Independent assessments were performed posttreatment and at 6- and 12-month follow-ups. At 12-month follow-up, intent-to-treat binge-eating remission rates were 51% (CBT), 36% (BWL), and 40% (CBT + BWL), and mean percent BMI losses were -0.9, -2.1, and 1.5, respectively. Mixed-models analyses revealed that CBT produced significantly greater reductions in binge eating than BWL through 12-month follow-up and that BWL produced significantly greater percent BMI loss during treatment. The overall significant percent BMI loss in CBT + BWL was attributable to the significant effects during the BWL component. Binge-eating remission at major assessment points was associated significantly with greater percent BMI loss cross-sectionally and prospectively (i.e., at subsequent follow-ups). CBT was superior to BWL for producing reductions in binge eating through 12-month follow-up, while BWL produced statistically greater, albeit modest, weight losses during treatment. Results do not support the utility of the sequential approach of providing BWL following CBT. Remission from binge eating was associated with significantly greater percent BMI loss. Findings support BWL as an alternative treatment option to CBT for BED.
Article
The original cognitive-behavioural model of bulimia nervosa (BN) has been enhanced to include four additional maintaining mechanisms: low self esteem, clinical perfectionism, interpersonal problems, and mood intolerance. These models have been used to guide cognitive-behavioural treatment for BN, but the enhanced model has yet to be directly evaluated as a whole in a clinical sample. This study aimed to compare and evaluate the original and the enhanced cognitive-behavioural models of BN using structural equation modelling. The Eating Disorder Examination and self-report questionnaires were completed by 162 patients seeking treatment for BN (N = 129) or atypical BN (N = 33). Fit indices suggested that both the original and enhanced models provided a good fit to the data, but the enhanced model accounted for more variance in dietary restraint and binge eating. In the enhanced model, low self esteem was associated with greater overevaluation of weight and shape, which, in turn, was associated with increased dietary restraint. Interpersonal problems were also directly associated with dietary restraint, and binge eating was associated with increased purging. While the current study provides support for some aspects of the enhanced cognitive-behavioural model of BN, some key relationships in the model were not supported, including the important conceptual relationship between dietary restraint and binge eating.
Article
Treatment guidelines recommend evidence-based guided self-help (GSH) as the first stage of treatment for bulimia nervosa and binge eating disorder. The current randomised control trial evaluated a cognitive behavioural therapy-based GSH pack, 'Working to Overcome Eating Difficulties,' delivered by trained mental health professionals in 6 sessions over 3 months. It was congruent with the transdiagnostic approach and so was intended as suitable for all disordered eating, except severe anorexia nervosa. Eighty one clients were randomly allocated to either a GSH or waiting list condition. Eating disorder psychopathology (EDE-Q), key behavioural features and global distress (CORE) were measured at pre- and post-intervention, and 3- and 6-month follow-up. Results showed significant improvements in eating disorder psychopathology, laxative abuse, exercise behaviours, and global distress, with the GSH condition being superior to the waiting list on all outcomes. Treatment gains were maintained at 3 and 6 months. This study adds to the evidence supporting GSH for disordered eating, including EDNOS. However, further work is needed to establish the factors that contribute to observed therapeutic improvements and determine for whom GSH is most suitable.
Article
Background: A specific manual-based form of cognitive behavioural therapy (CBT) has been developed for the treatment of bulimia nervosa (CBT-BN) and other common related syndromes such as binge eating disorder. Other psychotherapies and modifications of CBT are also used. Objectives: To evaluate the efficacy of CBT, CBT-BN and other psychotherapies in the treatment of adults with bulimia nervosa or related syndromes of recurrent binge eating. Search strategy: Handsearch of The International Journal of Eating Disorders since first issue; database searches of MEDLINE, EXTRAMED, EMBASE, PsycInfo, CURRENT CONTENTS, LILACS, SCISEARCH, CENTRAL and the The Cochrane Collaboration Depression, Anxiety & Neurosis Controlled Trials Register; citation list searching and personal approaches to authors were used. Search date June 2007. Selection criteria: Randomised controlled trials of psychotherapy for adults with bulimia nervosa, binge eating disorder and/or eating disorder not otherwise specified (EDNOS) of a bulimic type which applied a standardised outcome methodology and had less than 50% drop-out rate. Data collection and analysis: Data were analysed using the Review Manager software program. Relative risks were calculated for binary outcome data. Standardised mean differences were calculated for continuous variable outcome data. A random effects model was applied. Main results: 48 studies (n = 3054 participants) were included. The review supported the efficacy of CBT and particularly CBT-BN in the treatment of people with bulimia nervosa and also (but less strongly due to the small number of trials) related eating disorder syndromes.Other psychotherapies were also efficacious, particularly interpersonal psychotherapy in the longer-term. Self-help approaches that used highly structured CBT treatment manuals were promising. Exposure and Response Prevention did not enhance the efficacy of CBT.Psychotherapy alone is unlikely to reduce or change body weight in people with bulimia nervosa or similar eating disorders. Authors' conclusions: There is a small body of evidence for the efficacy of CBT in bulimia nervosa and similar syndromes, but the quality of trials is very variable and sample sizes are often small. More and larger trials are needed, particularly for binge eating disorder and other EDNOS syndromes. There is a need to develop more efficacious therapies for those with both a weight and an eating disorder.
