Article

How many individuals achieve symptom abstinence following psychological treatments for bulimia nervosa? A meta-analytic review

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Objectives: It is unclear how many patients with bulimia nervosa (BN) completely abstain from the core behavioral symptoms after receiving psychological treatment. The present meta-analysis of randomized controlled trials (RCTs) aimed to (a) estimate the prevalence of patients who abstain from binge eating and/or purging following all psychological treatments for BN, and (b) test whether these abstinence estimates are moderated by the type of treatment modality delivered, the definition of abstinence applied, and trial quality. Method: Forty-five RCTs were included, with 78 psychotherapy conditions. Pooled event rates were calculated using random effects models. Results: At post-treatment, the total weighted percentage of treatment-completers who achieved abstinence was 35.4% (95% CI = 29.6, 41.7), while the total weighted percentage of abstinence for all randomized patients (intention-to-treat) was 29.9% (95% CI = 25.7, 33.2). Abstinence estimates were highest in trials that used behavioral-based treatments (e.g., cognitive-behavioral therapy, behavior therapy). There was also evidence that guided self-help interventions produced the lowest post-treatment abstinence rates, but with no difference at follow-up from clinician-led treatments, and studies that used a shorter timeframe for defining abstinence (i.e., 14 days symptom-free compared to 28-days symptom-free) produced the highest abstinence rates. Abstinence estimates at follow-up for both the completer (34.6%; 95% CI = 29.3, 40.2) and intention-to-treat (28.6%; 95% CI = 25.1, 32.3) analyses were essentially the same as the post-treatment estimates. Discussion: Over 60% of patients fail to fully abstain from core BN symptoms even after receiving our most empirically-supported treatments. The present findings highlight the urgency toward improving the effectiveness of psychological treatments for BN.

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... The sample size calculation described in the protocol paper was based on change in Global EDE-Q score. Objective binge eating was included as a secondary outcome, in addition to self-induced vomiting and laxative use (Linardon & Wade, 2018). ...
... Levels of symptom change were in line with the results of a systematic review by Linardon and Wade (2018), which noted binge eating cessation rates in CBT-based self-help treatments of around 14%. ...
... Another noteworthy finding was that, unlike fGSH, eGSH was not significantly more effective in reducing self-induced vomiting than the waiting list condition. This result is consistent with the observation that CBTbased self-help is less effective in reducing purging than binge eating (Linardon & Wade, 2018). ...
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Objective Increasing the availability and accessibility of evidence‐based treatments for eating disorders is an important goal. This study investigated the effectiveness and cost‐effectiveness of guided self‐help via face‐to‐face meetings (fGSH) and a more scalable method, providing support via email (eGSH). Method A pragmatic, randomized controlled trial was conducted at three sites. Adults with binge‐eating disorders were randomized to fGSH, eGSH, or a waiting list condition, each lasting 12 weeks. The primary outcome variable for clinical effectiveness was overall severity of eating psychopathology and, for cost‐effectiveness, binge‐free days, with explorative analyses using symptom abstinence. Costs were estimated from both a partial societal and healthcare provider perspective. Results Sixty participants were included in each condition. Both forms of GSH were superior to the control condition in reducing eating psychopathology (IRR = −1.32 [95% CI −1.77, −0.87], p < .0001; IRR = −1.62 [95% CI −2.25, −1.00], p < .0001) and binge eating. Attrition was higher in eGSH. Probabilities that fGSH and eGSH were cost‐effective compared with WL were 93% (99%) and 51% (79%), respectively, for a willingness to pay of £100 (£150) per additional binge‐free day. Discussion Both forms of GSH were associated with clinical improvement and were likely to be cost‐effective compared with a waiting list condition. Provision of support via email is likely to be more convenient for many patients although the risk of non‐completion is greater.
... Despite the large amount of research being conducted in the field, the efficacy of BI-focused interventions in ED remains limited (Alleva et al., 2015;Ziser et al., 2018). Particularly, interventions targeting BI only, lead to small improvement, highlighting the need for enhancing current therapeutic strategies (Alleva et al., 2015;Linardon et al., 2017Linardon et al., , 2018Linardon & Wade, 2018). Additionally, there is evidence that BID persists in patients with ED once the intervention is finished (Engel & Keizer, 2017;Eshkevari et al., 2014). ...
... Despite the large amount of research being conducted in the field, the efficacy of BI-focused interventions in ED remains limited (Alleva et al., 2015;Ziser et al., 2018). Particularly, interventions targeting BI only, lead to small improvement, highlighting the need for enhancing current therapeutic strategies (Alleva et al., 2015;Linardon et al., 2017Linardon et al., , 2018Linardon & Wade, 2018). Additionally, there is evidence that BID persists in patients with ED once the intervention is finished (Engel & Keizer, 2017;Eshkevari et al., 2014). ...
Article
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Body image (BI) disturbance is a relevant factor in the etiology and treatment of eating disorders (ED). Although progress has been made in recent decades in understanding BI and its relationship with ED, the efficacy of BI disturbance prevention and intervention programs is still limited. In order to reach deeper understanding of BI disturbance and clarify the interactions between some protective and risk factors related to this construct, we carried out a literature review on some specific BI-related factors that so far have been analyzed independently. We specifically examined positive and negative BI; embodiment and its role in the development of positive and negative BI; and self-compassion as a protective factor that promotes positive embodiment (vs. disembodiment) and protection against body shame. We conclude that integrating the available evidence on these factors into BI models may be used to enhance our understanding of BI and improve the efficacy of prevention and intervention programs to help fight negative BI (by reducing body shame and disembodiment) and promote positive BI (by increasing self-compassion and positive embodiment). Keywords: body image, positive embodiment, body shame, self-compassion
... different combinations of active experimental treatments, multimodal interventions and different variants of treatment as usual or active psychotherapy control conditions). Rates of ED remission, in terms of abstinence from ED behaviors have, however been synthesized in two meta analyses of RCTs for BN [36] and BED [37]. For BN, the rate was 30% and for BED 45%. ...
... The treatment effects for CBT described in this study are in line with treatment effects identified by Linardon et al. for CBT in BN [36] and BED [37] when using the same criteria for ED remission (i.e., 28 days abstinence from bingeing and purging). The present study is, however, the first meta-analysis of the proportion of patients with AN achieving weight restoration in outpatient samples receiving pure psychotherapeutic treatment and analyzing differences in treatment effects between diagnoses. ...
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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.
... Rates of remission, in terms of abstinence from the core behavioral symptoms have, however, been synthesized metaanalytically for BN (34) and BED (35). For BN, the rate was 30% and for BED 45%, for all patients who started therapy. ...
... treatment effects identi ed by Linardon et al. for CBT in BN(34) and BED(35) when using the same criteria for remission (i.e., 28 days abstinence from bingeing and purging). The present study is, however, the rst meta-analytic estimation of the proportion of patients with AN achieving weight restoration in outpatient samples receiving pure psychotherapeutic treatment.The role of change in psychopathology for remission in CBT and PIT For CBT, change in speci c psychopathology only emerged as a signi cant predictor of remission when controlling for differences between diagnoses. ...
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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.
... If inefficiencies in central coherence and set-shifting are clearly present among people with nonunderweight eating disorders, then this group too may benefit from adjunct CRT treatment. This would highlight a need for further treatment studies investigating the efficacy of CRT among this group, meeting a need for more research that seeks to improve the suboptimal retention (Linardon, Hindle, & Brennan, 2018) and abstinence outcomes after treatment (Linardon & Wade, 2018). ...
... Given preliminary findings that CRT may increase treatment retention for AN (Hagan et al., 2020;Lock et al., 2013), it would be of interest to examine if the same effect exists for people with BN. Furthermore, many people with BN fail to abstain from binge eating and/or purging posttreatment (Linardon & Wade, 2018). It is possible that these suboptimal outcomes result from the executive functioning inefficiencies observed, but to date, no studies have examined whether these inefficiencies moderate eating disorder treatment outcomes. ...
Article
Objective This systematic review and meta‐analysis compared previously documented inefficiencies in central coherence and set‐shifting between people with nonunderweight eating disorders (bulimia nervosa and binge‐eating disorder) and people with anorexia nervosa. Method We performed random‐effects meta‐analyses on 16 studies (1,112 participants) for central coherence and 38 studies (3,505 participants) for set‐shifting. Random effects meta‐regressions were used to test whether the effect sizes for people with nonunderweight eating disorders were significantly different from the effect sizes for people with anorexia nervosa. Results People with anorexia nervosa (Hedge's g = −0.53, 95% CIs: −0.80, −0.27, p < .001) and bulimia nervosa (Hedge's g = −0.70, 95% CIs: −1.14, −0.25, p = .002), but not binge‐eating disorder, had significantly poorer central coherence than healthy controls. Similarly, people with anorexia nervosa (Hedge's g = −0.38, 95% CIs: −0.50, −0.26, p < .001) and bulimia nervosa (Hedge's g = −0.55, 95% CIs: −0.81, −0.29, p < .001), but not binge‐eating disorder, had significantly poorer set‐shifting than healthy controls. The effect sizes for people with nonunderweight eating disorders did not significantly differ from those for people with anorexia nervosa. Discussion Our meta‐analysis was underpowered to make definitive judgments about people with binge‐eating disorder. However, we found that people with bulimia nervosa clearly have central coherence and set‐shifting inefficiencies which do not significantly differ from those observed in people with anorexia nervosa. Clinically, this suggests that people with bulimia nervosa might benefit from adjunctive approaches to address these inefficiencies, such as cognitive remediation therapy.
... Clinical eating disorders are often difficult to treat with standard cognitive behavioral therapy (CBT) (Fairburn et al., 1991;Linardon and Wade, 2018;Shapiro et al., 2007). Due to the high drop-out and relapse rates (Fairburn et al., 1991;Linardon and Wade, 2018;Shapiro et al., 2007) patients with ED require complex treatment modalities, such as schema therapy (Simpson, 2012). ...
... Clinical eating disorders are often difficult to treat with standard cognitive behavioral therapy (CBT) (Fairburn et al., 1991;Linardon and Wade, 2018;Shapiro et al., 2007). Due to the high drop-out and relapse rates (Fairburn et al., 1991;Linardon and Wade, 2018;Shapiro et al., 2007) patients with ED require complex treatment modalities, such as schema therapy (Simpson, 2012). Several research has shown that patients with EDs pathology have some specific early maladaptive schemas (e.g., Meneguzzo et al., 2020;Unoka et al., 2010) and schema modes, such as "Shamed Child mode" with internalized body shame (Simpson, 2012). ...
Article
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The main purpose of our study was to examine the psychometric properties of Conradts’ Weight- and Body-Related Shame and Guilt Scale (WEB-SG) and associations of body shame and guilt with maladaptive eating behaviors and general chronic shame among Hungarian and Norwegian university students. Therefore, we collected data from 561 university students from both nations in a cross-sectional questionnaire study. Participants completed the following standardized self-report questionnaires in this online survey: WEB-SG, Eating Attitude Test-26 (EAT-26) and Experience of Shame Scale (ESS). We tested the measurement model of the WEB-SG with confirmatory factor analysis (CFA), and we performed CFA with covariates analysis to examine the association between WEB-guilt (WEB-G) and WEB-shame (WEB-S) and predictors. Our empirical model of WEB-SG has adequate fit with Conradts’ theoretical model among both samples. The body-related guilt positively associated with dieting and negatively related to oral control in both groups. We found a significant positive relationship between WEB-S and BMI in Hungarian sample. According to our results, WEB-SG is an adequate questionnaire for assessing weight and body-related shame and guilt in Hungarian and Norwegian non-clinical samples. Maladaptive weight and body-related guilt could be a relevant factor in proneness to anorexia. Our results highlight WEB-G and WEB-S as two critical factors in the assessment and treatment of eating difficulties.
