Article

Dropout from cognitive-behavioral therapy for eating disorders: A meta-analysis of randomized, controlled trials

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Abstract

Objective: Cognitive-behavioral therapy (CBT) is efficacious for a range of eating disorder presentations, yet premature dropout is one factor that might limit CBTs effectiveness. Improved understanding of dropout from CBT for eating disorders is important. This meta-analysis aimed to study dropout from CBT for eating disorders in randomized controlled trials (RCTs), by (a) identifying the types of dropout definitions applied, (b) providing estimates of dropout, (c) comparing dropout rates from CBT to non-CBT interventions for eating disorders, and (d) testing moderators of dropout. Method: RCTs of CBT for eating disorders that reported rates of dropout were searched. Ninety-nine RCTs (131 CBT conditions) were included. Results: Dropout definitions varied widely across studies. The overall dropout estimate was 24% (95% CI = 22-27%). Diagnostic type, type of dropout definition, baseline symptom severity, study quality, and sample age did not moderate this estimate. Dropout was highest among studies that delivered internet-based CBT and was lowest in studies that delivered transdiagnostic enhanced CBT. There was some evidence that longer treatment protocols were associated with lower dropout. No significant differences in dropout rates were observed between CBT and non-CBT interventions for all eating disorder subtypes. Conclusion: Present study dropout estimates are hampered by the use of disparate dropout definitions applied. This meta-analysis highlights the urgency for RCTs to utilize a standardized dropout definition and to report as much information on patient dropout as possible, so that strategies designed to minimize dropout can be developed, and factors predictive of CBT dropout can be more easily identified.

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... long waiting times) [7,9,10,[19][20][21][22]. Although these studies were able to detect significant factors influencing PTT, all concluded that small sample sizes, few reliable study replications and lack of heterogeneity across patient populations make it difficult to draw firm conclusions on the nature of and motivations for treatment dropout [7][8][9][10]. ...
... Reviews have shown that around 40% of people receiving treatment for an eating disorder do not finish the full course of treatment, with this figure rising to 50% for people with anorexia receiving inpatient treatment [6,7]. A meta-analysis of cognitive behavioural therapy (CBT) in all eating disorders reported an estimated dropout rate from CBT of 24% [8]. Premature termination of treatment (PTT), also know as 'dropout' and 'attrition' , references a patient's independent decision to terminate treatment or early discharge by staff [6,8,9]. ...
... A meta-analysis of cognitive behavioural therapy (CBT) in all eating disorders reported an estimated dropout rate from CBT of 24% [8]. Premature termination of treatment (PTT), also know as 'dropout' and 'attrition' , references a patient's independent decision to terminate treatment or early discharge by staff [6,8,9]. However, variation in definitions is reported to impede PTT rate estimations and make cross-study comparisons difficult [8,10]. ...
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Background High rates of premature treatment termination are a well-reported issue in eating disorder treatment, and present a significant barrier for treatment effectiveness and longer term health outcomes of patients with eating disorders. Understanding patient perspectives on this phenomenon is essential in improving treatment completion rates and informing research and intervention development. The aim of this review is to synthesise qualitative literature on patient perspectives of premature termination of eating disorder treatment and to summarise the key issues leading to discontinuation of treatment. Methods A systematic review of 1222 articles was conducted to identify studies using qualitative methods to investigate patient experiences of prematurely terminating eating disorder treatment. Ten articles were included in the review, with thematic synthesis used to analyse the primary research and develop overarching analytical themes. Results Conflict around enmeshment of eating disorder with identity, and lack of support with reconstructing a sense of self without the eating disorder; challenges of managing pressures of social and clinical relationships while feeling unheard and misunderstood by both; expectations and disappointments around treatment; and dissatisfaction with progress were key themes behind premature termination of treatment. Conclusions The findings of this review demonstrate the key issues influencing the decision to end treatment early, highlighting the contribution of individual, environmental, and service-level factors. Implications of these factors are discussed and suggestions raised for future research and service development.
... Personal contacts contribute to an improved alliance with the therapist and in combination with positive treatment and outcome expectations can provoke a symptom reduction without providing symptom-oriented interventions (Greenberg et al., 2006;Wampold et al., 2016). Larger dropout rates of up to 37% need to be expected for GSH treatment of BED patients according to a meta-analysis (Linardon et al., 2018) and to which extent dropout rates and treatment outcomes can be influenced by expectations remains unclear. ...
... The rate of prematurely treatment termination during the active treatment phase was comparable to estimates from internet-based treatments that did not include a face-to-face contact (24% on average), as summarized in the review by Aardoom et al. (2013). The dropout rates in our study were lower than in other GSH programs (37%) as shown in the meta-analysis of Linardon et al. (2018). Including post-treatment and follow-up measures, with 36.5%, ...
... Patients' narrative feedback revealed that the structured but still individualized content of the guidance of the therapist, who continuously motivated and validated them for their efforts, was appreciated. More research is needed with respect to the education and experience levels of the therapists, their expressive writing skills, and their ability to establish complementary and need-oriented relationships with the patient in internet-based treatments (Linardon et al., 2018;Sucala et al., 2012;Wilson & Zandberg, 2012). Beintner et al. (2014) reported results in favour of more experienced therapists regarding the outcome in a CBT-GSH for BED. ...
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Objective: Internet-based guided self-help (GSH) programs increase accessibility and utilization of evidence-based treatments in binge-eating disorder (BED). We evaluated acceptance and short as well as long-term efficacy of our 8-session internet-based GSH program in a randomized clinical trial with an immediate treatment group, and two waitlist control groups, which differed with respect to whether patients received positive expectation induction during waiting or not. Method: Sixty-three patients (87% female, mean age 37.2 years) followed the eight-session guided cognitive-behavioural internet-based program and three booster sessions in a randomized clinical trial design including an immediate treatment and two waitlist control conditions. Outcomes were treatment acceptance, number of weekly binge-eating episodes, eating disorder pathology, depressiveness, and level of psychosocial functioning. Results: Treatment satisfaction was high, even though 27% of all patients dropped out during the active treatment and 9.5% during the follow-up period of 6 months. The treatment, in contrast to the waiting conditions, led to a significant reduction of weekly binge-eating episodes from 3.4 to 1.7 with no apparent rebound effect during follow-up. All other outcomes improved as well during active treatment. Email-based positive expectation induction during waiting period prior to the treatment did not have an additional beneficial effect on the temporal course and thus treatment success, of binge episodes in this study. Conclusion: This short internet-based program was clearly accepted and highly effective regarding core features of BED. Dropout rates were higher in the active and lower in the follow-up period. Positive expectations did not have an impact on treatment effects.
... Both completer analyses and intent-to-treat analyses will be conducted, as previous studies on web-based interventions report notable dropout rates (Linardon et al., 2018), and completers might systematically differ from non-completers . For this purpose, two sensitivity analyses will be run: (1) the conservative lastobservation-carried-forward (LOCF) method, employing the last available measurement point of each subject, and (2) the multiple imputations by chained equations (MICE) approach using each participant's Body Mass Index, global eating psychopathology, number of bingeeating episodes determined in the EDE interview, and years since illness onset as predictors. ...
... Another challenge that might occur is a high dropout from the study, which has been frequently reported in previous trials on interventions for eating disorders (Linardon et al., 2018). Low adherence might be especially problematic for the present study, as the high number of assessments combining traditional questionnaires with EMA will lead to a relatively high burden for participants. ...
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Background: Individuals with bulimia nervosa (BN) experience persistent episodes of binge eating and inappropriate compensatory behavior associated with impaired physical and mental health. Despite the existence of effective treatments, many individuals with BN remain untreated, leading to a high burden and an increased risk of chronicity. Web-based interventions may help facilitate access to evidence-based treatments for BN by reducing barriers to the health care system. Methods: The present study will investigate the effectiveness of a web-based self-help intervention for BN in a two-armed, randomized controlled trial. Individuals diagnosed with BN (N = 152) will be randomly assigned to either (1) an intervention group receiving a 12-week web-based intervention or (2) a waitlist control group with delayed access to the intervention. Further assessments will be scheduled 6 (mid-treatment) and 12 (post-treatment) weeks after baseline. Changes in the number of binge eating episodes and compensatory behaviors will be examined as primary outcomes. Secondary outcomes include global eating pathology, functional impairments, well-being, comorbid psychopathology, self-esteem, and emotion regulation abilities. Discussion: Adding web-based interventions into routine care is a promising approach to overcome the existing treatment gap for patients with BN. Therefore, the current study will test the effectiveness of a web-based intervention for BN under standard clinical care settings. Trial registration: ClinicalTrials.gov, Identifier: NCT04876196 (registered on May 6th, 2021).
... Rates of attrition seen in the current study are similar to those from systematic reviews [41]. Whilst numbers were small, the present findings suggest that attrition occurs over the course of treatment, although a large number failed to attend the final session (i.e., after Session 9, which was the modal number). ...
... Given the limited data available, it is difficult to form conclusions but this could reflect avoidance towards the end of treatment or that participants had made sufficient gains that they did not feel a final session was necessary [42]. Similar patterns have been observed in groupbased CBT for atypical EDs [43] although other literature suggests that attrition tends to occur earlier in treatment [44] and reviews in this area have noted the limited data on the timing of dropout [41]. ...
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Purpose This study tests the value of a measure of eating disorder (ED) psychopathology in predicting outcome following guided self-help in a non-underweight sample with regular binge eating. It examines whether early reductions in ED psychopathology are associated with remission status at post-treatment. Methods Seventy-two adults with bulimia nervosa, binge-eating disorder, or an atypical form of these illnesses received up to ten sessions of cognitive behaviour therapy-based guided self-help. Using a session-by-session measure of eating pathology and associated reliable change indices, response was analysed using receiver operating characteristic analysis to predict outcomes at post-treatment. Results In this routine care setting, nearly one-quarter of the sample achieved remission following GSH, approximately two-thirds of whom showed early change in ED psychopathology. Early change prior to session 6 was accurate in predicting later remission. Individuals showing early change did not differ from others on baseline characteristics or rates of attrition. Conclusion Data suggest that a majority of those who respond to treatment will do so before the second half of treatment, information that could be used to ensure that evidence-based treatments are used as effectively as possible. Level of evidence Level III.
... individual, group). 40 Third, it will be helpful to continue to identify factors that moderate intervention response in order to establish more precise delivery models and realize the full potential of Internet-based interventions for improving mental health care delivery. ...
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Background: ICare represents a consortium of European Investigators examining the effects of online mental health care for a variety of common mental health disorders provided in a variety of settings. This article provides an overview of the evidence of effectiveness for Internet-based treatment for four common mental health disorders that are the focus of much of this work: depression, anxiety, substance abuse and eating disorders. Methods: The overview focused primarily on systematic reviews and meta-analyses identified through PubMed (Ovid) and other databases and published in English. Given the large number of reviews specific to depression, anxiety, substance abuse and/or eating disorders, we did not focus on reviews that examined the effects of Internet-based interventions on mental health disorders in general. Each article was reviewed and summarized by one of the senior authors, and this review was then reviewed by the other senior authors. We did not address issues of prevention, cost-effectiveness, implementation or dissemination, as these are addressed in other reviews in this supplement. Results: Across Internet-based intervention studies addressing depression, anxiety, substance abuse and eating disorders primarily among adults, almost all reviews and meta-analyses found that these interventions successfully reduce symptoms and are efficacious treatments. Generally, effect sizes for Internet-based interventions treating eating disorders and substance abuse are lower compared with interventions for depression and anxiety. Conclusions: Given the effectiveness of Internet-based interventions to reduce symptoms of these common mental health disorders, efforts are needed to examine issues of how they can be best disseminated and implemented in a variety of health care and other settings.