Article
This waitlist-controlled study evaluated the efficacy of a short version of a group CBT for BED followed by booster sessions after the active treatment phase. Thirty-six females with BED were randomly assigned to CBT (eight weekly sessions during active treatment plus five booster sessions during follow-up) or a waitlist condition. At the end of the active treatment, binge eating was significantly reduced relative to waitlist. Furthermore, at 12-month follow-up short-term CBT produced significant improvements in binge eating symptoms relative to baseline. Findings suggest that the short-term CBT followed by booster sessions may provide a valuable treatment option for patients with BED.
Article
The specificity and magnitude of the effects of cognitive behavior therapy in the treatment of bulimia nervosa were evaluated. Seventy-five patients who met strict diagnostic criteria were treated with either cognitive behavior therapy, a simplified behavioral version of this treatment, or interpersonal psychotherapy. Assessment was by interview and self-report questionnaire, and many aspects of functioning were evaluated. All three treatments resulted in an improvement in the measures of the psychopathology. Cognitive behavior therapy was more effective than interpersonal psychotherapy in modifying the disturbed attitudes to shape and weight, extreme attempts to diet, and self-induced vomiting. Cognitive behavior therapy was more effective than behavior therapy in modifying the disturbed attitudes to shape and weight and extreme dieting, but it was equivalent in other respects. The findings suggest that cognitive behavior therapy, when applied to patients with bulimia nervosa, operates through mechanisms specific to this treatment and is more effective than both interpersonal psychotherapy and a simplified behavioral version of cognitive behavior therapy.
Article
The influence of food type on the restrained eating pattern was examined. In Study 1, subjects rated the degree to which each of 149 foods were dietary permissable or dietary forbidden. The number of avoided foods correlated positively with restraint score. Study 2 compared Herman and Mack's (1975) 1- and 2-milk shake preloads to two nonforbidden preloads of equivalent calories. Food type, and not perceived calories, was found to be the element of the preload required to cause disinhibition among restrained eaters, both within the experiment and outside the experimental setting. Study 3 examined the effects of anticipated consumption (varying food type and calories) on the restrained eating pattern. Only restrained eaters anticipating a forbidden food (whether high or low in calories) were disinhibited. The restrained literature was reconsidered in light of the forbidden food hypothesis.
Article
In an effort to elucidate the role of cognitive factors in the maintenance of bulimia nervosa, the efficacy of two psychological treatments was examined in a randomised control trial: cognitive behaviour therapy in the absence of explicit exposure instructions was compared with exposure and response prevention treatment in the absence of cognitive restructuring procedures. In the short term both treatments were successful at effecting substantial improvement in both the specific and the non-specific psychopathology of the disorder. However, at a one year follow up, whilst improvements were well maintained for those who had received the cognitive-behavioural treatment, virtually all of those who had responded to the purely behavioural treatment had relapsed. This provides some support for the cognitive model of the maintenance of bulimia nervosa. Nevertheless, the two treatment groups could not be distinguished on post-treatment measures of cognitive disturbance and neither was it the case that residual levels of cognitive disturbance, as assessed, predicted relapse. This may suggest that the level at which the necessary cognitive change takes place may not be accessible by conventional assessment procedures.
Article
A detailed comparison was made of two methods for assessing the features of eating disorders. An investigator-based interview was compared with a self-report questionnaire based directly on that interview. A number of important discrepancies emerged. Although the two measures performed similarly with respect to the assessment of unambiguous behavioral features such as self-induced vomiting and dieting, the self-report questionnaire generated higher scores than the interview when assessing more complex features such as binge eating and concerns about shape. Both methods underestimated body weight.
Article
This article describes the use of a slightly modified version of the Eating Disorders Examination (EDE) in children. Sixteen children aged between 7 and 14 years attending an eating disorders clinic over a 5-month period were recruited to the study. The two main modifications to the EDE were (A) the inclusion of a sort task to assess overvalued ideas about weight and shape and (B) the reformulation of certain items to assess intent rather than actual behavior. The existing EDE scoring system was used, resulting in item, subscale, and global scores. Of the 16 children (10 F 6 M), 11 had a diagnosis of anorexia nervosa, and 5 of eating disorder not otherwise specified (EDNOS). There were interesting differences in responses on items assessing core overvalued ideas, with weight and/or shape concerns emerging as of great importance in terms of self-evaluation in the majority of children with anorexia nervosa. Results suggest that this may be a useful assessment tool in children, with some children obtaining global and subscale scores consistent with adult norms for females with eating disorders. Problems of the administration of the EDE to this patient group are discussed and details of the modifications used are outlined.