... There was limited evidence for the of one treatment approach over another in RCTs with active control groups, and more extensive research with a focus on longer-term maintenance of therapy gains, efficacy, mechanisms of change and complex models of care was recommended [12]. In another more recent meta-analysis, Linardon [13] estimated the prevalence of patients with BED who achieved bingeeating abstinence following psychological or behavioural treatments. The most common treatment delivered was CBT (either in a clinician-led or guided self-help format), and other interventions include behavioural weight loss, behavioural weight loss combined with CBT, IPT, DBT, behaviour therapy, non-specific supportive therapy, mindfulness, psychodynamic therapy, and a combined psychotherapy approach. ...
... The highest abstinence rate was observed in IPT, and clinician-led group treatments produced significantly higher posttreatment (but not follow-up) abstinence estimates than guided self-help treatments. The meta-analysis demonstrated that 50% of patients with BED do not fully respond to treatment, and there is, therefore, a need to explore other psychotherapies to improve outcomes [13]. ...
Article
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Background Research into psychotherapy for binge-eating disorder (BED) has focused mainly on cognitive behavioural therapies, but efficacy, failure to abstain, and dropout rates continue to be problematic. The experience of negative emotions is among the most accurate predictors for the occurrence of binge eating episodes in BED, suggesting benefits to exploring psychological treatments with a more specific focus on the role of emotion. The present study aimed to explore the feasibility of individual emotion-focused therapy (EFT) as a treatment for BED by examining the outcomes of a pilot randomised wait-list controlled trial. Methods Twenty-one participants were assessed using a variety of feasibility measures relating to recruitment, credibility and expectancy, therapy retention, objective binge episodes and days, and binge eating psychopathology outcomes. The treatment consisted of 12 weekly one-hour sessions of EFT for maladaptive emotions over 3 months. A mixed model approach was utilised with one between effect (group) using a one-way analysis of variance (ANOVA) to test the hypothesis that participants immediately receiving the EFT treatment would demonstrate a greater degree of improvement on outcomes relating to objective binge episodes and days, and binge eating psychopathology, compared to participants on the EFT wait-list; and one within effect (time) using a repeated-measures ANOVA to test the hypothesis that participation in the EFT intervention would result in significant improvements in outcome measures from pre to post-therapy and then maintained at follow-up. Results Recruitment, credibility and expectancy, therapy retention outcomes indicated EFT is a feasible treatment for BED. Further, participants receiving EFT demonstrated a greater degree of improvement in objective binge episodes and days, and binge eating psychopathology compared to EFT wait-list control group participants. When participants in the EFT wait-list control group then received treatment and outcomes data were combined with participants who initially received the treatment, EFT demonstrated significant improvement in objective binge episodes and days, and binge eating psychopathology for the entire sample. Conclusions These findings provide further preliminary evidence for the feasibility of individual EFT for BED and support more extensive randomised control trials to assess efficacy. Trial registration The study was retrospectively registered with the Australian New Zealand Clinical Trials Registry ( ACTRN12620000563965 ) on 14 May 2020.
... However, treatment effects are limited [13][14][15]. A recent metaanalysis of psychological treatments for BN showed that over 50% of treatment participants continue to engage in ED behaviors following treatment [16]. There are not currently any empirically-supported treatments for adults with avoidant/restrictive food intake disorder although CBT for ARFID is promising [17]. ...
... It aimed to expand upon Wierenga and colleagues' examination of TBT-S [37] by reporting outcomes for a mixed diagnostic sample that is reflective of the program's patient population at 12-month follow-up. This expansion allows for the evaluation of symptom trajectory and recovery rates among a heterogeneous range of patients presenting for TBT-S over a longer period of follow-up given the high rates of relapse upon discharging from higher levels of care [16]. Additionally, outcome analyses in the present study accounted for missing data to address a potential response bias in the previous study. ...
Article
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Background Adult eating disorder treatments are hampered by lack of access and limited efficacy. This open-trial study evaluated the acceptability and preliminary efficacy of a novel intervention for adults with eating disorders delivered to young adults and parent-supports in an intensive, multi-family format (Young Adult Temperament-Based Treatment with Supports; YA-TBT-S). Methods 38 YA-TBT-S participants ( m age = 19.58; SD 2.13) with anorexia nervosa (AN)-spectrum disorders, bulimia nervosa (BN)-spectrum disorders, and avoidant/restrictive food intake disorder (ARFID) completed self-report assessments at admission, discharge, and 12-month follow-up. Assessments measured program satisfaction, eating disorder psychopathology and impairment, body mass index (BMI), and trait anxiety. Outcomes were analyzed using linear mixed effects models to examine changes in outcome variables over time. Results Treatment was rated as highly satisfactory. 53.33% were in partial or full remission at 12-month follow-up. 56% of participants received other treatment within the 12-month follow-up period, suggesting that YA-TBT-S may be an adjunctive treatment. Participants reported reductions in ED symptomatology (AN and BN), increases in BMI (AN and ARFID), and reductions in clinical impairment (AN and ARFID) at 12-month follow-up. Conclusions YA-TBT-S is a feasible and acceptable adjunctive treatment for young adults with a broad range of ED diagnoses and may be a method for involving parents in ED treatment in ways that are acceptable to both parents and YA. Further evaluation of efficacy is needed in larger samples, and to compare YA-TBT-S to other ED treatment approaches. Plain English summary Eating disorders are costly and dangerous psychiatric disorders that affect millions of individuals each year. Despite their risks and societal costs, currently available treatments are limited. This study examined the acceptability and efficacy of Young Adult, Temperament-Based Treatment with Supports (YA-TBT-S), a new treatment program for adults with eating disorders. YA-TBT-S was rated highly, and a significant portion of participants improved based on ratings collected 12 months after program participation. Those with anorexia nervosa (AN) and bulimia nervosa (BN) showed significant reductions in eating disorder pathology, and those with AN and avoidant/restrictive food intake disorder (ARFID) showed increases in BMI over time.
... Cognitive behavioral therapy (CBT) is considered the gold standard treatment for BED and BN [8][9][10]. Recent meta-analyses show that despite CBT's efficacy, up to 50-60% of patients with BED and BN do not fully respond to treatment [11,12]. In addition, long-term recovery is often not sustained [13]. ...
Article
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Binge-eating disorder (BED) and bulimia nervosa (BN) have adverse psychological and medical consequences. Innovative interventions, like the integration of virtual reality (VR) with cue-exposure therapy (VR-CET), enhance outcomes for refractory patients compared to cognitive behavior therapy (CBT). Little is known about the feasibility and acceptability of translating VR-CET into real-world settings. To investigate this question, adults previously treated for BED or BN with at least one objective or subjective binge episode/week were recruited from an outpatient university eating disorder clinic to receive up to eight weekly one-hour VR-CET sessions. Eleven of 16 (68.8%) eligible patients were enrolled; nine (82%) completed treatment; and 82% (9/11) provided follow-up data 7.1 (SD = 2.12) months post-treatment. Overall, participant and therapist acceptability of VR-CET was high. Intent-to-treat objective binge episodes (OBEs) decreased significantly from 3.3 to 0.9/week (p < 0.001). Post-treatment OBE 7-day abstinence rate for completers was 56%, with 22% abstinent for 28 days at follow-up. Among participants purging at baseline, episodes decreased from a mean of one to zero/week, with 100% abstinence maintained at follow-up. The adoption of VR-CET into real-world clinic settings appears feasible and acceptable, with a preliminary signal of effectiveness. Findings, including some loss of treatment gains during follow-up may inform future treatment development.
... A recent meta-analysis of psychological treatments for BN showed that over 50% of treatment participants continue to engage in ED behaviors following treatment. (17) There are not currently any empirically-supported treatments for adults with avoidant/restrictive food intake disorder although CBT for ARFID is promising.(18) Accordingly, even the most well-studied treatment approaches are limited. ...
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Background: Adult eating disorder treatments are hampered by lack of access and limited efficacy. This open-trial study evaluated the acceptability and preliminary efficacy of a novel intervention for adults with eating disorders delivered to young adults and parent-supports in an intensive, multi-family format (Young Adult Temperament-Based Treatment with Supports; YA-TBT-S). Methods: 38 YA-TBT-S participants (m age = 19.58; SD 2.13) with anorexia nervosa (AN)-spectrum disorders, bulimia nervosa (BN)-spectrum disorders, and avoidant/restrictive food intake disorder (ARFID) completed self-report assessments at admission, discharge, and 12-month follow-up. Assessments measured program satisfaction, eating disorder psychopathology and impairment, body mass index (BMI), and trait anxiety. Outcomes were analyzed using linear mixed effects models to examine changes in outcome variables across diagnoses over time. Results: Treatment was rated as highly satisfactory. 53.33% were in partial or full remission at 12-month follow-up. Participants reported reductions in ED symptomatology (AN and BN), increases in BMI (AN and ARFID), and reductions in clinical impairment (AN and ARFID) at 12-month follow-up. Conclusions: YA-TBT-S is a feasible and acceptable treatment that may improve ED outcomes in young adults with a broad range of diagnoses. Further evaluation of efficacy is needed in larger samples, and to compare YA-TBT-S to other ED treatment approaches.
... Cognitive behavioral therapy (CBT) is considered the gold standard treatment for BED and BN [8][9][10]. Recent metaanalyses show that despite CBT's efficacy, up to 50%-60% of patients with BED and BN do not fully respond to treatment [11,12]. In addition, long-term recovery is often not sustained [13]. ...
Preprint
Full-text available
Binge-eating disorder (BED) and bulimia nervosa (BN) have adverse psychological and medical consequences. Novel interventions, like the integration of virtual reality (VR) with cue-exposure therapy (VR-CET), enhance outcomes for refractory patients compared to cognitive behavior therapy (CBT). Little is known about the feasibility and acceptability of translating VR-CET into real-world settings. To investigate this question, adults previously treated for BED or BN with at least one objective or subjective binge episode/week were recruited from an outpatient University eating disorder clinic to receive up to eight weekly one-hour VR-CET sessions. Eleven of 16 (68.8%) eligible patients enrolled; nine (82%) completed treatment; 82% (9/11) provided follow-up data 7.1 (SD=2.12) months post-treatment. Overall, participant and therapist acceptability of VR-CET was high. Intent-to-treat objective binge episodes (OBEs) decreased significantly from 3.3 to 0.9/week (p < .001). Post-treatment OBE 7-day abstinence rate for completers was 56%, with 22% abstinent for 28 days at follow-up. Among participants purging at baseline, episodes decreased from a mean of one to zero/week, with 100% abstinence maintained at follow-up. The adoption of VR-CET into real-world clinic settings appears feasible and acceptable, with a preliminary signal of efficacy. Findings, including some loss of treatment gains during follow-up may inform future treatment development.
... 22 Using this information, dietitians can then collaboratively develop a nutrition care plan with the patient to address nutritional deficiencies and promote a balanced nutritional intake, as well as provide nutrition education to challenge patients' inaccurate beliefs about food. [22][23][24][25] Although reviews of the medical, [26][27][28] pharmacological, [29][30][31] and psychological interventions 26,32,33 for EDs have been conducted, current literature regarding the impact of integrating dietetic intervention into treatment for adult outpatients with an ED has not been systematically reviewed and evaluated. This has meant that clinical recommendations regarding dietetic management in current practice guidelines have not offered definitive guidance about how dietitians can best contribute to the multidisciplinary management of patients with an ED. ...