... [22][23][24][25][26] In Japan, there are two reports on the effectiveness and feasibility of CBT for BN or BED, 27 28 and the national health insurance has covered CBT in Japan since 2018. However, according to a meta-analysis of RCTs, the dropout rate for CBT is approximately 24%, 29 and there are large individual differences in treatment responsiveness. ...
Article
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Introduction Anorexia nervosa is a refractory psychiatric disorder with a mortality rate of 5.9% and standardised mortality ratio of 5.35, which is much higher than other psychiatric disorders. The standardised mortality ratio of bulimia nervosa is 1.49; however, it is characterised by suicidality resulting in a shorter time to death. While there is no current validated drug treatment for eating disorders in Japan, cognitive–behavioural therapy (CBT) is a well-established and commonly used treatment. CBT is also recommended in the Japanese Guidelines for the Treatment of Eating Disorders (2012) and has been covered by insurance since 2018. However, the neural mechanisms responsible for the effect of CBT have not been elucidated, and the use of biomarkers such as neuroimaging data would be beneficial. Methods and analysis The Eating Disorder Neuroimaging Initiative is a multisite prospective cohort study. We will longitudinally collect data from 72 patients with eating disorders (anorexia nervosa and bulimia nervosa) and 70 controls. Data will be collected at baseline, after 21–41 sessions of CBT and 12 months later. We will assess longitudinal changes in neural circuit function, clinical data, gene expression and psychological measures by therapeutic intervention and analyse the relationship among them using machine learning methods. Ethics and dissemination The study was approved by The Ethical Committee of the National Center of Neurology and Psychiatry (A2019-072). We will obtain written informed consent from all patients who participate in the study after they had been fully informed about the study protocol. All imaging, demographic and clinical data are shared between the participating sites and will be made publicly available in 2024. Trial registration number UMIN000039841
... Treatment of choice is cognitive-behavioral therapy (CBT), which aims at restoring a healthy daily eating pattern by modifying dysfunctional beliefs, goal setting, and self-control strategies such as keeping food diaries (Hay et al., 2009). CBT is moderately effective with 40-60% of the patients still symptomatic at the end of treatment and drop-out rates of approximately 22% for BED and 26% for BN (Linardon et al., 2018;Turton et al., 2016). To improve treatment efficacy and reduce drop-out rates, additional interventions are needed. ...
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Binge eating disorder (BED) and bulimia nervosa (BN) are characterized by binge eating. Frequently related to negative affect, binge eating is considered unwanted eating behavior. It is often preceded by a shift away from the goal of a healthy eating pattern. Implementation intentions are ‘if-then’ plans that may prevent such shifts in goals. In a students’ sample with subthreshold binge eating, two implementation intention conditions were compared to a control condition in which only goals were formed. In the behavior-focused condition, implementation intentions targeted binge eating; in the emotion-focused condition, implementation intentions targeted negative affect preceding binge eating. All participants received three sessions and kept food diaries for four weeks, followed by a post-test and a one-month, three-months, and six-months follow-up. Compared to the control condition, both implementation intention conditions showed significant and large reductions in binge eating lasting for six months. Effects did not differ between both implementation intention conditions. Three implementation intention sessions reduced subthreshold binge eating. This continued for six months after the final session. Contrary to expectations, behavior-focused and emotion-focused implementation intentions were equally effective, possibly due to other triggers than negative affect. Future research should address their usefulness in BED and BN.
... The overall attrition rate for the Foodfix study was 33%. This attrition rate is similar to binge eating disorder treatments delivered through a range of modalities (3-41%), and various cognitive behavioural therapy modalities (including e-therapy) for eating disorders treatment (22-27%) [30,31]. By allowing participants to schedule and reschedule appointments independently on an online scheduling appointment system, the FoodFix study provided increased flexibility to participants and achieved similar retention rates to that of programs requiring more formal scheduling by personnel. ...
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Addictive eating prevalence is estimated at 15–20% in studied populations, and is associated with concurrent mental health conditions and eating disorders as well as overweight and obesity. However, few evidence-based interventions targeting addictive eating are available. The further development of evidence-based interventions requires assessment of intervention feasibility and efficacy. This study aimed to determine the feasibility, including intervention delivery and program acceptability, of FoodFix; a personality targeted intervention for the treatment of addictive eating behaviours in Australian adults. Participants (n = 52) were randomised to intervention (n = 26) or wait-list control groups (n = 26) and received three personalised telehealth sessions with an Accredited Practising Dietitian over seven weeks. Intervention delivery was assessed by tracking adherence to scheduled timing of intervention sessions. Program acceptability of participants was assessed via an online process evaluation survey and program acceptability of intervention providers was assessed via semi-structured phone interviews. In total, 79% of participants adhered to scheduled timing for session two and 43% for session three, defined as within one week (before/after) of the scheduled date. Further, 21% of participants completed the process evaluation survey (n = 11). The majority of participants were extremely/very satisfied with FoodFix (n = 7, 63%). Intervention providers (n = 2) expressed that they felt adequately trained to deliver the intervention, and that the overall session format, timing, and content of FoodFix was appropriate for participants. These findings highlight the importance of assessing intervention feasibility to further understand intervention efficacy.
... 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). ...
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.
... Anorexia nervosa (AN) is an enduring and deliberating eating disorder, with severe psychological, physiological, and social consequences (Fichter, Quad ieg, Crosby, & Koch, 2017). Despite advances in identifying the risk and maintaining factors of the illness, AN remains challenging to treat (Murray, Quintana, Loeb, Grif ths, & Le Grange, 2019;Oldershaw, Startup, & Lavender, 2019), with studies reporting high rates of relapse (Berends, Boonstra, & van Elburg, 2018) and treatment drop-out (Dejong, Broadbent, & Schmidt, 2012;Linardon, Hindle, & Brennan, 2018). Although no gold-standard therapy is available for adults (Resmark, Herpertz, Herpertz-Dahlmann, & Zeeck, 2019;van den Berg et al., 2019), cognitive behavioural therapy (CBT) has been shown to be moderately effective for symptom reduction and is one of the recommended, most widely used psychotherapeutic approaches to treating AN (Zeeck et al., 2018). ...
Article
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Objective Power posing involves the adoption of an expansive bodily posture. This study examined whether power posing could benefit individuals with anorexia nervosa (AN) and women with normal weight in regards to interoceptive ability and affective states. Method Participants included 50 inpatients and outpatients with AN as well as 51 normal‐weight women. Interoceptive accuracy (IAcc), measured by the heartbeat tracking task and interoceptive sensibility (IS), measured by confidence ratings, were assessed at baseline, after a single power posing session and after 1 week of daily training. Also, the short‐term effects of power posing on subjective feelings of dominance, pleasantness, and arousal were investigated. Results Both groups increased in their IAcc after one power posing session. Also, there was a significant main effect of time on feelings of dominance and pleasantness in the short‐term. Women with AN displayed lower levels of IS, dominance, and pleasantness as well as higher levels of arousal than women without AN. Discussion These findings suggest that power posing has the potential to increase IAcc, subjective feelings of power and pleasant affect in the short‐term. Further research should investigate which mechanisms foster the effectiveness of this intervention to tailor it to the needs of women with AN. Highlights • Feelings of powerlessness are prominent in AN but few concrete interventions exist that directly address this concern. • Power posing has the potential to increase interoceptive accuracy, subjective feelings of power and pleasant affect in the short‐term. • Women with AN display lower levels of interoceptive sensibility than women without AN.
... The most frequently reported reasons for discontinuation of pharmacotherapy were lack of efficacy and adverse effects. For nonpharmacotherapy, it is important to consider that treatment is generally time-limited, with the defined number of sessions varying across therapies [36,37]. As such, discontinuation of nonpharmacotherapy in this study may be related to the end of treatment. ...
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Purpose: In the Canadian healthcare setting, there is limited understanding of the pathways to diagnosis and treatment for patients with binge eating disorder (BED). Methods: This retrospective chart review examined the clinical characteristics, diagnostic pathways, and treatment history of adult patients diagnosed with BED. Results: Overall, 202 charts from 57 healthcare providers (HCPs) were reviewed. Most patients were women (69%) and white (78%). Mean ± SD patient age was 37 ± 12.1 years. Comorbidities identified in > 20% of patients included obesity (50%), anxiety (49%), depression and/or major depressive disorder (46%), and dyslipidemia (26%). Discussions regarding a diagnosis of BED were typically initiated more often by HCPs than patients. Most patients (64%) received a diagnosis of BED ≥ 3 years after symptom onset. A numerically greater percentage of patients received (past or current) nonpharmacotherapy than pharmacotherapy (84% vs. 67%). The mean ± SD number of binge eating episodes/week numerically decreased from pretreatment to follow-up with lisdexamfetamine (5.4 ± 2.8 vs. 1.7 ± 1.2), off-label pharmacotherapy (4.7 ± 3.9 vs. 2.0 ± 1.13), and nonpharmacotherapy (6.3 ± 4.8 vs. 3.5 ± 6.0) Across pharmacotherapies and nonpharmacotherapies, most patients reported improvement in symptoms of BED (84-97%) and in overall well-being (80-96%). Conclusions: These findings highlight the importance of timely diagnosis and treatment of BED. Although HCPs are initiating discussions about BED, earlier identification of BED symptoms is required. Furthermore, these data indicate that pharmacologic and nonpharmacologic treatment for BED is associated with decreased binge eating and improvements in overall well-being. Level of evidence: IV, chart review.
... Still, more than 60% do not fully abstain from symptoms after CBT (Linardon & Wade, 2018). High rates of premature treatment termination (Linardon, Hindle, & Brennan, 2018) and relapses (Södersten, Bergh, Leon, Brodin, & Zandian, 2017) may be due to insufficient delivery (Mulkens, de Vos, de Graaff, & Waller, 2018;Waller, Stringer, & Meyer, 2012), and patient's clinical heterogeneity beyond what is captured by the diagnostic criteria. Hence, the efficacy of new treatment options needs to be explored to reach out to persons with BN or BED who, for some reason, do not benefit from CBT or other kind of psychological treatments. ...