Article
Research suggests that cognitive-behavioral therapy (CBT) is the most effective psychotherapeutic treatment for bulimia nervosa. One exception was a study that suggested that interpersonal psychotherapy (IPT) might be as effective as CBT, although slower to achieve its effects. The present study is designed to repeat this important comparison. Two hundred twenty patients meeting DSM-III-R criteria for bulimia nervosa were allocated at random to 19 sessions of either CBT or IPT conducted over a 20-week period and evaluated for 1 year after treatment in a multisite study. Cognitive-behavioral therapy was significantly superior to IPT at the end of treatment in the percentage of participants recovered (29% [n=32] vs 6% [n=71), the percentage remitted (48% [n=53] vs 28% [n = 31]), and the percentage meeting community norms for eating attitudes and behaviors (41% [n=45] vs 27% [n=30]). For treatment completers, the percentage recovered was 45% (n= 29) for CBT and 8% (n= 5) for IPT. However, at follow-up, there were no significant differences between the 2 treatments: 26 (40%) CBT completers had recovered at follow-up compared with 17 (27%) IPT completers. Cognitive-behavioral therapy was significantly more rapid in engendering improvement in patients with bulimia nervosa than IPT. This suggests that CBT should be considered the preferred psychotherapeutic treatment for bulimia nervosa.
Article
This paper is concerned with the psychopathological processes that account for the persistence of severe eating disorders. Two separate but interrelated lines of argument are developed. One is that the leading evidence-based theory of the maintenance of eating disorders, the cognitive behavioural theory of bulimia nervosa, should be extended in its focus to embrace four additional maintaining mechanisms. Specifically, we propose that in certain patients one or more of four additional maintaining processes interact with the core eating disorder maintaining mechanisms and that when this occurs it is an obstacle to change. The additional maintaining processes concern the influence of clinical perfectionism, core low self-esteem, mood intolerance and interpersonal difficulties. The second line of argument is that in the case of eating disorders shared, but distinctive, clinical features tend to be maintained by similar psychopathological processes. Accordingly, we suggest that common mechanisms are involved in the persistence of bulimia nervosa, anorexia nervosa and the atypical eating disorders. Together, these two lines of argument lead us to propose a new transdiagnostic theory of the maintenance of the full range of eating disorders, a theory which embraces a broader range of maintaining mechanisms than the current theory concerning bulimia nervosa. In the final sections of the paper we describe a transdiagnostic treatment derived from the new theory, and we consider in principle the broader relevance of transdiagnostic theories of maintenance.
Article
Cognitive behavioral therapy (CBT) and certain medications have been shown to be effective for binge eating disorder (BED), but no controlled studies have compared psychological and pharmacological therapies. We conducted a randomized, placebo-controlled study to test the efficacy of CBT and fluoxetine alone and in combination for BED. 108 patients were randomized to one of four 16-week individual treatments: fluoxetine (60 mg/day), placebo, CBT plus fluoxetine (60 mg/day) or CBT plus placebo. Medications were provided in double-blind fashion. Of the 108 patients, 86 (80%) completed treatments. Remission rates (zero binges for 28 days) for completers were: 29% (fluoxetine), 30% (placebo), 55% (CBT+fluoxetine), and 73% (CBT+placebo). Intent-to-treat (ITT) remission rates were: 22% (fluoxetine), 26% (placebo), 50% (CBT+fluoxetine), and 61% (CBT+placebo). Completer and ITT analyses on remission and dimensional measures of binge eating, cognitive features, and psychological distress produced consistent findings. Fluoxetine was not superior to placebo, CBT+fluoxetine and CBT+placebo did not differ, and both CBT conditions were superior to fluoxetine and to placebo. Weight loss was modest, did not differ across treatments, but was associated with binge eating remission. CBT, but not fluoxetine, demonstrated efficacy for the behavioral and psychological features of BED, but not obesity.
Article
We performed a randomized controlled study to test the relative efficacy of guided self-help (gsh) cognitive-behavioral therapy (CBTgsh) and behavioral weight loss treatment (BWLgsh) treatments for binge eating disorder (BED). To provide an additional partial control for non-specific influences of attention, a third control (CON) treatment condition was included. We tested the treatments using a guided self-help approach given the promising results from initial studies using minimal therapist guidance. Ninety consecutive overweight patients (19 males, 71 females) with BED were randomly assigned (5:5:2 ratio) to one of three treatments: CBTgsh (N=37), BWLgsh (N=38), or CON (N=15). The three 12-week treatment conditions were administered individually following guided self-help protocols. Overall, 70 (78%) completed treatments; CBTgsh (87%) and CON (87%) had significantly higher completion rates than BWLgsh (67%). Intent-to-treat analyses revealed that CBTgsh had significantly higher remission rates (46%) than either BWLgsh (18%) or CON (13%). Weight loss was minimal and differed little across treatments. The findings suggest that CBT, administered via guided self-help, demonstrates efficacy for BED, but not for obesity. The findings support CBT administered via guided self-help as a first step in the treatment of BED and provide evidence for its specific effects.