Article
Context: Eating disorders (EDs) are complex mental illnesses that require medical, psychological, and dietetic intervention to assist patients achieve recovery. Objective: Available evidence was reviewed regarding dietetic intervention for adult outpatients with an ED and the quality of this evidence was assessed. Data sources: Systematic literature searches were conducted using 5 databases (MEDLINE, PreMEDLINE, EMBASE, CINAHL, PsycINFO) for studies comparing adults with an ED receiving a dietetic intervention with those receiving a psychological intervention alone, those receiving a combined dietetic and psychological intervention, or a control group. Data extraction: Literature searches returned 3078 results, with 10 articles reporting on 9 randomized controlled trials meeting the inclusion criteria. The quality of evidence was assessed using the Cochrane Risk-of-Bias tool and Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. Data analysis: GRADE assessments for studies involving individuals with anorexia nervosa indicated very low quality of evidence for outcomes including weight, ED psychopathology and ED behaviors , and no studies measured nutritional changes. For studies conducted with participants with bulimia nervosa or binge eating disorder, only 1 study included a group receiving combined evidence-based psychological and dietetic intervention. A combined intervention produced moderate-quality evidence for lower attrition, greater abstinence from ED behaviors, and more meals eaten per week in comparison with a stand-alone psychological or dietetic intervention. Conclusions: There is currently limited evidence to sufficiently assess the impact of incorporating dietetic interventions into outpatient treatment for adults with an ED; however, available evidence supports clinical practice guidelines that dietetic intervention should not be delivered as a stand-alone treatment. Additional methodologically sound studies in larger samples are required to fully inform dietetic treatment in EDs and incorporation of such interventions as part of a multidisciplinary treatment approach.
... Further, patients exhibit heterogenous outcomes in response to empirically-supported ED treatments. In randomized controlled trials, existing treatments fail to provide clinically meaningful improvement and/or full symptom remission by end of treatment for at least 30% of adult patients across diagnostic groups (Fairburn et al., 2015;Linardon & Wade, 2018;Zipfel et al., 2014). Remission rates are even lower in community and private treatment settings (Linardon, Messer, & Fuller-Tyszkiewicz, 2018). ...
Article
Objective Patterns of response to eating disorder (ED) treatment are heterogeneous. Advance knowledge of a patient's expected course may inform precision medicine for ED treatment. This study explored the feasibility of applying machine learning to generate personalized predictions of symptom trajectories among patients receiving treatment for EDs, and compared model performance to a simpler logistic regression prediction model. Method Participants were adolescent girls and adult women (N = 333) presenting for residential ED treatment. Self‐report progress assessments were completed at admission, discharge, and weekly throughout treatment. Latent growth mixture modeling previously identified three latent treatment response trajectories (Rapid Response, Gradual Response, and Low‐Symptom Static Response) and assigned a trajectory type to each patient. Machine learning models (support vector, k‐nearest neighbors) and logistic regression were applied to these data to predict a patient's response trajectory using data from the first 2 weeks of treatment. Results The best‐performing machine learning model (evaluated via area under the receiver operating characteristics curve [AUC]) was the radial‐kernel support vector machine (AUCRADIAL = 0.94). However, the more computationally‐intensive machine learning models did not improve predictive power beyond that achieved by logistic regression (AUCLOGIT = 0.93). Logistic regression significantly improved upon chance prediction (MAUC[NULL] = 0.50, SD = .01; p <.001). Discussion Prediction of ED treatment response trajectories is feasible and achieves excellent performance, however, machine learning added little benefit. We discuss the need to explore how advance knowledge of expected trajectories may be used to plan treatment and deliver individualized interventions to maximize treatment effects.
... Further research is needed to replicate our findings and consider how therapist experience influences treatment choice and outcomes for AN.Whilst our results broadly converge with those from past studies, they confirm the need for further improvements in ED treatments. More than half of patients treated for AN remain unremitted and 50-60% of patients with BN(Linardon & Wade, 2018;Svaldi et al., 2019) and BED(Hilbert et al., 2019) are not abstinent at treatment end. Data from evaluation studies must be used to close the research-practice gap to ensure continued refinement of treatment models and improved accessibility of treatment.A clear challenge in this work is data quality.Wolpert and Rutter (2018) have highlighted the necessity of working with routinely collected data despite the limitations related to quality. ...
Article
Objective This study aimed to evaluate the effectiveness of evidenced‐based psychological treatments (specifically, Cognitive‐Behaviour Therapy for Eating Disorders [CBT‐ED] and Maudsley Anorexia Nervosa Treatment for Adults [MANTRA]) for a transdiagnostic eating disorder population in a routine clinical setting. In particular, it aimed to determine the extent to which treatment was provided in line with current clinical guidelines (NICE, 2017) and how effective treatment was in improving eating disorder and general psychopathology. Method Three hundred and seventy‐nine participants meeting criteria for DSM‐5 anorexia nervosa, bulimia nervosa, binge‐eating disorder or other specified feeding or eating disorder completed pre‐ and posttreatment measures of eating disorder pathology and general distress. Clinicians recorded weight and episodes of bingeing and purging. Results Ninety seven percent of participants received treatment in line with evidence‐based psychotherapies. Treatment was completed by 59.9% of the whole sample. Using stringent criteria and ITT analysis 21.4% met criteria for remission at end of treatment. In the underweight sample, there was a significant increase in BMI, averaging 1.38 kg/m² over treatment, with similar outcomes for MANTRA and CBT‐ED. Discussion These findings, in a large transdiagnostic population, add to emerging literature on the translation of evidence‐based psychotherapies to real‐world clinical settings. Our results converge well with prior similar studies. Findings highlight the need for routine data collection in services and for the ongoing improvement of treatments for the eating disorders.
... The highest abstinence rate was observed in IPT, and clinician-led group treatments produced signi cantly higher posttreatment (but not follow-up) abstinence estimates than guided self-help treatments. The meta-analysis demonstrated that 50% of patients with BED do not fully respond to treatment, and there is, therefore, a need to explore other psychotherapies to improve outcomes (13). ...
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Background: Research into psychotherapy for binge-eating disorder (BED) has focused mainly on cognitive behavioural therapies, but efficacy, failure to abstain, and dropout rates continue to be problematic. The experience of negative emotions is among the most accurate predictors for the occurrence of binge eating episodes in BED, suggesting benefits to exploring psychological treatments with a more specific focus on the role of emotion. The present study aimed to explore the feasibility of individual emotion-focused therapy (EFT) as a treatment for BED by examining the outcomes of a pilot randomised wait-list controlled trial. Methods: Twenty-one participants were assessed using a variety of feasibility measures relating to recruitment, credibility and expectancy, therapy retention, objective binge episodes and days, and binge eating psychopathology outcomes. The treatment consisted of 12 weekly one-hour sessions of EFT for maladaptive emotions over three months. A mixed model approach was utilised with one between effect (group) using a one-way analysis of variance (ANOVA) to test the hypothesis that participants immediately receiving the EFT treatment would demonstrate a greater degree of improvement on outcomes relating to objective binge episodes and days, and binge eating psychopathology, compared to participants on the EFT wait-list; and one within effect (time) using a repeated-measures ANOVA to test the hypothesis that participation in the EFT intervention would result in significant improvements in outcome measures from pre to post-therapy and then maintained at follow-up. Results: Recruitment, credibility and expectancy, therapy retention outcomes indicated EFT is a feasible treatment for BED. Further, participants receiving EFT demonstrated a greater degree of improvement in objective binge episodes and days, and binge eating psychopathology compared to EFT wait-list control group participants. When participants in the EFT wait-list control group then received treatment and outcomes data were combined with participants who initially received the treatment, EFT demonstrated significant improvement in objective binge episodes and days, and binge eating psychopathology for the entire sample. Conclusions: These findings provide further preliminary evidence for the feasibility of individual EFT for BED and support more extensive randomised control trials to assess efficacy. Trial registration: The study was retrospectively registered with the Australian New Zealand Clinical Trials Registry (ACTRN12620000563965) on 14 May 2020 https://www.anzctr.org.au/ACTRN12620000563965.aspx
... One issue is that, despite decades of research, approximately 60% of individuals with BN who receive the best available treatments do not achieve symptom abstinence. 46 Another key issue relates to the access, cost, and dissemination of specialty BN treatments. One way that this issue has been addressed is through guided self-help therapies, such as CBT. 10 It might also be useful to identify the specific components of current and new treatments that are beneficial, inert, or harmful through the multiphasic optimization strategy. ...
Article
Purpose Bulimia nervosa (BN) is an eating disorder characterized by binge eating, inappropriate compensatory behaviors, and body image concerns in persons at or above a healthy weight. BN is a serious disorder with medical sequelae and marked psychosocial impairment. To reduce and eliminate symptoms of BN, psychological and pharmacologic treatments for BN have been developed. We review the current state-of-the-art treatments for BN. Methods We conducted a narrative review of the BN treatment literature to synthesize the current evidence base, provide recommendations, and propose future directions for BN treatment research. Findings Currently, the first-line, state-of-the-art treatment for adults with BN is cognitive-behavioral therapy (CBT). Interpersonal therapy is a second-line evidence-based treatment for adults with BN, and dialectical behavior therapy and integrative cognitive-affective therapy are also promising. For BN in adolescents, family-based treatment for BN or CBT are evidence-based approaches. Pharmacotherapy is best considered adjunctive to psychotherapy in adults with BN but may be helpful, depending on the type of psychotherapy and whether psychotherapy is ineffective or unavailable. Fluoxetine 60 mg/d is the medication of choice for adults with BN. Little is known with respect to pharmacologic treatment of BN in adolescents, although fluoxetine 60 mg/d holds promise. Implications Despite decades of treatment-development research in BN, there is room for improvement because nearly 60% of those with BN do not achieve remission with specialty treatment and strikingly few randomized controlled trials for BN in adolescents exist. Moreover, the field should address issues related to treatment dissemination, access, and cost.
... Based on our results, we formulated several hypotheses, which may help guide future basic research and ultimately the development of tailored interventions. These are dearly needed, considering that currently only around 30% of BN patients achieve abstinence from binge-purge behaviours after treatment (Linardon & Wade, 2018). ...
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Background Negative mood often triggers binge eating in bulimia nervosa (BN). We investigated motivational salience as a possible underlying mechanism using event-related potentials (ERPs) as indicators of motivated attention allocation (P300) and sustained processing (LPP). Methods We collected ERPs (P300: 350–400 ms; LPP: 600–1000 ms) from 21 women with full-syndrome or partially remitted BN and 21 healthy women (HC), matched for age and body mass index. Idiosyncratic negative and neutral situations were used to induce corresponding mood states (counterbalanced), before participants viewed images of high- and low-calorie foods and neutral objects, and provided ratings for pleasantness and desire to eat. Results P300 was larger for foods than objects; LPP was largest for high-calorie foods, followed by low-calorie foods, then objects. The BN group showed an increased desire to eat high-calorie foods under negative mood and stronger mood induction effects on ERPs than the HC group, with generally reduced P300 and a small increase in LPP for high-calorie foods. Effects were limited to circumscribed electrode positions. Exploratory analyses showed clearer effects when comparing high vs. low emotional eaters. Conclusion We argue that negative mood decreased the availability of cognitive resources (decreased P300) in BN, thereby facilitating disinhibition and food cravings (increased desire-to-eat ratings). Increased sustained processing might be linked to emotional eating tendencies rather than BN pathology per se, and reflect approach motivation, conflict, or regulatory processes. Negative mood appears to induce complex changes in food image processing, whose understanding may contribute to the development of tailored interventions in the future.
... A more recent meta-analysis estimated the prevalence of patients with BED who achieved binge-eating abstinence following psychological or behavioral treatments (14). The most common treatment delivered was CBT (either in a clinician-led or guided self-help format), and other interventions includebehavioral weight loss, behavioral weight loss combined with CBT, IPT, DBT,behavior therapy, non-speci c supportive therapy, mindfulness, psychodynamic therapy, and a combined psychotherapy approach. ...