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Objective: To compare effects of physical exercise and dietary therapy (PED-t) to cognitive behavioral therapy (CBT) in treatment of bulimia nervosa (BN) and binge-eating disorder (BED). Method: The active sample (18-40 years of age) consisted of 76 women in the PED-t condition and 73 in the CBT condition. Participants who chose not to initiate treatment immediately (n = 23) were put on a waiting list. Outcome measures were the eating disorder examination questionnaire (EDE-Q), Clinical Impairment Assessment (CIA), Satisfaction with Life Scale (SWLS), Beck Depression Inventory (BDI), and numbers in remission at posttreatment, and at 6-, 12-, and 24-months follow-up. Results: Both treatment conditions produced medium to strong significant improvements on all outcomes with long-term effect. The PED-t produced a faster improvement in EDE-Q and CIA, but these differences vanished at follow-ups. Only PED-t provided improvements in BDI, still with no between-group difference. Totally, 30-50% of participants responded favorable to treatments, with no statistical between-group difference. Discussion: Both treatments shared a focus on normalizing eating patterns, correcting basic self-regulatory processes and reducing idealized aesthetic evaluations of self-worth. The results point to the PED-t as an alternative to CBT for BN and BED, although results are limited due to compliance and dropout rates. Replications are needed by independent research groups as well as in more clinical settings.
... We could not identify study characteristics associated with estimates, but noted considerable heterogeneity in attrition rates across trials. Although these estimates are comparable to attrition rates reported in face-to-face treatments (Linardon, Hindle, et al., 2018), that one in four participants are expected to drop out from digital intervention trials underscores the importance of developing and implementing effective retention strategies. Doing so may protect against threats to the validity of trial findings and improve treatment outcomes. ...
Article
Objectives: E-mental health (digital) interventions can help overcome existing barriers that stand in the way of people receiving help for an eating disorder (ED). Although e-mental health interventions for treating and preventing EDs have been met with enthusiasm, earlier reviews brought attention to poor quality of evidence, and offered solutions to enhance their evidence base. To assess developments in the field, we conducted an updated meta-analysis on the efficacy of e-mental health interventions for treating and preventing EDs, paying attention to whether trial quality and outcomes have improved in recent trials. We also assessed whether user-centered design principles have been implemented in existing digital interventions. Method: Four databases were searched for RCTs of digital interventions for treating and preventing EDs. Thirty-six RCTs (28 prevention- and 8 treatment-focused) were included. Results: Some evidence that study quality improved in recent prevention-focused trials was found. Few trials involved the end-user in the design or development stage of the intervention. Issues with intervention engagement were noted, and 1 in 4 participants dropped out from prevention- and treatment-focused trials. Digital interventions were more effective than control conditions in reducing established risk factors and symptoms in prevention- (g's = 0.19 to 0.43) and treatment-focused trials (g's = 0.29 to 0.69), respectively. Effect sizes have not increased in recent trials. Few trials compared a digital intervention with a face-to-face intervention. Whether digital interventions can prevent ED onset is unclear. Conclusion: Digital interventions are a promising approach to ED treatment and prevention, but improvements are still needed. Three key recommendations are provided. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
... Greater drop-out in the eGSH condition reflects trends observed in previous studies (see Linardon, Hindle, & Brennan, 2018) questioning the acceptability of "non-traditional" methods of delivery and asynchronous feedback in CBT (Victor, Krug, Vehoff, Lyons, & Willutzki, 2018 Email (n = 23) 11.8 (4.5) 16.8 (7.1) Email versus face-to-face À0.60 (À3.17, 1.97) .6491 ...
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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.
... Overall, digital ED programs demonstrate improvements in ED symptoms, with evidence supporting iCBT. However, intervention engagement remains a significant challenge [71]. Future research is needed to develop strategies that promote continued engagement with digital treatment programs. ...
Article
Background: Eating disorders are prevalent on college campuses and pose significant risks to student health, well-being, and academic performance. However, few students receive access to evidence-based prevention and treatment. Objective: The present review synthesizes the recent literature on ED screening, prevention, and treatment approaches on college campuses in the United States. We provide an overview of ED screening efforts on college campuses, including relevant screening tools, summarize the extant literature on prevention programming, as well psychological and pharmacological treatment approaches, and outline limitations of current programming and provide future directions for research. Conclusion: Recent advances in ED screening, prevention, and treatment efforts highlight the importance of early detection and intervention. Innovative approaches to screening and dissemination of evidence-based prevention and treatment programs on college campuses are warranted. Implications for future research are discussed.
... There were no dropouts in the DMT group and the no-show rates were low, suggesting that the patients were committed to the therapy. This seems important considering the high dropout rates in EDs [88]. ...
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Background: Body image disturbance and alexithymia are two core aspects of Eating Disorders (EDs). However, standard treatments for EDs do not include specific techniques to approach these issues on a bodily level. This pilot study evaluated the effects of a Dance Movement Therapy (DMT) intervention on body image and alexithymia in patients with EDs, and also explored their experience of the therapeutic process. Method: 14 patients with EDs were recruited from a private clinic. Seven were assigned via quasi-randomization to the DMT group and the others (n = 5) continued their treatment as usual. The length of the intervention was 14 weeks. All participants completed the Multidimensional Body Self Relations Questionnaire (MBSRQ) and the Toronto Alexithymia Scale (TAS-20) at the beginning and at the end of the intervention. Additionally, the DMT group wrote reflective diaries about their experience at the end of each session, which were analyzed using qualitative methods. Results: Between the pre- and post-intervention, the participants of the DMT group significantly improved in Body Areas Satisfaction (effect size: 0.95) and Appearance Evaluation (effect size: 1.10), and they decreased significantly in Appearance Orientation (effect size: 1.30). A decrease in Overweight Preoccupation was observed (effect size: 0.75), however this was not statistically significant. The control group did not show significant changes in any of the MBSRQ subscales. Neither the DMT group nor the control group improved significantly in the alexithymia scores. The qualitative analysis revealed valuable insights into the participants' processes throughout the sessions. In general, participants received the DMT intervention positively. They reported improvements in their mood states and an increase in their self-awareness. They also appreciated the relationship with the group and the therapist. Conclusion: These results indicate that DMT might be a complementary treatment option for EDs, as it may be able to address body image issues more effectively than verbal therapies. More studies with larger samples are needed to confirm these promising preliminary results.
... Whether dropout from therapy is a behavioral expression of insufficient therapeutic alliance (and there may be several other reasons for dropping out) in eating disorders requires further study. A recent review of CBT studies found higher dropout when delivery was online versus in person (Linardon, Hindle, & Brennan, 2018). ...
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The COVID‐19 pandemic has forced an abrupt change in the delivery of clinical services, including for individuals with an eating disorder. We present this Virtual Issue as a resource for the eating disorder community to showcase research published in the International Journal of Eating Disorders that provides information on effective strategies to help address the challenges arising from COVID‐19‐related disruptions. Articles included describe original research or systematic reviews on obstacles to health services use and strategies to improve access to care; technological tools to provide or enhance interventions; patients' and clinicians' attitudes or perspectives on using digital tools for clinical care; factors influencing therapeutic alliance; and ideas for improving reach and uptake of digital interventions. We hope that readers will find ways to observe and record their own experiences during this global crisis; the experiences of people at risk for developing or exhibiting an eating disorder; and the experiences of those who care for people with an eating disorder. These lived experiences will be invaluable in formulating hypotheses for future studies in service of advancing the understanding of eating disorders and improving interventions and policies for reducing the burden of suffering attributable to eating disorders.
... Eating disorders (EDs) pose serious risks to psychological and physical health [1,2], resulting in an elevated risk of death for those with EDs compared with the general population [3][4][5]. treatment [9]. Innovation is needed to improve treatment outcomes. ...
Article
Novel treatment options for eating disorders (EDs) are critically needed to enhance treatment outcomes and reduce the rates of treatment dropouts. On average, only 50% of individuals receiving evidence-based care remit, whereas 24% drop out before treatment completion. One particularly promising direction involves integrating virtual reality (VR) with existing evidence-based treatments (EBTs) such as cue exposure therapy (CET). Across psychiatric disorders, VR-based interventions are demonstrating at least preliminary efficacy and noninferiority to traditional treatments. Furthermore, VR technology has become increasingly portable, resulting in improved acceptance, increased access, and reductions in cost. However, more efficient research processes may be needed to uncover the potential benefits of these rapid technological advances. This viewpoint paper reviews existing empirical support for integrating VR with EBTs (with a focus on its use with EDs) and proposes key next steps to more rapidly bring this innovative technology-based intervention into real-world clinic settings, as warranted. VR-CET for EDs is used to illustrate a suggested process for developing such treatment enhancements. We recommend following a deployment-focused model of intervention development and testing to enable rapid implementation of robust, practice-ready treatments. In addition, our review highlights the need for a comprehensive clinical protocol that supports clinicians and researchers in the implementation and testing of VR-CET and identifies key missing protocol components with rationale for their inclusion. Ultimately, this work may lead to a more complete understanding of the full potential of the applications and integrations of VR into mental health care globally.
... Second, the follow-up period of one-month was inadequate to determine if there were any lasting effects of the Yoga program. Third, the attrition rate in this study was 26%, which while high is on par with attrition rates observed in eating disorder outpatient treatments (29%-73%; Fassino, Pierò, Tomba, & Abbate-Daga, 2009) and RCTs of CBT for eating disorders (24%; Linardon, Hindle, & Brennan, 2018). Questions remain about what differentiated study completers from noncompleters and this is an important area for future investigation. ...
Article
Yoga has begun to be incorporated into the treatment of eating disorders despite limited empirical support for this practice. The purpose of this study was to investigate the efficacy of incorporating Yoga into the treatment of eating disorders. This preliminary randomized controlled trial investigated the benefits of participating in an eight-week Kripalu Yoga program for 53 women with symptoms of bulimia nervosa and binge eating disorder. Compared to waitlist controls, Yoga participants experienced decreases in binge eating frequency, emotional regulation difficulties and self-criticism, and increases in self-compassion. Yoga participants also experienced increases in state mindfulness skills across the eight weeks of the Yoga program. While these results are encouraging and suggest Yoga may have a valuable role to play in the treatment of eating disorders, it is important to stress their tentative nature. Further research, adopting a more rigorous design, is needed to address the limitations of the present study and expand on these findings.
... No hubo diferencias significativas en los rangos de abandono observados entre las intervenciones TCC y no TCC para todos los subtipos de TCA. Una de las conclusiones que llegan es que las estimaciones de abandono del estudio actual se ven obstaculizadas por el uso de definiciones dispares de abandono aplicadas (Linardon, Hindle y Brennan, 2018). ...
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La psicoterapia es un recurso efectivo y eficaz, pero no lo es para todas las personas. Uno de los problemas clínicos con el que nos encontramos en este campo es la terminación prematura por parte del paciente sin acuerdo con el psicoterapeuta. El problema mencionado deriva en dos problemas, uno conceptual y otro operacional, existiendo distintas definiciones del término como así diferentes maneras de medirlo. El objetivo general de este trabajo es realizar una revisión no sistemática sobre el tema, teniendo como ejes las distintas maneras en que se ha definido el concepto, las diversas formas de medirla, los resultados de meta-análisis realizados sobre la temática y las variables que pueden modularla.
... The mean dropout rates in this trial were higher at the end of treatment (31.6%) compared to a mean around 24% reported in a recent meta-analysis of RCTs testing CBT for ED [39]. Nonetheless, the authors highlighted the large range of dropout definition in studies. ...