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Full-text available
Background: Research into psychotherapy for binge-eating disorder (BED) has focused mainly on cognitive behavioural therapies, but efficacy, failure to abstain, and dropout rates continue to be problematic. The experience of negative emotions is among the most accurate predictors for the occurrence of binge eating episodes in BED, suggesting benefits to exploring psychological treatments with a more specific focus on the role of emotion. The present study aimed to explore the feasibility and efficacy of individual emotion-focused therapy (EFT) as a treatment for BED by examining the outcomes of a pilot randomised waitlist-controlled trial. Methods: Twenty-one participants were assessed using measures of feasibility (recruitment, credibility and expectancy, and therapy retention), and efficacy (objective binge episodes and days, and binge eating psychopathology). The treatment consisted of 12 weekly one-hour sessions of EFT for maladaptive emotions over three months. A mixed model approach was utilised with one between effect (group) using a one-way analysis of variance (ANOVA) to test the hypothesis that participants immediately receiving the EFT treatment would demonstrate a greater degree of improvement on outcomes relating to objective binge episodes and days, and binge eating psychopathology, compared to participants on the EFT waitlist; and one within effect (time) using a repeated-measures ANOVA to test the hypothesis that participation in the EFT intervention would result in significant improvements in outcome measures from pre to post-therapy and then maintained at follow-up. Results: Recruitment, credibility and expectancy, and therapy retention outcomes indicated EFT is a feasible treatment for BED. Participants receiving EFT demonstrated a greater degree of improvement in objective binge episodes and days, and binge eating psychopathology compared to EFT waitlist control group participants. When participants in the EFT waitlist control group then received treatment and outcomes data were combined with participants who initially received the treatment, EFT demonstrated significant improvement in objective binge episodes and days, and binge eating psychopathology for the entire sample. Conclusions: These findings provide further preliminary evidence for the feasibility and efficacy of individual EFT for BED and support more extensive randomised control trials.
... On the other hand, only 25% of people with an ED seek treatment (Hart, Granillo, Jorm, & Paxton, 2011;Micali et al., 2017) with considerable barriers to receiving timely and appropriate diagnosis and treatment (Ali et al., 2017). Between 22 and 42% of children with anorexia nervosa receiving Family Based Treatment have poor outcome at 12-month follow-up (Eisler et al., 2016;Lock et al., 2010), and only 33% of people with bulimia nervosa and binge ED are remitted at end of outpatient cognitive behaviour therapy (CBT; Linardon & Wade, 2018). It is evident that optimising our treatments still has a long way to go, and this will require a large body of research. ...
Article
Objective Setting specific research priorities and involving consumers in this process is one pathway to driving better intervention outcomes in eating disorders (EDs). We reviewed research priority setting in the field and the involvement of consumers in this priority setting. Method A systematic review following the PRSIMA statement was conducted and eight studies were identified for inclusion; four included substantial input from consumers, and four were researcher led. Similarities and differences across the types of studies were examined. Results Research priorities informed by consumers were primarily concerned with producing better interventions and outcomes. A large degree of overlap with researcher‐led priorities was present. The former studies had a greater focus on early intervention, bridging the research‐practice gap, and recovery, while the latter were more likely to address diagnosis, genetic factors, brain circuitry, and pharmacotherapy. Priorities endorsed across more than one consumer‐informed study included: the role of self‐harm, working with health care professionals to increase early detection, supporting transition between services, and six issues about improved treatments. Conclusions The ED field needs to engage in more meaningful involvement of co‐design across consumers, clinicians and researchers along the entire research journey, not just research priority setting. An integrated research strategy incorporating a co‐design perspective has the potential to drive better outcomes.
... More recently, dialectical behavior therapy (DBT) has been investigated with some promising results (Hill et al. 2011). While psychotherapy is efficacious for some, only about 30-40% of treatment completers with BN achieve symptom abstinence (Linardon and Wade 2018). ...
... Outcomes from cognitive behavioral therapies (CBTs) for bulimia nervosa (BN) including the enhanced cognitive behavioral therapy (CBT-E) and thirdwave behavioral treatments such as mindfulness-and acceptance-based treatments (MABTs) leave significant room for improvement with nearly 70% of patients remaining symptomatic following receipt of a full course of treatment (Linardon et al., 2017;Linardon, Messer et al., 2018;Linardon & Wade, 2018). Identifying the treatment mechanisms associated with improvement in BN symptoms can improve outcomes by allowing future versions of CBTs to focus on the most impactful treatment components (Jansen, 2016). ...
Article
Overvaluation of shape and weight (OSW) is supported as an important mechanism underlying improvement in bulimia nervosa (BN) during behavioral therapies (CBTs). It is not yet clear, however, whether changes in OSW temporally precede and prospectively predict changes in BN symptoms during CBTs, limiting the ability to establish causality. The present study is the first to examine whether session-by-session changes in OSW prospectively predict session-by-session changes in BN symptoms during CBTs and clinical outcomes at the end-of-treatment. Participants with BN (n = 44) who received 20 sessions of CBTs completed a brief survey at each session assessing OSW and BN symptom frequency during the past week. Results showed small but significant session-by-session reductions in OSW and BN symptoms during CBTs. Session-by-session improvements in OSW in any given week prospectively predicted reductions in restrictive eating, binge eating, and compulsive exercise in the following week but did not prospectively predict improvements in purging, while improvements in restrictive eating and compulsive exercise in any given week prospectively predicted reductions in OSW in the following week. Average session-by-session change in OSW during treatment was positively associated with remission status and improvements in eating pathology at the end-of-treatment. Changes in OSW temporally precede and prospectively predict changes in BN symptoms during CBTs, and vice versa. These findings may have critical implications for treatment planning and implementation.
... Approximately 10% of women, and a smaller but significant number of men, experience clinically significant binge eating (5). While there are empirically supported treatments for LOC, many who receive treatment continue to experience symptoms (6). ...
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Loss of control eating is a core, transdiagnostic eating disorder symptom associated with psychological distress, functional impairment, and reduced quality of life. However, the factors that contribute to persistent loss of control eating despite negative consequences are not fully understood. Understanding the mechanisms that maintain loss of control eating is crucial to advance treatments that interrupt these processes. Affect regulation models of loss of control eating hypothesize that negative emotions trigger loss of control eating, and that loss of control eating is negatively reinforced because it temporarily decreases negative affect. Several variations on this basic affect regulation model have been proposed, including theories suggesting that negative affect decreases during loss of control eating rather than afterwards (escape theory), and that loss of control eating replaces one negative emotion with another that is less aversive (trade-off theory). Experience sampling designs that measure negative affect and eating behavior multiple times per day are optimally suited to examining the nuanced predictions of these affect regulation models in people's everyday lives. This paper critically reviews experience sampling studies examining associations between negative affect and loss of control eating, and discusses the implications for different affect regulation models of loss of control eating. The review concludes by proposing an expanded affect-focused model of loss of control eating that incorporates trait-level individual differences and momentary biological and environmental variables to guide future research. Clinical implications and recommendations are discussed.
... Eating disorders are associated with significant impairment, including poorer quality of life (Mitchison et al., 2012), psychological distress (Kärkkäinen et al., 2018), and elevated risk for comorbid disorders (Berkman et al., 2007). Despite these consequences, less than a quarter of individuals with eating disorders receive treatment (Hart et al., 2011), and treatment is associated with modest recovery rates (Linardon & Wade, 2018), high dropout , and considerable economic burden (Ágh et al., 2016). Developing and evaluating intervention strategies that target risk factors remain a priority for prevention and early intervention. ...
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Objectives Mindfulness-based interventions have shown effectiveness in reducing risk factors for disordered eating; however, little is known about mechanisms. This online study evaluated two isolated metacognitive components of mindfulness, adopting a decentered or non-judgemental stance towards internal experiences, respectively, for reducing body dissatisfaction and negative affect. Methods Women (N = 330, Mage = 25.18, SD = 4.44) viewed appearance-ideal media images before listening to a 5-min audio recording that guided them to (a) distance themselves from their experience (decentering), (b) accept their experience without judgement (non-judgement), or (c) rest (active control). Participants reported state body dissatisfaction and negative affect at baseline, post-media exposure, and final assessment. Trait measurements (weight and shape concerns, mindfulness, emotion regulation) were assessed as potential moderators. Participants self-reported engagement and acceptability. Results All groups reported significant reductions in body dissatisfaction and negative affect following the recording (d = 0.15–0.38, p < 0.001), with no between-group differences. Trait measurements did not moderate effects. Conclusions The results suggest rest was as effective as the metacognitive components in ameliorating immediate negative impacts of appearance-related threats. Alternatively, coping strategies spontaneously adopted by the control group may have supplied temporary relief. Findings highlight the importance of including suitable control; further research should investigate when and for whom specific aspects of mindfulness-based interventions may be particularly helpful.
... At 3-month follow-up abstinence rates from binge eating and self-induced vomiting was 44.4 % and 80.6 % respectively. This is in line with other guided self-help studies for BED showing abstinence rates from binge eating of 40.4 % (Linardon, 2018), and favorable compared to guided self-help studies for BN showing abstinence rates from binge eating and purging of 31.6 % for treatment completers (Linardon and Wade, 2018). In a recent review by Pittock et al. (2018), abstinence rates from binge eating ± other behaviors were found to be 22.1 to 46.5 %. ...
Article
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Background Eating disorders (ED) are severe psychiatric conditions, characterized by decreased quality of life and high mortality. However, only a minority of patients with ED seek care and very few receive treatment. Internet-delivered cognitive behavioral therapy (ICBT) has the potential to increase access to evidence-based treatments. Aims The aims of the present study were to (1) develop and evaluate the usability of an Internet-delivered guided self-help treatment based on Enhanced Cognitive Behavioral Therapy (ICBT-E) for patients with full or subthreshold bulimia nervosa (BN) or binge eating disorder (BED) with a user centered design process, and (2) to evaluate its feasibility and preliminary outcome in a clinical environment. Method The study was undertaken in two stages. In Stage I, a user-centered design approach was applied with iterative phases of prototype development and evaluation. Participants were eight clinicians and 30 individuals with current or previous history of ED. In Stage II, 41 patients with full or subthreshold BN or BED were recruited to a single-group open trial to evaluate the feasibility and preliminary outcome of ICBT-E. Primary outcome variables were diagnostic status and self-rated ED symptoms. Results The user-centered design process was instrumental in the development of the ICBT-E, by contributing to improvements of the program and to the content being adapted to the needs and preferences of end-users. The overall usability of the program was found to be good. ICBT-E targets key maintaining factors in ED by introducing healthy eating patterns and addressing over-evaluation of weight and shape. The results indicate that ICBT-E, delivered in a clinical setting, is a feasible and promising treatment for full or subthreshold BN or BED, with a high level of acceptability observed and treatment completion of 73.2 %. Participation in ICBT-E was associated with significant symptom reductions in core ED symptomology, functional impairment as well as depressive symptoms, and the results were maintained at the 3-month follow-up. Conclusions ICBT-E was developed with end-users' preferences in mind, in accordance with the identified recommendations, and the program was perceived as usable by end-users. The study demonstrated the potential of ICBT-E, which marks a step forward in the effort to make powerful, empirically supported psychological interventions targeting ED more widely available and accessible.
... Furthermore, 50-70% of people with bulimia nervosa or binge eating disorder continue to experience binge eating or purging after receiving the most widely recommended evidence-based treatment for these conditions, enhanced cognitive behavioural therapy [5]. ...
Article
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Purpose The aim of this study was to expand the evidence on the feasibility and impact of food-specific inhibitory control training in a community sample of people with disinhibited eating. Methods Recruitment and data collection were conducted during the COVID-19 outbreak, in Italy. Ninety-four adult individuals with disinhibited eating were randomised to one of two conditions: App-based food-specific inhibitory control training or waiting list. Participants were assessed at baseline, end of intervention (2 weeks following baseline) and follow-up (one week later). The assessment measures included questionnaires about eating behaviour and mood. Results Seventy-three percent of the sample reported a diagnosis of binge eating disorder, and 20.4% a diagnosis of bulimia nervosa. Retention rates were 77% and 86% for the food-specific inhibitory control training and the waiting list conditions, respectively. Almost half of the participants allocated to the training condition completed the “recommended” dose of training (i.e., 10 or more sessions). Those in the training condition reported lower levels of wanting for high-energy dense foods ( p < 0.05), a trend for lower levels of perceived hunger ( p = 0.07), and lower levels of depression ( p < 0.05). Binge eating symptoms, disinhibition, wanting for high-energy dense foods, stress and anxiety were significantly lower at end of intervention, compared to baseline ( p < .05). Conclusion Findings corroborated the feasibility of food-specific inhibitory control training, and its impact on high-energy dense foods liking. The study expands the evidence base for food-specific inhibitory control training by highlighting its impact on perceived hunger and depression. The mechanisms underlying these effects remain to be clarified. Level of evidence Level I, Evidence obtained from at least one properly designed randomized controlled trials; systematic reviews and meta-analyses; experimental studies.
... Bulimia nervosa (BN) is an eating disorder (ED) characterized by recurrent binge eating and compensatory behaviors. Current treatments for BN are sub-optimal, with nearly 70% of individuals failing to achieve full remission at post-treatment (Linardon & Wade, 2018), highlighting a need to identify maintenance factors of BN that might negatively impact outcomes. Self-regulation deficits (i.e., difficulties with regulating emotions and behavior; Claes et al., 2012;Prefit, Candea, & Szentagotai-Tatar, 2019;Waxman, 2009), including emotion regulation difficulties and impulsivity, are implicated in the maintenance of BN. ...
Article
Objective: Just-in-time adaptive interventions (JITAIs), momentary interventions delivered at identified times of risk, may improve skill utilization during cognitive-behavioral therapy (CBT-E) for bulimia-spectrum eating disorders (BN-EDs). JITAIs may be especially helpful for individuals with self-regulation deficits, including emotion regulation deficits and elevated impulsivity. Method: Participants (N = 55 with BN-EDs) received 16 sessions of CBT-E with electronic self-monitoring and were randomized to receive JITAIs (JITAIs-On) or not receive JITAIs (JITAIs-Off). Baseline Difficulties in Emotion Regulation Scale (DERS) and UPPS-P Impulsive Behavior Scale (UPPS-P) total scores were examined as moderators of baseline to post-treatment change in binge episodes, compensatory behaviors, and Eating Disorder Examination (EDE) global score using repeated measures ANOVAs. Results: Emotion regulation difficulties significantly moderated compensatory behavior change (F[1, 51] = 4.31, p = .04, ηp ² = 0.08) such that individuals with emotion regulation deficits demonstrated greater improvements in the JITAIs-On condition. Impulsivity moderated change in binge episodes (F[1, 51] = 8.94, p = .004, ηp ² = 0.15) and compensatory behaviors (F[1, 51] = 7.83, p = .007, ηp ² = 0.13), such that individuals with high impulsivity showed greater improvement in the JITAIs-On condition. Neither DERS nor UPPS-P scores moderated EDE global score change. Discussion: JITAIs appear particularly beneficial for facilitating skill use during treatment for BN-EDs for individuals with self-regulation deficits, yielding improved treatment outcomes. Public significance statement: Reminders to use therapy skills that are delivered via smartphone as an individual goes about their daily life may improve treatment response among individuals with bulimia nervosa who have difficulty coping with emotions or who tend to act impulsively. Results from this study indicate that individuals with these difficulties benefitted more from cognitive-behavioral therapy when it was accompanied by in-the-moment reminders to use therapeutic skills, which may facilitate long-term recovery. CLINICAL TRIALS. Gov registration number: NCT03673540.
... However, outcomes from the best available psychotherapies for EDs are suboptimal, with remission rates for different EDs ranging between 30 and 60% (e.g. [4]), and little is known about how to proceed when first-line treatments are ineffective. To improve outcomes, novel treatment alternatives are needed. ...
Article
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Purpose of Review We review recent evidence on the use of neuromodulation for treating eating disorders (EDs), including anorexia nervosa, bulimia nervosa and binge eating disorder. We evaluate studies on (a) modern non-invasive methods of brain stimulation, such as transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS), (b) electroconvulsive therapy (ECT) and (c) more invasive techniques, including deep brain stimulation (DBS). Recent Findings Most reports on the clinical applications of neuromodulation in EDs are limited to case studies, case series and small clinical trials. The majority have focused on severe, enduring and hard-to-treat cases of AN. In this population, data suggest that both rTMS and DBS have therapeutic potential and are safe and acceptable. Summary High-quality clinical trials in different ED populations are needed which investigate different stimulation methods, sites and parameters, the use of neuromodulation as stand-alone and/or adjunctive treatment, as well as the mechanisms of action.
... Despite the high prevalence and negative consequences, many patients with binge eating remain undiagnosed and untreated [6]. Even among those who are diagnosed and receive the most validated cognitive-behavioral therapy, 60% of them fail to fully abstain from binge eating [7]. To facilitate early diagnosis and to inform the development of novel treatment strategies, there is a critical need to identify the biomarkers that are involved in the development and maintenance of binge eating. ...
Article
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Objective Binge eating, a core diagnostic symptom in binge eating disorder and bulimia nervosa, increases the risk of multiple physiological and psychiatric disorders. The neurotransmitter dopamine is involved in food craving, decision making, executive functioning, and impulsivity personality trait; all of which contribute to the development and maintenance of binge eating. The objective of this paper is to review the associations of dopamine levels/activities, dopamine regulator (e.g., dopamine transporter, degrading enzymes) levels/activities, and dopamine receptor availability/affinity with binge eating. Methods A literature search was conducted in PubMed and PsycINFO to obtain human and animal studies published since 2010. Results A total of 31 studies (25 human, six animal) were included. Among the human studies, there were 12 case–control studies, eight randomized controlled trials, and five cross-sectional studies. Studies used neuroimaging (e.g., positron emission tomography), genetic, and pharmacological (e.g., dopamine transporter inhibitor) techniques to describe or compare dopamine levels/activities, dopamine transporter levels/activities, dopamine degrading enzyme (e.g., catechol-O-methyltransferase) levels/activities, and dopamine receptor (e.g., D1, D2) availability/affinity among participants with and without binge eating. Most human and animal studies supported an altered dopaminergic state in binge eating (26/31, 83.9%); however, results were divergent regarding whether the altered state was hyperdopaminergic (9/26, 34.6%) or hypodopaminergic (17/26, 65.4%). The mixed findings may be partially explained by the variability in sample characteristics, study design, diagnosis criteria, and neuroimaging/genetic/pharmacological techniques used. However, it is possible that instead of being mutually exclusive, the hyperdopaminergic and hypodopaminergic state may co-exist, but in different stages of binge eating or in different individual genotypes. Conclusions For future studies to clarify the inconsistent findings, a homogenous sample that controls for confounders that may influence dopamine levels (e.g., psychiatric diseases) is preferable. Longitudinal studies are needed to evaluate whether the hyper- and hypo-dopaminergic states co-exist in different stages of binge eating or co-exist in individual phenotypes. Plain Language Summary Binge eating is characterized by eating a large amount of food in a short time and a feeling of difficulty to stop while eating. Binge eating is the defining symptom of binge eating disorder and bulimia nervosa, both of which are associated with serious health consequences. Studies have identified several psychological risk factors of binge eating, including a strong desire for food, impaired cognitive skills, and distinct personality traits (e.g., quick action without careful thinking). However, the physiological markers of binge eating remain unclear. Dopamine is a neurotransmitter that is heavily involved in feeding behavior, human motivation, cognitive ability, and personality. Therefore, dopamine is believed to play a critical role in binge eating. This review synthesized study findings related to the levels and activities of dopamine, dopamine regulators, and dopamine receptors in the context of binge eating. The primary finding is that most studies that used neuroimaging, genetic, or drug techniques found an altered dopaminergic state related to binge eating. However, the literature is inconsistent concerning the direction of the alteration. Considering the mixed findings and the limitations in study design, future studies, especially those that include repeated measurements, are needed to clarify the role of dopamine in binge eating.
... Cognitive behavioral therapy (CBT) is recognized as the most effective treatment for adults with BN, producing symptom remission more reliably and durably than the alternative psychological and pharmacological modalities tested, although a substantial minority of patients experience persistent symptoms [2,[21][22][23]. While few studies have evaluated CBT for adolescents with BN [24], many patients in randomized controlled trials (RCTs) are young adults, and it seems reasonable to hypothesize that the approach may be similarly effective for individuals who are just a few years younger [25,26]. ...
Chapter
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Cognitive behavioral therapy (CBT) is currently recognized as the most effective treatment for adults with eating disorders (EDs); however, few studies have examined CBT’s efficacy for younger patients. In this chapter, we describe how to adapt CBT for children and adolescents with EDs. Similar to the approach used with adults, CBT for younger patients involves an array of interventions designed to modify beliefs and behaviors related to eating, weight, and shape. These include developing a clinical formulation, psychoeducation, enhancing motivation, open weighing, meal planning, self-monitoring, cognitive restructuring, exposure therapy, and relapse prevention. Individual CBT for children and adolescents with EDs should be augmented with family involvement, with the frequency and format of family sessions varying as a function of the patient’s age, symptom pattern and severity, and other considerations. Particularly during the early phase of treatment for underweight patients, family sessions focus on coaching the patient’s caregivers to support their child with normalized eating and weight restoration. As patients become more active participants in treatment and behavior change, family involvement is reduced gradually.
... Bulimia nervosa (BN), characterized in part by regular binge eating and purging, is associated with medical complications, functional impairment, and high rates of mortality and chronicity [1][2][3][4][5][6][7]. First-line pharmacotherapy (selective serotonin reuptake inhibitors) and psychotherapy (cognitive behavioral therapy) promote full remission in less than half of patients with BN [8,9]. Moreover, BN frequently co-occurs with high levels of affective dysregulation and non-eating-related impulsive behaviors, such as shoplifting and substance use [10][11][12]. ...
Article
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Purpose Adults with bulimia nervosa (BN) and co-occurring emotional dysregulation and multiple impulsive behaviors are less responsive to existing interventions. Initial data suggest that the combination of Dialectical Behavior Therapy (DBT) and a mood stabilizer, lamotrigine, significantly reduces symptoms of affective and behavioral dysregulation in these patients. Identifying candidate neurobiological mechanisms of change for this novel treatment combination may help guide future randomized controlled trials and inform new and targeted treatment development. Here, we examined neurocognitive and symptom changes in a female patient with BN and severe affective and behavioral dysregulation who received DBT and lamotrigine. Methods Go/no-go task performance data and resting-state functional MRI scans were acquired before the initiation of lamotrigine (after 6 weeks in an intensive DBT program), and again after reaching and maintaining a stable dose of lamotrigine. The patient completed a battery of symptom measures biweekly for 18 weeks over the course of treatment. Results After lamotrigine initiation, the patient made fewer errors on a response inhibition task and showed increased and new connectivity within frontoparietal and frontolimbic networks involved in behavioral and affective control. Accompanying this symptom improvement, the patient reported marked reductions in bulimic symptoms, behavioral dysregulation, and reactivity to negative affect, along with increases in DBT skills use. Conclusion Improved response inhibition and cognitive control network connectivity should be further investigated as neurocognitive mechanisms of change with combined DBT and lamotrigine for eating disorders. Longitudinal, controlled trials integrating neuroimaging and symptom measures are needed to fully evaluate the effects of this treatment. Level of Evidence IV: Evidence obtained from multiple time series with or without the intervention, such as case studies.
... The economic costs of binge eating and related EDs (including bulimia nervosa [BN], binge-eating disorder [BED], and the binge eating/purging subtype of anorexia nervosa [AN-BP]) are substantial [11]. While existing treatments can decrease the frequency of binge eating, more than half of people continue to experience binge eating even after treatment [12,13]. Better understanding of the factors that lead to binge eating is important to advance research and intervention. ...