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Purpose: The association between binge eating and obesity is increasing. Treatments for disorders of recurrent binge eating comorbid with obesity reduce eating disorder (ED) symptoms, but not weight. This study investigated the efficacy and safety of introducing a weight loss intervention to the treatment of people with disorders of recurrent binge eating and a high body mass index (BMI). Methods: A single-blind randomized controlled trial selected adults with binge eating disorder or bulimia nervosa and BMI ≥ 27 to < 40 kg/m2. The primary outcome was sustained weight loss at 12-month follow-up. Secondary outcomes included ED symptoms. Mixed effects models analyses were conducted using multiple imputed datasets in the presence of missing data. Results: Ninety-eight participants were randomized to the Health Approach to Weight Management and Food in Eating Disorders (HAPIFED) or to the Cognitive Behavioural Therapy-Enhanced (CBT-E). No between-group differences were found for percentage of participants achieving weight loss or secondary outcomes, except for reduction of purging behaviour, which was greater with HAPIFED (p = 0.016). Binge remission rates specifically at 12-month follow-up favoured HAPIFED (34.0% vs 16.7%; p = 0.049). Overall, significant improvements in the reduction of ED symptoms were seen in both groups and these were sustained at the 12-month follow-up. Conclusion: HAPIFED was not superior to CBT-E in promoting clinically significant weight loss and was not significantly different in reducing most ED symptoms. No harm was observed with HAPIFED, in that no worsening of ED symptoms was observed. Further studies should test approaches that target both the management of ED symptoms and the high BMI. Level of evidence: Level I, randomized controlled trial TRIAL REGISTRATION: US National Institutes of Health clinical trial registration number NCT02464345, date of registration 1 June 2015.
... As described earlier, global remission and recovery rates for CBT and other standard treatments are not good. An average of 24% of patients drop out of treatment (Linardon et al., 2018), roughly 37% of those who continue treatment reach remission (Hay et al., 2009;Hay, 2013), subsequent relapse rates are about 30% (Södersten et al., 2017), leading to true recovery for perhaps between 10% and 25% (Von Holle et al., 2008). These outcomes are subject to definitions of remission and recovery that are often lax and/or vague. ...
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Mainstream forms of psychiatric talk therapy and cognitive behavioral therapy (CBT) do not reliably generate lasting recovery for eating disorders. We discuss widespread assumptions regarding the nature of eating disorders as fundamentally psychological disorders and highlight the problems that underlie these notions, as well as related practical problems in the implementation of mainstream treatments. We then offer a theoretical and practical alternative: a dynamical systems model of eating disorders in which behavioral interventions are foregrounded as powerful mediators between psychological and physical states. We go on to present empirical evidence for behavioral modification specifically of eating speed in the treatment of eating disorders, and a hypothesis accounting for the etiology and progression, as well as the effective treatment, of the full spectrum of eating problems. A dynamical systems approach mandates that in any dietary and lifestyle change as profound as recovery from an eating disorder, acknowledgment must be made of the full range of pragmatic (psychological, cultural, social, etc.) factors involved. However, normalizing eating speed may be necessary if not sufficient for the development of a reliable treatment for the full spectrum of eating disorders, in its role as a mediator in the complex feedback loops that connect the biology and the psychology with the behaviors of eating.
... There were no dropouts in the DMT group and the no-show rates were low, suggesting that the patients were committed to the therapy. This seems important considering the high dropout rates in EDs [88]. ...
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Background: Body image disturbance and alexithymia are two core aspects of Eating Disorders (EDs). However, standard treatments for EDs do not include specific techniques to approach these issues on a bodily level. This pilot study evaluated the effects of a Dance Movement Therapy (DMT) intervention on body image and alexithymia in patients with EDs, and also explored their experience of the therapeutic process. Method: 14 patients with EDs were recruited from a private clinic. Seven were assigned via quasi-randomization to the DMT group and the others (n = 5) continued their treatment as usual. The length of the intervention was 14 weeks. All participants completed the Multidimensional Body Self Relations Questionnaire (MBSRQ) and the Toronto Alexithymia Scale (TAS-20) at the beginning and at the end of the intervention. Additionally, the DMT group wrote reflective diaries about their experience at the end of each session, which were analyzed using qualitative methods. Results: Between the pre-and post-intervention, the participants of the DMT group significantly improved in Body Areas Satisfaction (effect size: 0.95) and Appearance Evaluation (effect size: 1.10), and they decreased significantly in Appearance Orientation (effect size: 1.30). A decrease in Overweight Preoccupation was observed (effect size: 0.75), however this was not statistically significant. The control group did not show significant changes in any of the MBSRQ subscales. Neither the DMT group nor the control group improved significantly in the alexithymia scores. The qualitative analysis revealed valuable insights into the participants' processes throughout the sessions. In general, participants received the DMT intervention positively. They reported improvements in their mood states and an increase in their self-awareness. They also appreciated the relationship with the group and the therapist. Conclusion: These results indicate that DMT might be a complementary treatment option for EDs, as it may be able to address body image issues more effectively than verbal therapies. More studies with larger samples are needed to confirm these promising preliminary results.
... The overall improvement of ED symptomatology after treatment confirmed the well-known efficacy of CBT-E in patients with AN and BN (Atwood & Friedman, 2020;Dalle Grave et al., 2016). However, data regarding remission and dropout rates (51.2% and 25.4%, respectively) were unsatisfactory, as previously observed in the literature (Atwood & Friedman, 2020;Linardon et al., 2018), underscoring the importance of evaluating factors that predict treatment outcome in order to identify new potential targets of intervention. (Cassioli et al., 2021). ...
Article
Objective: This study aimed to explore the role of attachment insecurity in predicting a worse longitudinal trend of eating disorder (ED) psychopathology and body uneasiness in patients with Anorexia Nervosa (AN) or Bulimia Nervosa (BN) treated with Enhanced Cognitive Behavior Therapy, considering the longitudinal interplay between these dimensions. Method: In total, 185 patients with AN or BN performed the baseline assessment, and 123 were re-evaluated after 1 year of treatment. Participants completed questionnaires evaluating ED psychopathology (Eating Disorders Examination Questionnaire) and body uneasiness (body uneasiness test). For the assessment of adult attachment, the Experiences in Close Relationships-Revised was administered at baseline. Bivariate latent change score analysis within the structural equation modeling framework was performed to investigate the evolution of ED psychopathology and body uneasiness, their longitudinal interplay, and the role of attachment style as an outcome predictor. Results: After treatment, all psychopathological features showed an overall improvement. Higher baseline levels of body uneasiness predicted a worse course of ED psychopathology. The change in body uneasiness over time depended on changes over time in ED psychopathology, but not vice versa. Insecure attachment predicted a worse longitudinal trend of ED psychopathology, and, through this impairment, it indirectly maintained higher levels of body uneasiness, as confirmed by mediation analyses. Discussion: The role of attachment insecurity as a predictor of treatment outcome suggests the need for an integration of the cognitive-behavioral conceptualization of EDs with a developmental perspective that considers attachment-related issues. Public significance statement: Considering the burden of EDs in terms of public health and the unsatisfactory response to standard treatments, the identification of outcome predictors is of considerable clinical interest. This study demonstrated that attachment insecurity was associated with worse longitudinal trends of ED psychopathology and body uneasiness in patients with AN and BN treated with CBT-E, highlighting the importance of personalizing treatment programs taking into account a developmental perspective on these disorders.
... The provision of clinician support as an adjunct to self-help programs has been suggested as a viable solution to one of the most powerful critiques of digital interventions, that being the high rates of non-adherence [37,38]. Internetdelivered CBT has the highest dropout rates of all ED treatments, ranging up to 47.2% [44]. Given the potential impact of non-adherence upon the therapeutic outcomes for patients, several reviews have highlighted the need for ongoing development and examination of novel digital treatments, with the aim of reducing the discrepancy in adherence between online platforms and more traditional modes of face-to-face treatment delivery [35,37,38]. ...
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Background Despite the availability of effective treatments for bulimia nervosa (BN), a number of barriers to accessibility exist. Examples include access to trained clinicians, the expense of treatment, geographical limitations, and personal limitations such as stigma regarding help seeking. Self-help interventions, delivered via a digital platform, have the potential to overcome treatment gaps by providing patients with standardised, evidence-based treatments that are easily accessible, cost-effective, and require minimal clinician support. Equally, it is important to examine the shortcomings of digital interventions when compared to traditional to face-to-face delivery (e.g., high dropout rates) in order to maximise the therapeutic effectiveness of online, self-help interventions. Methods A three-arm, multisite randomised controlled trial will be conducted in Australia examining the effectiveness and cost-effectiveness of a newly developed online self-help intervention, Binge Eating eTherapy (BEeT), in a sample of patients with full or sub-threshold BN. The BEeT program consists of 10, multimedia sessions delivering the core components of cognitive behaviour therapy. Eligible participants will be randomised to one of three groups: independent completion of BEeT as a purely self-help program, completion of BEeT alongside clinician support (in the form of weekly telemedicine sessions), or waitlist control. Assessments will take place at baseline, weekly, post-intervention, and three-month follow up. The primary outcome is frequency of objective binge episodes. Secondary outcomes include frequency of other core eating disorder behavioural symptoms and beliefs, psychological distress, and quality of life. Statistical analyses will examine treatment effectiveness, feasibility, acceptability and cost effectiveness. Discussion There is limited capacity within the mental health workforce in Australia to meet the demand of people seeking treatment for eating disorders. This imbalance has only worsened following outbreak of the COVID-19 pandemic. Further research is required into innovative digital modes of treatment delivery with the capacity to service mental health needs in an accessible and affordable manner. Self-help programs may also appeal to individuals who are more reluctant to engage in traditional face-to-face treatment formats. This study will provide rigorous evidence on how to diversify treatment options for individuals with BN, ensuring more people with the illness can access evidence-based treatment. The study has been registered with the Australia New Zealand Clinical Trials Registry (ANZCTR Registration Number: ACTRN12619000123145p). Registered 22 January 2019, https://www.australianclinicaltrials.gov.au/anzctr/trial/ACTRN12619000123145.
... Generally, treatment response from cognitive behavioral therapies (CBTs) for bulimic spectrum eating disorders (EDs) is poor (Agras et al., 2000;Linardon, 2018;Linardon et al., 2018). Assignment of homework is a hypothesized strategy for improving response during CBTs for EDs (Linardon et al., 2017;Wilson et al., 2002). ...