Article
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Purpose of Review Binge eating is a transdiagnostic symptom that disproportionately affects females. Sexually dimorphic gonadal hormones (e.g., estradiol, testosterone) substantially impact eating behavior and may contribute to sex differences in binge eating. We examine recent evidence for the role of gonadal hormones in binge eating risk across development. Recent Findings Both organizational (long-lasting impact on the central nervous system (CNS)) and activational (transient influences on the CNS) hormone effects may contribute to sex differences in binge eating. Gonadal hormones also impact within-sex variability in binge eating, with higher estradiol levels in females and higher testosterone levels in males protective across development. Emerging evidence suggests that the impact of gonadal hormones may be greatest for people with other risk factors, including genetic, temperamental (e.g., high negative affect), and psychosocial (e.g., exposure to weight-based teasing) risk. Summary Gonadal hormones contribute to sex differences and within-sex variability in binge eating across development.
... Cognitive Behavioural Therapy (CBT) is regarded as the treatment-of-choice for BN and BED (Costa & Melnik, 2016). However, the evidence-base for its efficacy reveals that remission rates are moderate (Brownley et al., 2016), with fewer than 50% of patients with BN, and approximately 50% of patients with BED achieving abstinence from binge eating at the end of treatment (Hay, 2013;Hilbert et al., 2019;Linardon & Wade, 2018). Over the last decade, it has been proposed that digital interventions targeting specific maintaining factors (e.g. ...
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Current treatments for binge eating disorder (BED) and bulimia nervosa (BN) only show moderate efficacy, warranting the need for novel interventions. Impairments in food-related inhibitory control contribute to BED/BN and could be targeted by food-specific inhibitory control training (ICT). The aim of this study was to establish the feasibility and acceptability of augmenting treatment for individuals with BN/BED with an ICT app (FoodT), which targets motor inhibition to food stimuli using a go/no-go paradigm. Eighty patients with BED/BN receiving psychological and/or pharmacological treatment were randomly allocated to a treatment-as-usual group (TAU; n = 40) or TAU augmented with the 5-min FoodT app daily (n = 40) for 4 weeks. This mixed-methods study assessed feasibility outcomes, effect sizes of clinical change, and acceptability using self-report measures. Pre-registered cut-offs for recruitment, retention, and adherence were met, with 100% of the targeted sample size (n = 80) recruited within 12 months, 85% of participants retained at 4 weeks, and 80% of the FoodT + TAU group completing ≤8 sessions. The reduction in binge eating did not differ between groups. However, moderate reductions in secondary outcomes (eating disorder psychopathology: SES = −0.57, 95% CI [-1.12, −0.03]; valuation of high energy-dense foods: SES = −0.61, 95% CI [-0.87, −0.05]) were found in the FoodT group compared to TAU. Furthermore, small greater reductions in food addiction (SES = −0.46, 95% CI [-1.14, 0.22]) and lack of premeditation (SES = −0.42, 95% CI [-0.77, −0.07]) were found in the FoodT group when compared to TAU. The focus groups revealed acceptability of FoodT. Participants discussed personal barriers (e.g. distractions) and suggested changes to the app (e.g. adding a meditation exercise). Augmenting treatment for BED/BN with a food-specific ICT app is feasible, acceptable, and may reduce clinical symptomatology with high reach and wide dissemination.
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Bulimia nervosa (BN) is characterized by recurrent binge eating, compensatory behaviors, and weight/shape overvaluation in the absence of underweight status. BN occurs across the lifespan and in all gender and racial/ethnic groups. Development of BN involves a complex interplay of genetic, personality, and developmental factors. BN can result in negative health and nutritional consequences warranting medical and dietetic management. Psychological treatments include cognitive-behavioral approaches for adults, and family-based treatment for adolescents. Pharmacotherapy is effective in managing symptoms. Future research should focus on inclusion of underrepresented groups in treatment trials. Long-term outcomes are mixed, suggesting the need for more accessible treatment.
Article
Cognitive Behavior Therapy (CBT) for bulimia nervosa (BN) requires patient skill utilization (use of treatment skills) and skill acquisition (successful skill use) for symptom improvement. Treatment outcomes are unsatisfactory, possibly due to poor skill acquisition and utilization by post-treatment. Just-in-time adaptive interventions (JITAIs), momentary interventions delivered at opportunities for skill practice, may improve skill acquisition and utilization. Participants ( N = 56 individuals with bulimia-spectrum eating disorders) completed electronic self-monitoring in CBT+ and received JITAIs or no JITAIs alongside 16 sessions of CBT. Feasibility, acceptability, target engagement, and treatment outcomes were evaluated. JITAIs demonstrated feasibility and acceptability. Treatment outcomes and target engagement did not differ between conditions. The lack of group differences in target engagement and treatment outcomes may be explained by skill use self-monitoring promoting skill utilization and acquisition or low statistical power. Our findings suggest that JITAIs are feasible and acceptable during CBT for BN and warrant additional study.
Article
Objective: We aimed to evaluate the feasibility, acceptability, and potential impact of a tele-guided digital-based intervention based on the addictive appetite model of recurrent binge eating. Method: Female college students with bulimia nervosa (BN) or binge-eating disorder (BED) (n = 22) received a 6-week guided intervention targeting addictive processes and emotion regulation. The feasibility of the intervention was evaluated, and the outcomes were assessed at baseline, the end of the intervention, and 1-month follow-up. Results: Of the participants, 86.4% (n = 19) completed the intervention. The self-help materials were viewed 6.03 ± 3.06 times per week, and the duration of using the self-help materials was 113.16 ± 160.19 min/week. The intervention group experienced a significant reduction with a moderate effect on binge eating at the end of the intervention (Hedges' g = 0.58), and the effects lasted through follow-up (Hedges' g = 0.82). Discussion: The results suggest that the digital intervention targeting a maintenance mechanism of recurrent binge eating was feasible and acceptable for patients with BN and BED, proving the potential for symptom improvement. Public significance: The addictive appetite model provides the framework for new interventions to improve treatments for BN and BED. This study found that the digital intervention based on the model was feasible and acceptable for patients with BN and BED.
Article
Background Theoretical models highlight the importance of emotion dysregulation as a key risk and maintaining factor for eating disorders. However, most studies testing these theories are cross-sectional. It remains unclear which dimensions of emotion dysregulation account for the onset and persistence of eating disorder behaviours. Methods To address these gaps, data were analyzed from 1321 adult women who completed study measures at baseline and eight-month follow-up. The dimensions of emotion dysregulation assessed were five subscales from the abbreviated 16-item Difficulties in Emotion Regulation Scale. Outcomes included the onset (versus asymptomatic) and persistence (versus remission) of binge eating and compensatory behaviours. Results Univariate logistic regressions showed that, among initially asymptomatic women, higher baseline levels of each emotion dysregulation dimension (except the “goals” subscale) predicted the onset of binge eating and compensatory behaviours at follow-up. Each dimension also predicted the persistence of compensatory behaviours at follow-up among women endorsing these behaviours at baseline, while the “impulse”, “strategies”, and “non-acceptance” dimensions predicted the persistence of binge eating. In multivariate analyses, only the “strategies” dimension predicted the onset and persistence of binge eating, while the “non-acceptance” dimension predicted the onset and persistence of compensatory behaviours. Limitations Only a limited number of emotion dysregulation dimensions were tested. Conclusion Findings demonstrate the importance of emotion dysregulation dimensions in accounting for the onset and maintenance of eating disorder behaviours. The delivery of specific intervention strategies designed to address emotion dysregulation may depend on the risk and symptom profile of an individual.
Article
Objective: Emotion regulation (ER) deficits are associated with illness severity in individuals with bulimia nervosa. We examined whether baseline ER abilities are associated with remission following enhanced cognitive behavioural therapy for eating disorders (CBT-E). Method: Participants (N = 50, 85.0% female) receiving CBT-E completed a measure (yielding a global score and six subscale scores) of ER pre-treatment. Remission was assessed by the Eating Disorder Examination at post-treatment and follow-up. Analyses tested associations between baseline ER and behavioural, cognitive, or full remission at post-treatment and three-month follow-up. Results: Lower global ER abilities, measured by the Difficulties in Emotion Regulation Scale, were associated with lower likelihood of behavioural and full, but not cognitive, remission at post-treatment. Specifically, individuals low in emotional clarity and impulse control were less likely to be behaviourally remitted. Those low in emotional acceptance, awareness, clarity, or strategies to manage emotion were less likely to be fully remitted. Global ER scores were not associated with any remission type at follow-up. Discussion: Baseline ER deficits were associated with lower likelihood of behavioural or full remission at post-treatment. However, ER was less associated with remission at follow-up, indicating that ER is most important during treatment. Findings highlight a need for targeted treatments aimed at improving ER.
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Eating disorders are common and have a high morbidity and mortality rates. They present with a range of comorbid features and require specialized treatment to achieve a positive outcome. The literature on eating disorders has expanded rapidly in the past 20 years and this article reviews diagnostic and defining features, assessment, etiology, comorbidities and treatment options. Recent advances in the understanding and treatment of eating disorders can be expected to produce positive outcomes in most cases.
Article
Background The sense of ‘loss of control’ (LOC), or a feeling of being unable to stop eating or control what or how much one is eating, is the most salient aspect of binge eating. However, the neural alterations that may contribute to this experience and eating behavior remain poorly understood. Methods We used functional near-infrared spectroscopy (fNIRS) to measure activation in the prefrontal cortices of 23 women with bulimia nervosa (BN) and 23 healthy controls (HC) during two tasks: a novel go/no-go task requiring inhibition of eating responses, and a standard go/no-go task requiring inhibition of button-pressing responses. Results Women with BN made more commission errors on both tasks. BN subgroups with the most severe LOC eating ( n = 12) and those who felt most strongly that they binge ate during the task ( n = 12) showed abnormally reduced bilateral ventromedial prefrontal cortex (vmPFC) and right ventrolateral prefrontal cortex (vlPFC) activation associated with eating-response inhibition. In the entire BN sample, lower eating-task activation in right vlPFC was related to more frequent and severe LOC eating, but no group differences in activation were detected on either task when this full sample was compared with HC. BN severity was unrelated to standard-task activation. Conclusions Results provide initial evidence that diminished PFC activation may directly contribute to more severe eating-specific control deficits in BN. Our findings support vmPFC and vlPFC dysfunction as promising treatment targets, and indicate that eating-specific tasks and fNIRS may be useful tools for identifying neural mechanisms underlying dysregulated eating.
Article
Background: Binge eating is a subjective loss of control while eating, leading to the consumption of large amounts of food. It can cause significant emotional distress and is often accompanied by purging behaviours (eg, meal skipping, over-exercising or vomiting). Objective: The aim of this study was to explore the potential for mobile sensing to detect indicators for binge eating episodes, with a view toward informing the design of future context-aware mobile interventions. Methods: Our study was conducted in two stages. The first involved the development of the DeMMI app. As part of this, we conducted a consultation session to explore whether the types of sensor data we were proposing to capture were seen to be useful and appropriate, as well as gathering feedback on some specific app features relating to self-report. The second stage involved carrying out a 6-week period of data collection with 10 participants experiencing binge eating (logging both their mood and episodes of binge eating) and 10 comparison participants (logging only mood). An optional interview was conducted post-study discussing their experience with using the app, 8 participants (3 binge eating and 5 comparisons) consented. Results: Findings showed unique differences in the types of sensor data that were triangulated with individuals' episodes (with nearby Bluetooth devices, screen and app usage features, mobility features, and mood scores showing relevance). Participants had a largely positive opinion about the app, its unobtrusive role, and its ease of use. Interacting with the app increased their awareness of and reflection around mood and their phone usage patterns. Moreover, they expressed no privacy concerns as the study information sheet alleviated these. Conclusions: In this study, we contribute a series of recommendations for future studies wishing to scale our approach, and for the design of bespoke mobile interventions to support this population. Clinicaltrial:
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.
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Nach der ICD-10 werden die Anorexia nervosa („Magersucht“) und die Bulimia nervosa („Ess-Brech-Sucht“) zu den Essstörungen gezählt, das DSM-5 hat außerdem die Binge-Eating-Störung („Störung mit Essanfällen“) aufgenommen. Sie haben eine hohe Komorbiditätsrate mit anderen psychischen Störungen und eine Lebenszeitprävalenz von etwa 2 % über beide Geschlechter und Altersgruppen. Frauen bzw. Mädchen sind bei der Anorexia nervosa und der Bulimie nervosa deutlich häufiger von Essstörungen betroffen als Männer bzw. Jungen. Der Verlauf von Essstörungen ist meist mit erheblichen somatischen Komplikationen und bei der Anorexia nervosa mit einem erheblichen Mortalitätsrisiko verbunden. Essstörungen sind multifaktoriell bedingt und entstehen durch die komplexe Interaktion biologischer, psychologischer und sozialer Faktoren. Für essgestörte Personen gibt es niedrig-, mittel- und hochschwellige Angebote, bei denen Psychotherapie die Methode der ersten Wahl ist. Für präventive Maßnahmen konnte kein Nachweis erbracht werden, dass sie die Entstehung einer Essstörung verhindern, sie können jedoch problematische subklinische Symptome reduzieren.
Article
Background Rumination is linked to negative affect (NA), and there is accumulating support for an association between rumination and eating disorder (ED) behaviors. However, no research has examined the dynamic interrelationships between negative affect, rumination, and binge eating in naturalistic settings. Methods The present study used ecological momentary assessment (EMA) to assess the hypotheses that momentary rumination would mediate relationships between NA and binge eating, and momentary NA would mediate relationships between rumination and binge eating. Given that rumination may be focused on weight, shape, and food in ED samples, models were examined separately for general and ED-specific rumination. Forty women completed a 10-day EMA protocol that included measures of NA, general and ED-specific rumination, and binge eating. Results Multilevel mediation models indicated significant within-subjects indirect effects, such that momentary general rumination mediated the association between NA and binge eating, and NA also mediated the association between general but not ED-specific rumination and binge eating. Between-subjects effects indicated women with higher overall NA reported greater ED-specific rumination, which was associated with greater binge eating. Limitations The study was limited by a modest sample size, and the design precludes causal inferences. Conclusions Results highlight the momentary interplay between rumination and NA as a mechanism underlying binge eating, as well as the specificity of ruminative thought content in relationship to binge eating. Future work is needed to address the construct of rumination in the context of eating disorder interventions.
Article
Cognitive behaviour therapy for eating disorders (CBT-ED) outperforms other treatments for non-underweight eating disorders in adults, but we have limited ability to match CBT-ED to individual profiles. We examined if we could identify who benefits most from two forms of 10-session CBT-ED; one emphasizing early behaviour change with substantial content on improving body image (CBT-T), and the other including motivational work and no content on body image using chapters from self-help books (CBTm). Participants were 98 consecutive referrals to the Flinders University Services for Eating Disorders. Fourteen clinical psychology postgraduates delivered the treatment under expert supervision. Outcome measures were completed on five occasions: baseline, 4-, 10-, 14- and 22-weeks post-randomisation. Our primary outcome was global eating psychopathology. Moderators included motivation (readiness and confidence to change) and body avoidance and body checking. Intent-to-treat analyses showed no difference between the groups with a significant main effect of time associated with large effect size improvements, commensurate with longer forms of CBT-ED. Participants with lower readiness to change in CBTm had significantly greater decreases in disordered eating over follow-up compared to those with low motivation in CBT-T. People with lower readiness to change might benefit from the incorporation of motivational work in CBT-ED.
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.
Article
Introduction Greater use of appearance‐focused social media, such as Instagram, is associated with increased body dissatisfaction and eating disorder (ED) symptoms; however, questions remain about the mechanism connecting social media use to disordered‐eating behaviors (DEBs). The proposed study evaluates how and for whom exposure to fitspiration or thinspiration on Instagram is associated with DEBs. Methods We will evaluate a hypothesized pathway from Instagram use to disordered‐eating mediated by negative affect. We will test how individual differences in internalized weight stigma, trait self‐esteem, and trait self‐comparison moderate the pathway from social media use to negative affect. We will recruit 175 undergraduate women who report engaging in DEBs on average at least once per week over the past 3 months. Participants will complete a 7‐day ecological momentary assessment protocol, during which they will report their Instagram use, affect, and engagement in DEBs. Results Multi‐level modeling will be used to assess moderated mediation. Results from this study will provide increased specificity about how Instagram usage is linked to eating pathology and who may be most vulnerable to experiencing distress. Discussion Information about negative affect from Instagram and engagement in DEBs could contribute to the development of Just‐In‐Time Interventions for problematic social media use.
Article
Objective To replicate findings from a prior study which identified prospective associations between use of products for weight control and subsequent receipt of a first‐time eating disorder (ED) diagnosis among female adolescents and young adults. Method Data from a prospective cohort study, Project EAT (Eating and Activity in Teens and Young Adults), were used to examine prospective associations between self‐reported past‐year diet pill and laxative use for weight control and self‐reported receipt of an ED diagnosis among females without prior receipt of an ED diagnosis (N = 1,015). Participants were followed from early/middle adolescence (EAT‐I; Mage = 14.9 years) into late adolescence/emerging adulthood (EAT‐II; Mage = 19.5 years) and young adulthood (EAT‐III; Mage = 24.8 years). Results First‐time receipt of an ED diagnosis was reported by 2.4% of participants at EAT‐II and 4.0% at EAT‐III. After adjusting for demographics and weight status, participants using diet pills (risk ratio [RR] = 3.58, 95% confidence interval [CI]: 1.96–6.54) and laxatives (RR = 2.77, 95% CI: 1.01–7.64) had greater risk of receiving a first‐time ED diagnosis within 5 years than those not using these products. Discussion The present study replicated prior findings, providing further evidence for a prospective link between use of products for weight control and subsequent receipt of an ED diagnosis.
Article
Objective: Alexithymia is proposed as a prominent clinical feature of eating disorders (EDs). However, despite theoretical reason to believe that alexithymia could interfere with the success of treatments, few studies have tested whether alexithymia changes over the course of treatment. The goals of the current study were to evaluate (a) changes in alexithymia over the course of intensive Dialectical Behaviour Therapy (DBT) for EDs, and (b) associations between alexithymia and ED symptoms over time. Method: A mixed-diagnostic group of patients with EDs (N = 894) completed the Eating Disorders Examination-Questionnaire (EDE-Q) and the Toronto Alexithymia Scale (TAS-20) throughout intensive treatment and at various lengths of follow-up (6, 12, 24 months). Results: Results suggested that even after controlling for relevant covariates, there were significant decreases in alexithymia from intake to discharge and discharge to follow-up. Models exploring changes in self-reported ED symptoms indicated that TAS-20 scores significantly related to ED symptoms across timepoints, such that greater alexithymia was associated with greater severity of symptoms. Conclusions: Altogether, findings support an association between alexithymia and ED symptoms over treatment and suggest that emotion-focussed therapies like DBT may result in decreases in alexithymia. Future research should explore whether this effect is consistent across therapies without an emotional focus.
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Systematic reviews should build on a protocol that describes the rationale, hypothesis, and planned methods of the review; few reviews report whether a protocol exists. Detailed, well-described protocols can facilitate the understanding and appraisal of the review methods, as well as the detection of modifications to methods and selective reporting in completed reviews. We describe the development of a reporting guideline, the Preferred Reporting Items for Systematic reviews and Meta-Analyses for Protocols 2015 (PRISMA-P 2015). PRISMA-P consists of a 17-item checklist intended to facilitate the preparation and reporting of a robust protocol for the systematic review. Funders and those commissioning reviews might consider mandating the use of the checklist to facilitate the submission of relevant protocol information in funding applications. Similarly, peer reviewers and editors can use the guidance to gauge the completeness and transparency of a systematic review protocol submitted for publication in a journal or other medium.
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Objective: The authors compared psychoanalytic psychotherapy and cognitive-behavioral therapy (CBT) in the treatment of bulimia nervosa. Method: A randomized controlled trial was conducted in which 70 patients with bulimia nervosa received either 2 years of weekly psychoanalytic psychotherapy or 20 sessions of CBT over 5 months. The main outcome measure was the Eating Disorder Examination interview, which was administered blind to treatment condition at baseline, after 5 months, and after 2 years. The primary outcome analyses were conducted using logistic regression analysis. Results: Both treatments resulted in improvement, but a marked difference was observed between CBT and psychoanalytic psychotherapy. After 5 months, 42% of patients in CBT (N=36) and 6% of patients in psychoanalytic psychotherapy (N=34) had stopped binge eating and purging (odds ratio=13.40, 95% confidence interval [CI]=2.45-73.42; p<0.01). At 2 years, 44% in the CBT group and 15% in the psychoanalytic psychotherapy group had stopped binge eating and purging (odds ratio=4.34, 95% CI=1.33-14.21; p=0.02). By the end of both treatments, substantial improvements in eating disorder features and general psychopathology were observed, but in general these changes took place more rapidly in CBT. Conclusions: Despite the marked disparity in the number of treatment sessions and the duration of treatment, CBT was more effective in relieving binging and purging than psychoanalytic psychotherapy and was generally faster in alleviating eating disorder features and general psychopathology. The findings indicate the need to develop and test a more structured and symptom-focused version of psychoanalytic psychotherapy for bulimia nervosa.
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Objective: To systematically review and quantitatively evaluate the efficacy of Family-Based Treatment (FBT) compared with individual treatment among adolescents with eating disorders. Method: The literature was reviewed using the MEDLINE search terms "family therapy AND Anorexia Nervosa," and "family therapy AND Bulimia Nervosa". This produced 12 randomized controlled trials involving adolescents with eating disorders and family therapy which were reviewed carefully for several inclusion criteria including: allocation concealment, intent-to-treat analysis, assessor blinding, behavioral family therapy compared with an individual therapy, and adolescent age group. References from these articles were searched. Only three studies met these strict inclusion criteria for meta-analysis. A random effects model and odds ratio was used for meta-analysis, looking at "remission" as the outcome of choice. Results: When combined in a meta-analysis, end of treatment data indicated that FBT was not significantly different from individual treatment (z = 1.62, p = 0.11). However, when follow-up data from 6 to 12 months were analyzed, FBT was superior to individual treatment (z = 2.94, p < 0.003), and heterogeneity was not significant (p = 0.59). Discussion: Although FBT does not appear to be superior to individual treatment at end of treatment, there appear to be significant benefits at 6-12 month follow-up for adolescents suffering from eating disorders.
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Little is known about how psychological treatments work. Research on treatment-induced mediators of change may be of help in identifying potential causal mechanisms through which they operate. Outcome-focused randomised controlled trials provide an excellent opportunity for such work. However, certain conceptual and practical difficulties arise when studying psychological treatments, most especially deciding how best to conceptualise the treatment concerned and how to accommodate the fact that most psychological treatments are implemented flexibly. In this paper, these difficulties are discussed, and strategies and procedures for overcoming them are described.
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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 effects of dialectical behavior therapy adapted for the treatment of binge/purge behaviors were examined. Thirty-one women (averaging at least one binge/purge episode per week) were randomly assigned to 20 weeks of dialectical behavior therapy or 20 weeks of a waiting-list comparison condition. The manual-based dialectical behavior therapy focused on training in emotion regulation skills. An intent-to-treat analysis showed highly significant decreases in binge/purge behavior with dialectical behavior therapy compared to the waiting-list condition. No significant group differences were found on any of the secondary measures. The use of dialectical behavior therapy adapted for treatment of bulimia nervosa was associated with a promising decrease in binge/purge behaviors.