Article
Introduction: Homework assignments are considered key components of behavioral treatments for bulimia nervosa (BN), but little is known about whether homework compliance predicts BN symptom improvement. The present study is the first to examine whether session-by-session change in homework compliance predicts session-by-session changes in BN symptoms during behavioral treatment. Method: Patients with BN-spectrum eating disorders (n = 42) received 20 sessions of behavioral treatment. Each session, their clinicians completed surveys assessing compliance with self-monitoring, behavioral, and written homework assignments and BN symptom frequency during the previous week. Results: Significant between-persons effects of self-monitoring and behavioral homework compliance were identified, such that patients with greater compliance in the past week experienced greater reductions in binge eating and purging the following week. There were significant within-persons effects of self-monitoring compliance on binge eating and behavioral homework compliance on restrictive eating, binge eating, and purging, such that greater than one's usual compliance predicted greater improvements in BN symptoms the following week. No significant effects of written homework compliance were identified. Conclusion: Compliance with self-monitoring and behavioral homework predict improvements in BN symptoms during behavioral treatment. These findings reinforce the importance of self-monitoring and behavioral homework compliance as drivers of change during treatment for BN.
... Adherence to assigned intervention was also either not reported or not clearly reported in most papers (n = 7) [29][30][31][32][33][35][36][37][38]. A majority of included studies had complete outcome data (n = 8) [29,30,[33][34][35]38,39], defined as attrition of less than 29% [41]. Whilst most papers collected data that adequately addressed the research questions (n = 8) [29][30][31][32][33][34][35][36]39], outcome measures were highly varied and non-standardised across studies. ...
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Eating disorders are potentially life-threatening mental health disorders that require management by a multidisciplinary team including medical, psychological and dietetic specialties. This review systematically evaluated the available literature to determine the effect of including a dietitian in outpatient eating disorder (ED) treatment, and to contribute to the understanding of a dietitian’s role in ED treatment. Six databases and Google Scholar were searched for articles that compared treatment outcomes for individuals receiving specialist dietetic treatment with outcomes for those receiving any comparative treatment. Studies needed to be controlled trials where outcomes were measured by a validated instrument (PROSPERO CRD42021224126). The searches returned 16,327 articles, of which 11 articles reporting on 10 studies were included. Two studies found that dietetic intervention significantly improved ED psychopathology, and three found that it did not. Three studies reported that dietetic input improved other psychopathological markers, and three reported that it did not. One consistent finding was that dietetic input improved body mass index/weight and nutritional intake, although only two and three studies reported on each outcome, respectively. A variety of instruments were used to measure each outcome type, making direct comparisons between studies difficult. Furthermore, there was no consistent definition of the dietetic components included, with many containing psychological components. Most studies included were also published over 20 years ago and are now out of date. Further research is needed to develop consistent dietetic guidelines and outcome measures; this would help to clearly define the role of each member of the multidisciplinary team, and particularly the role of dietitians, in ED treatment.
... Our study also suggests that briefer treatment for nonunderweight eating disorders produces comparable dropout rates to those reported for both RCTs and uncontrolled trials of longer CBT-ED (see Atwood & Friedman, 2020). However, a direct head-to-head comparison is required to draw any firm conclusions given the wide variety of definitions of dropout used in studies of CBT for eating disorders (Linardon et al., 2018). In CBT-T, clients are informed that the critical predictor of treatment outcome is early change in eating disorder symptoms. ...
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Objective: Treatment guidelines recommend that people with non-underweight eating disorders should receive up to 20 sessions of eating-disorder-focused cognitive behavioural therapy (CBT-ED). The present study reviewed ten studies of 10-session cognitive behavioural therapy for non-underweight patients (CBT-T). Method: We conducted a systematic review using four electronic databases and contacted researchers in the field for unpublished data. Random effects meta-analyses were conducted to pool within-group effect sizes. Results: From pre-treatment to post-treatment, medium to very large effect sizes were observed for eating disorder psychopathology, clinical impairment, depression, anxiety, and weekly frequencies of objective bingeing and vomiting. Furthermore, the effect of CBT-T appears to last after treatment with eating disorder psychopathology remaining below the norm for non-clinical females at follow-up. The dropout rate from CBT-T was 39%, and 65% of completers achieved a good outcome. Conclusions: While results should be interpreted as preliminary due to a number of limitations, the present study suggests that CBT-T is a promising treatment for people with non-underweight eating disorders, which can achieve a good outcome in half the time currently recommended in treatment guidelines. The present study, therefore, provides valuable justification for future randomised controlled trials directly comparing short and long forms of CBT�ED as well as examining who does best with which version.
... In a study performed in Western Australia, which was the first published CBT-E trial that included patients with a BMI < 17.5, 12 of 34 (35%) patients with AN completed the treatment [27], whereas a recent study involving the National Health Service in London reported that 54% of patients with AN completed CBT [28]. Results from different studies and settings are not directly comparable due to differences in patient samples and definitions of dropout [29]; for example, transfer to inpatient treatment is only included in some studies. In the ANTOP study, 35% of patients in the CBT-E group received residential crisis interventions during the trial and were not categorized as dropouts [6]. ...
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Background Enhanced cognitive behavioral therapy (CBT-E) is a promising treatment option for outpatients with anorexia nervosa (AN). We aimed to determine the effectiveness of CBT-E as a standard treatment for adult outpatients with AN from the specialized eating-disorder unit of a public hospital with responsibilities to their catchment area. Methods This study had an open, longitudinal design. Thirty three (of planned 100) outpatients aged > 16 years suffering from AN were included to receive 40 sessions of CBT-E. Eating-disorder psychopathology and body mass index (BMI) were assessed before and after treatment, while comorbid psychiatric symptoms and trauma experiences were evaluated at the baseline, and therapeutic alliance was assessed after 4 weeks of treatment. Results A high proportion (69%) of patients dropped out of the treatment. Patient recovery was considered when they reached BMI > 18.5 and Eating Disorder Examination Questionnaire (EDE-Q) score < 2.5, and 27% of all patients recovered. Conclusions Patients who completed the treatment had mostly satisfactory outcomes. Considering the high dropout rate, it is necessary to improve the strategies for engaging patients in therapy. Several aspects of CBT-E as a standard treatment are discussed regarding the high dropout rate. Trial registration ClinicalTrials.gov. Identifier: NCT02745067. Registered: April 20, 2016. https://clinicaltrials.gov/ct2/showNCT02745067
Article
Objective Mindfulness-based interventions (MBIs) are being increasingly used as interventions for eating disorders including binge eating. This systematic review and meta-analysis aimed to assess two decades of research on the efficacy of MBIs in reducing binge eating severity. Methods We searched PubMed, Scopus and Cochrane Library for trials assessing the use of MBIs to treat binge eating severity in both clinical and non-clinical samples. The systematic review and meta-analysis was pre-registered at PROSPERO (CRD42020182395). Results Twenty studies involving 21 samples (11 RCT and 10 uncontrolled samples) met inclusion criteria. Random effects meta-analyses on the 11 RCT samples (n = 618: MBIs n = 335, controls n = 283) showed that MBIs significantly reduced binge eating severity (g = −0.39, 95% CI -0.68, −0.11) at end of trial, but was not maintained at follow-up (g = −0.06, 95% CI, −0.31, 0.20, k = 5). No evidence of publication bias was detected. On the Cochrane Risk of Bias Tool 2, trials were rarely rated at high risk of bias and drop-out rates did not differ between MBIs and control groups. MBIs also significantly reduced depression, and improved both emotion regulation and mindfulness ability. Conclusion MBIs reduce binge eating severity at the end of trials. Benefits were not maintained at follow-up; however, only five studies were assessed. Future well-powered trials should focus on assessing diversity better, including more men and people from ethnic minority backgrounds.
Article
Objective: Hedonic hunger (i.e., the motivation to consume palatable foods in the absence of an energy deficit) has been associated with the onset and maintenance of loss of control (LOC) eating. However, it remains underexplored as a mechanism of action in outpatient cognitive behavioral therapy (CBT) for bulimia nervosa (BN). In the present study, we hypothesized that reductions in hedonic hunger would significantly mediate reductions in overall eating pathology and LOC episodes in two samples (N 1 = 28, N 2 = 23) of 20 and 16 sessions, respectively. Method: Participants completed the Eating Disorder Examination (EDE) and Power of Food Scale (PFS) at pre‐ and post‐treatment. Results: In both samples, EDE Global scores, LOC episodes, and PFS Total scores significantly improved over the course of treatment. In Sample 1, significant indirect effects of PFS Total scores on EDE Global scores and LOC episodes were observed. In Sample 2, the indirect effect of PFS Total scores was significant on EDE Global scores and nonsignificant on LOC episodes though it followed a similar pattern of change. Discussion: Results suggest that reductions in hedonic hunger are associated with better outcomes in CBT for BN. Replication and further research is needed to elucidate the treatment components driving these reductions.
Article
Objective: For those with binge-eating disorder (BED), access to evidence-based, face-to-face treatment is often constrained by clinician availability and high treatment costs. Emerging evidence suggests online therapy (eTherapy) may navigate these barriers and reduce binge-eating symptomatology; however, less evaluation has been done in those with BED, particularly with briefer programs targeting early change. This study investigated the feasibility and potential efficacy of a brief, supported eTherapy in those with BED or subthreshold BED. Method: Participants were 19 women with BED who completed a four-session eTherapy. This was a single-arm, pre-post intervention study, with participants completing weekly content and attending telehealth sessions. Key outcomes were assessed by the Eating Disorder Examination Questionnaire-Short (EDE-QS): objective binge episode days, loss of control over eating days, and eating disorder (ED) psychopathology via a total EDE-QS score. Results: Generalized and linear mixed models showed significantly reduced loss of control over eating days and ED psychopathology. Program feasibility was high, with strong program adherence and a below average attrition rate. Discussion: Pilot results support the feasibility and potential efficacy of a brief, behavioral-focused eTherapy program in reducing ED pathology in those with BED. Future research should further investigate findings in an adequately powered randomized controlled trial. Public significance: This study suggests that a brief, behavioral-focused online therapy, guided by non-expert clinicians, can be successfully administered to those with binge-eating disorder (BED) and may be efficacious at reducing eating disorder and other related symptomatology. Brief eTherapies that are effective, accessible, and rapidly available may facilitate earlier intervention in illness and improve treatment outcomes for individuals who experience this common and distressing disorder.
Article
Objective: The aim of this study was to determine whether posttraumatic stress disorder (PTSD) predicts non-completion of CBT-based day hospital treatment for bulimia nervosa (BN) and other specified feeding and eating disorder (OSFED). Method: Participants were 151 day hospital patients with BN or OSFED. Participants were assessed at pretreatment via interview and self-report measures. Cox regression was used to model the rate and timing of treatment termination; pretreatment binge and vomit frequencies, eating disorder-related clinical impairment, depression, and ED psychopathology were entered as covariates. Results: Participants who screened positive for PTSD (n = 64) had more severe ED psychopathology, ED-related impairment, negative schemas, and depression relative to those who did not screen positive. Cox regression indicated that PTSD significantly predicted premature termination and was associated with a 2.32 times greater risk. Individuals with BN or OSFED and co-occurring PTSD were particularly likely to terminate in the early phase of treatment compared with later in treatment. Conclusion: PTSD appears to affect some individuals' ability to complete intensive ED treatment. Future research should examine whether PTSD predicts premature termination from less intensive ED treatments, as well as in other intensive treatment settings, and whether PTSD predicts poorer outcomes from ED treatment.