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
Although third-wave behaviour therapies are being increasingly used for the treatment of eating disorders, their efficacy is largely unknown. This systematic review and meta-analysis aimed to examine the empirical status of these therapies. Twenty-seven studies met full inclusion criteria. Only 13 randomized controlled trials (RCT) were identified, most on binge eating disorder (BED). Pooled within- (pre-post change) and between-groups effect sizes were calculated for the meta-analysis. Large pre-post symptom improvements were observed for all third-wave treatments, including dialectical behaviour therapy (DBT), schema therapy (ST), acceptance and commitment therapy (ACT), mindfulness-based interventions (MBI), and compassion-focused therapy (CFT). Third-wave therapies were not superior to active comparisons generally, or to cognitive-behaviour therapy (CBT) in RCTs. Based on our qualitative synthesis, none of the third-wave therapies meet established criteria for an empirically supported treatment for particular eating disorder subgroups. Until further RCTs demonstrate the efficacy of third-wave therapies for particular eating disorder subgroups, the available data suggest that CBT should retain its status as the recommended treatment approach for bulimia nervosa (BN) and BED, and the front running treatment for anorexia nervosa (AN) in adults, with interpersonal psychotherapy (IPT) considered a strong empirically-supported alternative.
Article
Objective: Depressive symptoms are an important risk factor and consequence of binge eating and purging behavior in bulimia nervosa (BN). Although psychotherapy is effective in reducing symptoms of BN in the short- and long-term, it is unclear whether psychotherapy for BN is also effective in reducing depressive symptoms. This meta-analysis examined the efficacy of psychotherapy for BN on depressive symptoms in the short- and long-term. Method: Randomized controlled trials (RCTs) on BN that assessed depressive symptoms as an outcome were identified. Twenty-six RCTs were included. Results: Psychotherapy was more efficacious at reducing symptoms of depression at post-treatment (g = 0.47) than wait-lists. This effect was strongest when studies delivered therapist-led, rather than guided self-help, treatment. No significant differences were observed between psychotherapy and antidepressants. There was no significant post-treatment difference between CBT and other active psychological comparisons at reducing symptoms of depression. However, when only therapist-led CBT was analyzed, therapist-led CBT was significantly more efficacious (g = 0.25) than active comparisons at reducing depressive symptoms. The magnitude of the improvement in depressive symptoms was predicted by the magnitude of the improvement in BN symptoms. Discussion: These findings suggest that psychotherapy is effective for reducing depressive symptoms in BN in the short-term. Whether these effects are sustained in the long-term is yet to be determined, as too few studies conducted follow-up assessments. Moreover, findings demonstrate that, in addition to being the front-running treatment for BN symptoms, CBT might also be the most effective psychotherapy for improving the symptoms of depression that commonly co-occur in BN.
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.
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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.
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Objective: There is a paucity of randomized clinical trials (RCTs) for adolescents with bulimia nervosa (BN). Prior studies suggest cognitive-behavioral therapy adapted for adolescents (CBT-A) and family-based treatment for adolescent bulimia nervosa (FBT-BN) could be effective for this patient population. The objective of this study was to compare the relative efficacy of these 2 specific therapies, FBT-BN and CBT-A. In addition, a smaller participant group was randomized to a nonspecific treatment (supportive psychotherapy [SPT]), whose data were to be used if there were no differences between FBT-BN and CBT-A at end of treatment. Method: This 2-site (Chicago and Stanford) randomized controlled trial included 130 participants (aged 12-18 years) meeting DSM-IV criteria for BN or partial BN (binge eating and purging once or more per week for 6 months). Outcomes were assessed at baseline, end of treatment, and 6 and 12 months posttreatment. Treatments involved 18 outpatient sessions over 6 months. The primary outcome was defined as abstinence from binge eating and purging for 4 weeks before assessment, using the Eating Disorder Examination. Results: Participants in FBT-BN achieved higher abstinence rates than in CBT-A at end of treatment (39% versus 20%; p = .040, number needed to treat [NNT] = 5) and at 6-month follow-up (44% versus 25%; p = .030, NNT = 5). Abstinence rates between these 2 groups did not differ statistically at 12-month follow-up (49% versus 32%; p = .130, NNT = 6). Conclusion: In this study, FBT-BN was more effective in promoting abstinence from binge eating and purging than CBT-A in adolescent BN at end of treatment and 6-month follow-up. By 12-month follow-up, there were no statistically significant differences between the 2 treatments. Clinical trial registration information: -Study of Treatment for Adolescents With Bulimia Nervosa; http://clinicaltrials.gov/; NCT00879151.
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Understanding the factors that predict a favourable outcome following specialist treatment for an eating disorder may assist in improving treatment efficacy, and in developing novel interventions. This review and meta-analysis examined predictors of treatment outcome and drop-out. A literature search was conducted to identify research investigating predictors of outcome in individuals treated for an eating disorder. We organized predictors first by statistical type (simple, meditational, and moderational), and then by category. Average weighted mean effect sizes (r) were calculated for each category of predictor. The most robust predictor of outcome at both end of treatment (EoT) and follow-up was the meditational mechanism of greater symptom change early during treatment. Simple baseline predictors associated with better outcomes at both EoT and follow-up included higher BMI, fewer binge/purge behaviors, greater motivation to recover, lower depression, lower shape/weight concern, fewer comorbidities, better interpersonal functioning and fewer familial problems. Drop-out was predicted by more binge/purge behaviors and lower motivation to recover. For most predictors, there was large interstudy variability in effect sizes, and outcomes were operationalized in different ways. There were generally insufficient studies to allow analysis of predictors by eating disorder subtype or treatment type. To ensure that this area continues to develop with robust and clinically relevant findings, future studies should adopt a consistent definition of outcome and continue to examine complex multivariate predictor models. Growth in this area will allow for stronger conclusions to be drawn about the prediction of outcome for specific diagnoses and treatment types. © 2015 Wiley Periodicals, Inc.
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IntroductionIndividual studiesThe summary effectHeterogeneity of effect sizesSummary points
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Background Standardised effect sizes have been criticized because they are difficult to interpret and offer little clinical information. This meta-analyses examine the extent of actual improvement, the absolute numbers of patients no longer meeting criteria for major depression, and absolute rates of response and remission. Methods We conducted a meta-analysis of 92 studies with 181 conditions (134 psychotherapy and 47 control conditions) with 6937 patients meeting criteria for major depressive disorder. Within these conditions, we calculated the absolute number of patients no longer meeting criteria for major depression, rates of response and remission, and the absolute reduction on the BDI, BDI-II, and HAM-D. Results After treatment, 62% of patients no longer met criteria for MDD in the psychotherapy conditions. However, 43% of participants in the control conditions and 48% of people in the care-as-usual conditions no longer met criteria for MDD, suggesting that the additional value of psychotherapy compared to care-as-usual would be 14%. For response and remission, comparable results were found, with less than half of the patients meeting criteria for response and remission after psychotherapy. Additionally, a considerable proportion of response and remission was also found in control conditions. In the psychotherapy conditions, scores on the BDI were reduced by 13.42 points, 15.12 points on the BDI-II, and 10.28 points on the HAM-D. In the control conditions, these reductions were 4.56, 4.68, and 5.29. Discussion Psychotherapy contributes to improvement in depressed patients, but improvement in control conditions is also considerable.
Article
There are many terms used to describe treatment outcome for bulimia nervosa. However, the way such terms are conceptualised across various studies differs dramatically, making comparison of outcomes difficult. A consensus working definition of pivotal terms such as remission and recovery is important if treatments are to be adequately evaluated and clinical meaning derived for individuals with bulimia nervosa (BN). The central aim of the current review was to identify different definitions of remission and recovery and their utility in terms of client outcome after treatment for BN. Seventy one unique published treatment studies were identified that used 82 different outcome measures, of which 63 (77%) used behavioural outcomes only, with the most commonly used outcome (n=7 studies) being an abstinence of bingeing and vomiting for a 4 week period. The problems with the definitions of outcomes used to date are explored, and the implications of research in anorexia nervosa for forming consensus definitions of remission and recovery for BN will be examined. In addition, the review highlights the importance of considering the relationship between quality of life and outcome in assessing the "goodness of fit" of a definition of outcome.
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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.
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To investigate the predictive value of a wide range of variables for distinguishing subjects who demonstrate a favourable treatment response from those who do not, 86 women with a DSM-III-R diagnosis of bulimia nervosa who completed a group treatment programme for eating disorders were studied. Discriminant-function analysis of demographic variables, weight history, specific eating-disorder psychopathology, mood status and social adjustment before treatment was performed; five factors (depression and core symptoms of eating disorder) best discriminated 'positive' from 'poor' treatment responders, accounting for 44% of the variance.
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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.
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This study examined the relative efficacy of cognitive-behavioral and behavioral treatment approaches for bulimia nervosa. Female bulimic Ss were randomly assigned to cognitive-behavioral, behavioral, or attention placebo conditions. At posttreatment, 92% of the cognitive-behavioral group, 100% of the behavioral group, and 69% of the nonspecific self-monitoring group were abstinent from binge eating-purging. At 6-month follow-up, 69% of the cognitive-behavioral group, 38% of the behavioral group, and 15% of the nonspecific self-monitoring group were abstinent from binge eating and purging. The results support the conceptualization of bulimia nervosa as a multifaceted disorder best treated with an approach that directly addresses maladaptive cognitions, problematic behaviors, and the development of more adaptive coping skills.
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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.
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In a consensus-building process a group of experts from 19 European countries (COST Action B6) adapted the terms partial and full remission, relapse, recovery, and recurrence according to principles described by Frank et al. for depression. The empirical validity of the operationalizations was illustrated by longitudinal data on the post treatment course of 233 anorectic and 422 bulimic patients (diagnosed according to DSM-IIIR) from the German Project TR-EAT. These data were collected 2.5 years after admission using the Longitudinal Interval Follow-up Evaluation (LIFE) and statistically explored by survival-analysis. It was demonstrated that these consensus definitions measure what they intend to measure. They open a longitudinal perspective in that one can learn not only whether, but also when and with what probability patients change for the better or worse. Data suggest that persistence of symptom improvement has different implications for anorexia and bulimia nervosa. For example, relapse prevention would be most beneficial for bulimic patients for about 4 months after key symptoms remit, while this would be of less importance for anorexic patients. It is discussed whether and how this longitudinal approach can contribute to an empirically based rationale for targeted and individualized treatment.
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Randomized clinical trials (RCTs) not only are the gold standard for evaluating the efficacy and effectiveness of psychiatric treatments but also can be valuable in revealing moderators and mediators of therapeutic change. Conceptually, moderators identify on whom and under what circumstances treatments have different effects. Mediators identify why and how treatments have effects. We describe an analytic framework to identify and distinguish between moderators and mediators in RCTs when outcomes are measured dimensionally. Rapid progress in identifying the most effective treatments and understanding on whom treatments work and do not work and why treatments work or do not work depends on efforts to identify moderators and mediators of treatment outcome. We recommend that RCTs routinely include and report such analyses.
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Eating disorders are an important cause of physical and psychosocial morbidity in adolescent girls and young adult women. They are much less frequent in men. Eating disorders are divided into three diagnostic categories: anorexia nervosa, bulimia nervosa, and the atypical eating disorders. However, the disorders have many features in common and patients frequently move between them, so for the purposes of this Seminar we have adopted a transdiagnostic perspective. The cause of eating disorders is complex and badly understood. There is a genetic predisposition, and certain specific environmental risk factors have been implicated. Research into treatment has focused on bulimia nervosa, and evidence-based management of this disorder is possible. A specific form of cognitive behaviour therapy is the most effective treatment, although few patients seem to receive it in practice. Treatment of anorexia nervosa and atypical eating disorders has received remarkably little research attention.
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There has been enormous progress in psychotherapy research. This has culminated in recognition of several treatments that have strong evidence in their behalf. Even so, after decades of psychotherapy research, we cannot provide an evidence-based explanation for how or why even our most well studied interventions produce change, that is, the mechanism(s) through which treatments operate. This chapter presents central requirements for demonstrating mediators and mechanisms of change and reviews current data-analytic and designs approaches and why they fall short of meeting these requirements. The role of the therapeutic alliance in psychotherapy and cognitive changes in cognitive therapy for depression are highlighted to illustrate key issues. Promising lines of work to identify mediators and mechanisms, ways of bringing to bear multiple types of evidence, recommendations to make progress in understanding how therapy works, and conceptual and research challenges in evaluating mediators and mechanisms are also presented.
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