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Background Second-generation antipsychotics are often used off-label in the treatment of anorexia nervosa (AN) across the clinical spectrum. Patients with anorexia nervosa often cite concerns about metabolic effects, such as weight gain, as reasons for their reluctance to start or continue second-generation antipsychotics. Improving our understanding of the metabolic effect patients experience and reasons underlying their disinclination will enable us to build rapport and guide our clinical decisions. We therefore aimed to conduct a comprehensive review of dropouts, metabolic effects, and patient-reported outcomes associated with second-generation antipsychotic in people with AN.MethodEMBASE, Medline, and PsycINFO were searched for all relevant studies published until 2019, and retrieved studies were assessed for eligibility as per predefined inclusion criteria. A random-effects meta-analysis was conducted to assess overall dropout rates.ResultsOf 983 citations retrieved, 21 studies met the inclusion criteria for the systematic review and 10 studies had appropriate data for meta-analysis. Using the random effects model, the pooled dropout rate in the intervention arm (95% confidence interval) from psychopharmacological trials was 28% (19 to 38%) in people with AN. Personal reasons or factors associated with study were commonest reason for dropout, not adverse events or metabolic effects as hypothesized.Conclusion Compared to personal reasons, drug-related factors such as side effects seem to play a lesser role for the discontinuation of antipsychotic treatment under trial conditions. This suggests an urgent need to consider and fully examine potential individual and patient-related factors that influence dropout rates in psychopharmacological trials and treatment compliance in clinical settings.
Article
Background: Interest in the use of yoga to enhance engagement with and augment the benefits of psychological treatment has grown. However, a systematic approach to reviewing existing research examining the use of yoga with psychological treatment is lacking. Materials and Methods: This mapping review identified and synthesised research trialling yoga as an integrated or adjunct therapy with evidence‐based psychological interventions for the treatment of anxiety, depression, PTSD, and eating disorders. Results: Overall, the review identified ten published and three unpublished studies, representing either single group or small quasi‐experimental research designs. Discussion: Limited but promising findings were shown for yoga with CBT for anxiety and depression, and the integration of yoga within intensive treatment models for PTSD. Conclusions: Future research is encouraged to focus on controlled trials that enable examination of the component effect of yoga when applied with evidence‐based psychological treatment and acceptability and feasibility data to further knowledge regarding a role for yoga in clinical practice. KEYWORDS: anxiety, complementary therapy, depression, eating disorders, evidence‐based psychological treatment, mapping review, posttraumatic stress disorder, yoga
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Background: Although binge eating disorder (BED) is the most common eating pathology and carries a high mental and physical burden, access to specialized treatment is limited due to patient-related barriers and insufficient healthcare resources. Integrating web-based self-help programs into clinical care for BED may address this treatment gap by making evidence-based eating disorder interventions more accessible. Methods: A two-armed randomized controlled trial will be conducted to evaluate the effectiveness of a web-based self-help intervention for BED in routine care settings. Patients aged 18–65 years fulfilling the diagnostic criteria for BED (N = 152) will be randomly allocated to (1) an intervention group receiving a 12-week web-based self- help program or (2) a waitlist control group with delayed access to the intervention. The primary outcome will be the number of binge eating episodes. Secondary outcomes include global eating pathology, functional impair- ments, work capacity, well-being, comorbid psychopathology, self-esteem, and emotion regulation abilities. Measurements will be conducted at baseline (study entrance), 6 weeks after baseline (mid-treatment), and 12 weeks after baseline (post-treatment). To capture outcomes and treatment mechanisms in real-time, traditional self-reports will be combined with weekly symptom monitoring and ecological momentary assessment. Discussion: Evaluating the effectiveness of web-based interventions is essential to overcome the treatment gap for patients with BED. When adequately integrated into standard care, these programs have the potential to alleviate the high burden of BED for individuals, their families, and society. Trial registration: https://clinicaltrials.gov/ct2/show/NCT04876183, Identifier: NCT04876183 (registered on May 6th, 2021).
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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.
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The current issue is the first of the eighth volume of the Athens Journal of Sports, published by the Sport, Exercise, & Kinesiology Unit of the ATINER under the aegis of the Panhellenic Association of Sports Economists and Managers (PASEM).
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Objective It is difficult for individuals with eating disorders (EDs) to build and maintain motivation to recover. This challenge contributes to high rates of treatment dropout and relapse. To date, motivational interventions have been largely ineffective, and there is little research on factors that affect recovery motivation. To better understand recovery motivation and identify potential intervention targets, this study examines factors that affect recovery motivation in individuals with EDs. Method N = 13 participants completed qualitative interviews. All had been recovered from their diagnosed and treated ED for at least 1 year. We applied thematic analysis to interview transcripts in order to identify factors that had influenced recovery motivation and to classify their effects as helpful, harmful, or mixed. Results Six main themes were identified, with subthemes detailed under each: (a) important people and groups (e.g., social circle, mentor), (b) actions and attitudes of others (e.g., judgmental responses, failure to intervene), (c) treatment‐related factors (e.g., therapeutic skills, therapeutic alliance), (d) influential circumstances (e.g., removing triggers, pregnancy/children), (e) personal feelings and beliefs (e.g., obligation to others, hope for the future), and (f) the role of epiphanies (i.e., sudden insights or moments of change). Discussion In this study, we identified potentially malleable factors that may affect ED recovery motivation (e.g., removing triggers, focusing on obligation to others, getting involved in meaningful causes, securing non‐judgmental support, building hope for the future). These factors may be investigated as potential targets or strategies in motivational interventions for EDs.
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Purpose of Review Despite decades of research, knowledge of the mechanisms maintaining anorexia nervosa (AN) remains incomplete and clearly effective treatments elusive. Novel theoretical frameworks are needed to advance mechanistic and treatment research for this disorder. Here, we argue the utility of engaging a novel lens that differs from existing perspectives in psychiatry. Specifically, we argue the necessity of expanding beyond two historically common perspectives: (1) the descriptive perspective: the tendency to define mechanisms on the basis of surface characteristics and (2) the deficit perspective: the tendency to search for mechanisms associated with under-functioning of decision-making abilities and related circuity, rather than problems of over-functioning, in psychiatric disorders. Recent Findings Computational psychiatry can provide a novel framework for understanding AN because this approach emphasizes the role of computational misalignments (rather than absolute deficits or excesses) between decision-making strategies and environmental demands as the key factors promoting psychiatric illnesses. Informed by this approach, we argue that AN can be understood as a disorder of excess goal pursuit, maintained by over-engagement, rather than disengagement, of executive functioning strategies and circuits. Emerging evidence suggests that this same computational imbalance may constitute an under-investigated phenotype presenting transdiagnostically across psychiatric disorders. Summary A variety of computational models can be used to further elucidate excess goal pursuit in AN. Most traditional psychiatric treatments do not target excess goal pursuit or associated neurocognitive mechanisms. Thus, targeting at the level of computational dysfunction may provide a new avenue for enhancing treatment for AN and related disorders.
Article
The main aim of this study was to evaluate changes in attention level in response to different physical activity strategies for patients with binge eating and investigates the most effective type of training. Binge eating symptomatology is linked to attention disorders (ADHD) and motor activity is a constituent tool for their treatment. The variability of attention was used to determine the effectiveness of the sport training treatment, the physical activity protocols have been adapted for the patients in relation to their general health and emotional state. The medical team of "Villa Guerrini-Galantara" has created an open group dedicated to physical activity. The subjects were 15 and 52± SD years old, they were sedentary and volunteer to study. Attention levels were assessed at each training session with cognitive tests adapted from "Trail Making Test" and "The d2 Test" and named "T0-T1-T2-T3", before the training session (T+EX) and after the training session (EX+T). The research lasted 18 months and on the basis of the results obtained, a statistically significant difference emerges in in attention level compared to hypothesis (0.003<0.05p) and between the different types of training, which concerns only the administration of the first motor work protocol (P1). The physical activity protocol P1 seems to be a promising tool for enhancing therapeutic interventions. Keywords: attention, eating disorders, physical activity
Article
The impact of homework completion on outcome from cognitive behavioral therapies (CBTs) for eating disorders (EDs) is unknown. We examined homework completion during two CBTs for bulimia-spectrum EDs and tested the associations among homework and treatment outcomes. After each session, therapists rated the quantity of self-monitoring completed (e.g. tracking food intake and ED symptoms), and degree of completion of the previous week’s written (e.g. completing a worksheet) and behavioral (e.g. completing an at-home food exposure, regularly eating) homework on a Likert scale. On average, patients (N = 42) completed 50–100% of self-monitoring homework, moderate completion of written homework, and below-moderate completion of behavioral homework. Average behavioral homework completion, but not self- monitoring or written homework, was related to end-of-treatment symptom cessation. Improving homework completion might enhance the efficacy of CBTs for EDs.
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Objective: Binge-eating disorder (BED) is characterized by recurrent episodes of binge eating, accompanied by a lack of control and feelings of shame. Online intervention is a promising, accessible treatment approach for BED. In the current study, we compared completers with noncompleters in a 10-session guided internet-based treatment program (iBED) based on cognitive behavioral therapy. Methods: Adults (N = 75) with mild to moderate BED participated in iBED with weekly written support from psychologists. Participants were compared on the Eating Disorder Examination Questionnaire (EDE-Q), diagnostic criteria for BED (BED-Q), major depression inventory (MDI), quality of life (EQ-5D-5L), body mass index (BMI) and sociodemographic variables. Results: Minor differences were observed between completers and noncompleters on depression. No differences were found in BED-symptoms, BMI, and sociodemographic variables. Participants who completed treatment showed large reductions in eating disorder pathology. Discussion: More research is needed to determine risk factors for attrition or treatment outcome in internet-based interventions for BED. It is suggested that iBED is an efficient intervention for BED. However, more studies of internet-interventions are needed.
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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.
Article
Although treatment dropout is common among patients with eating disorders, very few studies have examined predictors of non-completion in day treatment. We investigated various potential predictors of dropout from adult day treatment. Participants were 295 adult patients with a diagnosis of Anorexia Nervosa (restricting or binge-eating/purging subtype), Bulimia Nervosa (BN), Other Specified Feeding or Eating Disorder, or Avoidant Restrictive Food Intake Disorder. Predictors included eating-disorder characteristics, motivation at the commencement of treatment, Body Mass Index (BMI), time spent in treatment and personality dimensions. Logistic regression analyses showed that for patients with a BMI of less than 20 at the start of treatment, low BMI was a significant predictor of staff-initiated termination due to not meeting weight gain goals. Furthermore, completing less than 6 weeks of treatment was associated with staff-initiated termination. For the whole sample, those with higher changes in weight over the course of treatment were less likely to terminate prematurely. None of the other predictor variables yielded significant results. Results of the current study highlight characteristics of patients who are more likely not to complete day treatment and can help identify patients who may be at risk for not succeeding in multi-diagnostic day treatment programs.
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Purpose A common challenge among a subgroup of individuals with obesity is binge eating, that exists on a continuum from mild binge eating episodes to severe binge eating disorder (BED). BED is common among bariatric patients and the prevalence of disordered eating and ED in bariatric surgery populations is well known. Conventional treatments and assessment of obesity seldom address the underlying psychological mechanisms of binge eating and subsequent obesity. This study, titled PnP (People need People) is a psychoeducational group pilot intervention for individuals with BED and obesity including patients with previous bariatric surgery. Design, feasibility, and a broad description of the study population is reported. Material and Methods A total of 42 patients were from an obesity clinic referred to assessment and treatment with PnP in a psychoeducational group setting (3-hour weekly meetings for 10 weeks). Of these, 6 (14.3%) patients had a previous history of bariatric surgery. Feasibility was assessed by tracking attendance, potentially adverse effects and outcome measures including body mass index (BMI), eating disorder pathology, overvaluation of shape and weight, impairment, self-reported childhood difficulties, alexithymia, internalized shame as well as health related quality of life (HRQoL). Results All 42 patients completed the intervention, with no adverse effects and a high attendance rate with a median attendance of 10 sessions, 95% CI (8.9,9.6) and 0% attrition. Extent of psychosocial impairment due to eating disorder pathology, body dissatisfaction and severity of ED symptoms were high among the patients at baseline. Additionally, self-reported childhood difficulties, alexithymia, and internalized shame were high among the patients and indicate a need to address underlying psychological mechanisms in individuals with BED and comorbid obesity. Improvement of HRQoL and reduction of binge eating between baseline and the end of the intervention was observed with a medium effect Conclusion This feasibility study supports PnP as a potential group psychoeducational intervention for patients living with BED and comorbid obesity. Assessments of BED and delivery of this intervention may optimize selection of candidates and bariatric outcomes. These preliminary results warrant further investigation via a randomized control trial (RCT) to examine the efficacy and effectiveness of PnP.
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: To examine the frequency of evidence-based treatment elements in popular smartphone apps for eating disorders (EDs), and to characterize the extent to which real-world users encounter different elements. Method: We searched the Apple App Store and Google Play Store for apps offering treatment or support to individuals with EDs. Then, we created a codebook of 47 elements found in evidence-based treatments for EDs. We examined the presence or absence of each element within each ED app. We also acquired estimates of the monthly active users (MAU) of each app. Results: The ED apps (n = 28) included a median of nine elements of empirically supported treatments (mean = 9.46, SD = 6.28). Four apps accounted for 96% of all MAU. MAU-adjusted analyses revealed that several elements are reaching more users than raw frequency tallies would suggest. For example, assessments were included in 32% of apps, but 84% of users used an app with assessments. Similar trends were found for cognitive restructuring (21% of apps, 56% of MAU), activity scheduling (39%, 57%), and self-monitoring (14%, 46%). Problem solving, exposure, and relapse prevention strategies, elements that are prominent in face-to-face empirically supported treatments, were rarely included in the apps. Discussion: Evidence-based content is commonly included in ED apps, with certain elements reaching more users than others. Additionally, the top four apps are responsible for nearly all active users. We recommend that ED clinicians and researchers familiarize themselves with these apps-those that patients are most likely to encounter.
Article
L'articolo presenta i percorsi alternati, una strategia terapeutica sistemica per le anoressie e bulimie adolescenziali ideata da Ugazio (2010; 2013; 2019). Si tratta di un percorso terapeutico pianificato, articolato in quattro fasi, che alternano format familiari a sedute individuali con la paziente. Questo approccio si fonda sulla teoria delle polarità semantiche familiari (Ugazio, 1998; 2012; 2018), secondo cui nella conversazione di e con queste famiglie prevale la semantica del potere. Attraverso la discussione di un caso clinico mostriamo come questa strategia aiuti a superare i dilemmi, legati alle dinamiche di potere, così caratteristici delle psicoterapie con i disturbi alimentari e massimizzi l'alleanza terapeutica con la famiglia e soprattutto con la paziente.
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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.
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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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Background Many patients with eating disorders do not receive help for their symptoms, even though these disorders have severe morbidity. The Internet may offer alternative low-threshold treatment interventions. Objective This study evaluated the effects of a Web-based cognitive behavioral therapy (CBT) intervention using intensive asynchronous therapeutic support to improve eating disorder psychopathology, and to reduce body dissatisfaction and related health problems among patients with eating disorders. MethodsA two-arm open randomized controlled trial comparing a Web-based CBT intervention to a waiting list control condition (WL) was carried out among female patients with bulimia nervosa (BN), binge eating disorder (BED), and eating disorders not otherwise specified (EDNOS). The eating disorder diagnosis was in accordance with the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, and was established based on participants’ self-report. Participants were recruited from an open-access website, and the intervention consisted of a structured two-part program within a secure Web-based application. The aim of the first part was to analyze participant’s eating attitudes and behaviors, while the second part focused on behavioral change. Participants had asynchronous contact with a personal therapist twice a week, solely via the Internet. Self-report measures of eating disorder psychopathology (primary outcome), body dissatisfaction, physical health, mental health, self-esteem, quality of life, and social functioning were completed at baseline and posttest. ResultsA total of 214 participants were randomized to either the Web-based CBT group (n=108) or to the WL group (n=106) stratified by type of eating disorder (BN: n=44; BED: n=85; EDNOS: n=85). Study attrition was low with 94% of the participants completing the posttest assignment. Overall, Web-based CBT showed a significant improvement over time for eating disorder psychopathology (F97=63.07, P
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Previous reviews of premature termination have yet to examine whether disparate psychotherapy treatments differ in their dropout rates for specific disorders. Using data from 587 studies, a series of meta-analyses were conducted comparing dropout rates between treatment approaches for 12 separate disorder categories. Although, significant differences between treatment approaches were found for depression [Q(9) = 22.69, p <.01], eating disorders [Q(7) = 14.63, p <.05], and posttraumatic stress disorder (PTSD) [Q(7) = 20.20, p <.01], treatments did not differ in their dropout rates for the remaining 9 diagnostic categories. Although integrative treatments resulted in the lowest dropout rates for depression and PTSD, dialectical-behavior therapy resulted in the lowest average dropout rate for eating disorders. The similarity in dropout rates for the majority of the disorder categories suggests that clients' decisions to drop out may depend more on other therapy variables (e.g., common factors, client characteristics, and therapist characteristics) rather than the specific type of treatment that is used. Additionally, our findings highlight the particular usefulness of an integrationist approach to therapy-it showed to be the most robust model for retaining clients in that its dropout rate was equal to or better than all of the other therapy approaches for 11 out of the 12 disorders examined.
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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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Intention-to-treat (ITT) analysis requires all randomised individuals to be included in the analysis in the groups to which they were randomised. However, there is confusion about how ITT analysis should be performed in the presence of missing outcome data. To explain, justify, and illustrate an ITT analysis strategy for randomised trials with incomplete outcome data. We consider several methods of analysis and compare their underlying assumptions, plausibility, and numbers of individuals included. We illustrate the ITT analysis strategy using data from the UK700 trial in the management of severe mental illness. Depending on the assumptions made about the missing data, some methods of analysis that include all randomised individuals may be less valid than methods that do not include all randomised individuals. Furthermore, some methods of analysis that include all randomised individuals are essentially equivalent to methods that do not include all randomised individuals. This work assumes that the aim of analysis is to obtain an accurate estimate of the difference in outcome between randomised groups and not to obtain a conservative estimate with bias against the experimental intervention. Clinical trials should employ an ITT analysis strategy, comprising a design that attempts to follow up all randomised individuals, a main analysis that is valid under a stated plausible assumption about the missing data, and sensitivity analyses that include all randomised individuals in order to explore the impact of departures from the assumption underlying the main analysis. Following this strategy recognises the extra uncertainty arising from missing outcomes and increases the incentive for researchers to minimise the extent of missing data.
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Premature discontinuation from therapy is a widespread problem that impedes the delivery of otherwise effective psychological interventions. The most recent comprehensive review found an average dropout rate of 47% across 125 studies (Wierzbicki & Pekarik, 1993); however, given a number of changes in the field over the past 2 decades, an updated meta-analysis is needed to examine the current phenomenon of therapy dropout. A series of meta-analyses and meta-regressions were conducted in order to identify the rate at which treatment dropout occurs and predictors of its occurrence. This review included 669 studies representing 83,834 clients. Averaging across studies using a random effects model, the weighted dropout rate was 19.7%, 95% CI [18.7%, 20.7%]. Further analyses, also using random effects models, indicated that the overall dropout rate was moderated by client diagnosis and age, provider experience level, setting for the intervention, definition of dropout, type of study (efficacy vs. effectiveness), and other design variables. Dropout was not moderated by orientation of therapy, whether treatment was provided in an individual or group format, and a number of client demographic variables. Although premature discontinuation is occurring at a lower rate than what was estimated 20 years ago (Wierzbicki & Pekarik, 1993), it is still a significant problem, with about 1 in every 5 clients dropping out of therapy. Special efforts should be made to decrease premature discontinuation, particularly with clients who are younger, have a personality or eating disorder diagnosis, and are seen by trainee clinicians.
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The aim of this study was to replicate and extend results of a previous blended efficacy and effectiveness trial of a low-intensity, manual-based guided self-help form of cognitive-behavioral therapy (CBT-GSH) for the treatment of binge eating disorders in a large health maintenance organization (HMO) and to compare them with usual care. To extend previous findings, the investigators modified earlier recruitment and assessment approaches and conducted a randomized clinical trial to better reflect procedures that may be reasonably carried out in real-world practices. The intervention was delivered by master's-level interventionists to 160 female members of a health maintenance organization who met diagnostic criteria for recurrent binge eating. Data collected at baseline, immediately posttreatment, and at six- and 12-month follow-ups were used in intent-to-treat analyses. At the 12-month follow-up, CBT-GSH resulted in greater remission from binge eating (35%, N=26) than usual care (14%, N=10) (number needed to treat=5). The CBT-GSH group also demonstrated greater improvements in dietary restraint (d=.71) and eating, shape, and weight concerns (d=1.10, 1.24, and .98, respectively) but not weight change. Replication of the pattern of previous findings suggests that CBT-GSH is a robust treatment for patients with recurrent binge eating. The magnitude of changes was significantly smaller than in the original study, however, suggesting that patients recruited and assessed with less intensive procedures may respond differently from their counterparts enrolled in trials requiring more comprehensive procedures.
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This meta-analytic review of 11 studies examined the relationship between psychotherapy dropout and therapeutic alliance in adult individual psychotherapy. Results of the meta-analysis demonstrate a moderately strong relationship between psychotherapy dropout and therapeutic alliance (d = .55). Findings indicate that clients with weaker therapeutic alliance are more likely to drop out of psychotherapy. The meta-analysis included a total of 1,301 participants, with an average of 118 participants per study, a standard deviation of 115 participants, and a range from 20 to 451 participants per study. Exploratory analyses were conducted to determine the influence of variables moderating the relationship between alliance and dropout. Client educational history, treatment length, and treatment setting were found to moderate the relationship between alliance and dropout. Studies with a larger percentage of clients who completed high school or higher demonstrated weaker relationships between alliance and dropout. Studies with lengthier treatments demonstrated stronger relationships between alliance and dropout. Inpatient settings demonstrated significantly larger effects than both counseling centers and research clinics. No significant differences were found between client-rated, therapist-rated, and observer/staff-rated alliance. Recommendations for clinicians and researchers are discussed.
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Despite proven efficacy of cognitive behavioral therapy (CBT) for treating eating disorders with binge eating as the core symptom, few patients receive CBT in clinical practice. Our blended efficacy-effectiveness study sought to evaluate whether a manual-based guided self-help form of CBT (CBT-GSH), delivered in 8 sessions in a health maintenance organization setting over a 12-week period by master's-level interventionists, is more effective than treatment as usual (TAU). In all, 123 individuals (mean age = 37.2; 91.9% female, 96.7% non-Hispanic White) were randomized, including 10.6% with bulimia nervosa (BN), 48% with binge eating disorder (BED), and 41.4% with recurrent binge eating in the absence of BN or BED. Baseline, posttreatment, and 6- and 12-month follow-up data were used in intent-to-treat analyses. At 12-month follow-up, CBT-GSH resulted in greater abstinence from binge eating (64.2%) than TAU (44.6%; number needed to treat = 5), as measured by the Eating Disorder Examination (EDE). Secondary outcomes reflected greater improvements in the CBT-GSH group in dietary restraint (d = 0.30); eating, shape, and weight concern (ds = 0.54, 1.01, 0.49, respectively; measured by the EDE Questionnaire); depression (d = 0.56; Beck Depression Inventory); and social adjustment (d = 0.58; Work and Social Adjustment Scale), but not weight change. CBT-GSH is a viable first-line treatment option for the majority of patients with recurrent binge eating who do not meet diagnostic criteria for BN or anorexia nervosa.
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Dropout (DO) is common in the treatment of eating disorders (EDs), but the reasons for this phenomenon remain unclear. This study is an extensive review of the literature regarding DO predictors in EDs. All papers in PubMed, PsycINFO and Cochrane Library (1980-2009) were considered. Methodological issues and detailed results were analysed for each paper. After selection according to inclusion criteria, 26 studies were reviewed. The dropout rates ranged from 20.2% to 51% (inpatient) and from 29% to 73% (outpatient). Predictors of dropout were inconsistent due to methodological flaws and limited sample sizes. There is no evidence that baseline ED clinical severity, psychiatric comorbidity or treatment issues affect dropout. The most consistent predictor is the binge-purging subtype of anorexia nervosa. Good evidence exists that two psychological traits (high maturity fear and impulsivity) and two personality dimensions (low self-directedness, low cooperativeness) are related to dropout. Implications for clinical practice and areas for further research are discussed. Particularly, these results highlight the need for a shared definition of dropout in the treatment of eating disorders for both inpatient and outpatient settings. Moreover, the assessment of personality dimensions (impulse control, self-efficacy, maturity fear and others) as liability factors for dropout seems an important issue for creating specific strategies to reduce the dropout phenomenon in eating disorders.
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Although the subject has been debated and examined for more than 3 decades, it is still not clear whether all psychotherapies are equally efficacious. The authors conducted 7 meta-analyses (with a total of 53 studies) in which 7 major types of psychological treatment for mild to moderate adult depression (cognitive-behavior therapy, nondirective supportive treatment, behavioral activation treatment, psychodynamic treatment, problem-solving therapy, interpersonal psychotherapy, and social skills training) were directly compared with other psychological treatments. Each major type of treatment had been examined in at least 5 randomized comparative trials. There was no indication that 1 of the treatments was more or less efficacious, with the exception of interpersonal psychotherapy (which was somewhat more efficacious; d = 0.20) and nondirective supportive treatment (which was somewhat less efficacious than the other treatments; d = -0.13). The drop-out rate was significantly higher in cognitive-behavior therapy than in the other therapies, whereas it was significantly lower in problem-solving therapy. This study suggests that there are no large differences in efficacy between the major psychotherapies for mild to moderate depression.
Article
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.
Article
The original and enhanced cognitive model of eating disorders proposes that cognitive-behavioral therapy (CBT) “works” through modifying dietary restraint and dysfunctional attitudes towards shape and weight. However, evidence supporting the validity of this cognitive model is limited. This meta-analysis examined whether CBT can indeed effectively modify these proposed maintaining mechanisms. Randomized controlled trials that compared CBT to control conditions or non-CBT interventions, and reported outcomes on dietary restraint and shape and weight concerns were searched. Twenty-nine trials were included. CBT was superior to control conditions in reducing shape (g=0.53) and weight (g=0.63) concerns, and dietary restraint (g=0.36). These effects occurred across all eating disorder presentations and treatment formats. Improvements in shape and weight concerns and restraint were also greater in CBT than non-CBT interventions (g’s=0.25, 0.24, 0.31, respectively) at post-treatment and follow-up. The magnitude of improvement in binge/purge symptoms was related to the magnitude of improvement in these maintaining mechanisms. Findings demonstrate that CBT has a specific effect in targeting the eating disorder maintaining mechanisms, and offers support to the underlying cognitive model. If changes in these variables during the course of treatment are shown to be causal mechanisms, then these findings show that CBT, relative to non-CBT interventions, is better able to modify these mechanisms.
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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
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Objective: Rapid and substantial behavior change (RSBC) early in cognitive behavior therapy (CBT) for eating disorders is the strongest known predictor of treatment outcome. Rapid change in other clinically relevant variables may also be important. This study examined whether rapid change in emotion regulation predicted treatment outcomes, beyond the effects of RSBC. Method: Participants were diagnosed with bulimia nervosa or purging disorder (N = 104) and completed ≥6 weeks of CBT-based intensive treatment. Hierarchical regression models were used to test whether rapid change in emotion regulation variables predicted posttreatment outcomes, defined in three ways: (1) binge/purge abstinence; (2) cognitive eating disorder psychopathology; and (3) depression symptoms. Baseline psychopathology and emotion regulation difficulties and RSBC were controlled for. Results: After controlling for baseline variables and RSBC, rapid improvement in access to emotion regulation strategies made significant unique contributions to the prediction of posttreatment binge/purge abstinence, cognitive psychopathology of eating disorders, and depression symptoms. Discussion: Individuals with eating disorders who rapidly improve their belief that they can effectively modulate negative emotions are more likely to achieve a variety of good treatment outcomes. This supports the formal inclusion of emotion regulation skills early in CBT, and encouraging patient beliefs that these strategies are helpful.
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
Objective: Rapid response to cognitive behavior therapy (CBT) for eating disorders (i.e., rapid and substantial change to key eating disorder behaviors in the initial weeks of treatment) robustly predicts good outcome at end-of-treatment and in follow up. The objective of this study was to determine whether rapid response to day hospital (DH) eating disorder treatment could be facilitated using a brief adjunctive CBT intervention focused on early change. Method: 44 women (average age 27.3 [8.4]; 75% White, 6.3% Black, 6.9% Asian) were randomly assigned to 1 of 2 4-session adjunctive interventions: CBT focused on early change, or motivational interviewing (MI). DH was administered as usual. Outcomes included binge/purge frequency, Eating Disorder Examination-Questionnaire and Difficulties in Emotion Regulation Scale. Intent-to-treat analyses were used. Results: The CBT group had a higher rate of rapid response (95.7%) compared to MI (71.4%; p = .04, V = .33). Those who received CBT also had fewer binge/purge episodes (p = .02) in the first 4 weeks of DH. By end-of-DH, CBT participants made greater improvements on overvaluation of weight and shape (p = .008), and emotion regulation (ps < .008). Across conditions, there were no significant baseline differences between rapid and nonrapid responders (ps > .05). Conclusions: The results of this study demonstrate that rapid response can be clinically facilitated using a CBT intervention that explicitly encourages early change. This provides the foundation for future research investigating whether enhancing rates of rapid response using such an intervention results in improved longer term outcomes. (PsycINFO Database Record
Article
Background: Evidence-based self-help is a recommended first stage of treatment for mild-moderate eating disorders. The provision of guidance enhances outcome. The literature evaluating exclusively 'guided' self-help (GSH) has not been systematically reviewed. Methods: The aim was to establish the effectiveness of GSH for reducing global eating disorder psychopathology and abstinence from binge eating, compared with controls. Results were pooled using random effects meta-analysis and heterogeneity explored using metaregression. Results: Thirty randomised controlled trials met the inclusion criteria. Results showed an overall effect of GSH on global eating disorder psychopathology (-0.46) and binge abstinence (-0.20). There was strong evidence for an association between diagnosis of binge eating disorder and binge abstinence. Discussion: Current interventions need to be adapted to address features other than binge eating. Further research is required to help us understand the effectiveness of GSH in children and young people, invariably high dropout rates and how technology can enhance interventions. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.
Article
Objective The authors compared cognitive-behavioral therapy (CBT) and psychodynamic therapy (PDT) for the treatment of bulimia nervosa (BN) in female adolescents. Method In this randomized controlled trial, 81 female adolescents with BN or partial BN according to the DSM-IV received a mean of 36.6 sessions of manualized disorder−oriented PDT or CBT. Trained psychologists blinded to treatment condition administered the outcome measures at baseline, during treatment, at the end of treatment, and 12 months after treatment. The primary outcome was the rate of remission, defined as a lack of DSM-IV diagnosis for BN or partial BN at the end of therapy. Several secondary outcome measures were evaluated. Results The remission rates for CBT and PDT were 33.3% and 31.0%, respectively, with no significant differences between them (odds ratio [OR] = 0.90, 95% CI = 0.35−2.28, p = .82). The within-group effect sizes were h = 1.22 for CBT and h = 1.18 for PDT. Significant improvements in all secondary outcome measures were found for both CBT (d = 0.51−0.82) and PDT (d = 0.24−1.10). The improvements remained stable at the 12-month follow-up in both groups. There were small between-group effect sizes for binge eating (d = 0.23) and purging (d = 0.26) in favor of CBT and for eating concern (d = −0.35) in favor of PDT. Conclusion CBT and PDT were effective in promoting recovery from BN in female adolescents. The rates of remission for both therapies were similar to those in other studies evaluating CBT. This trial identified differences with small effects in binge eating, purging, and eating concern. Clinical trial registration information—Treating Bulimia Nervosa in Female Adolescents With Either Cognitive-Behavioral Therapy (CBT) or Psychodynamic Therapy (PDT). http://isrctn.com/; ISRCTN14806095.
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This systematic review synthesised the literature on predictors, moderators, and mediators of outcome following Fairburn's CBT for eating disorders. Sixty-five articles were included. The relationship between individual variables and outcome was synthesised separately across diagnoses and treatment format. Early change was found to be a consistent mediator of better outcomes across all eating disorders. Moderators were mostly tested in binge eating disorder, and most moderators did not affect cognitive-behavioural treatment outcome relative to other treatments. No consistent predictors emerged. Findings suggest that it is unclear how and for whom this treatment works. More research testing mediators and moderators is needed, and variables selected for analyses need to be empirically and theoretically driven. Future recommendations include the need for authors to (i) interpret the clinical and statistical significance of findings; (ii) use a consistent definition of outcome so that studies can be directly compared; and (iii) report null and statistically significant findings.
Article
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.