ArticleLiterature Review

Efficacy of psychotherapy for bulimia nervosa and binge-eating disorder on self-esteem improvement: Meta-analysis

Authors:
Article

Efficacy of psychotherapy for bulimia nervosa and binge-eating disorder on self-esteem improvement: Meta-analysis

If you want to read the PDF, try requesting it from the authors.

Abstract

Objectives This meta‐analysis examined the effects of psychotherapy for bulimia nervosa (BN) and binge‐eating disorder (BED) on self‐esteem improvement. Method Randomized controlled trials (RCTs) of psychological treatments that assessed self‐esteem change in eating disorders were included. Thirty‐four RCTs were included; most sampled BED and then BN. Hedge's g effects were entered into random effects models. Results Psychotherapy for BN led to significantly greater post‐treatment improvements in self‐esteem than control conditions (g = 0.45; 95% CI [0.17, 0.73]). This effect was smaller when only analysing low risk of bias trials (g = 0.28; 95% CI [0.05, 0.51]). Psychotherapy for BED also led to significantly greater post‐treatment improvements in self‐esteem than controls (g = 0.20; 95% CI [0.05, 0.35]), with some evidence that guided self‐help was associated with the largest effects. This effect, however, was overestimated after adjustment for publication bias (g = 0.10; 95% CI [−0.05, 0.26]). There was no evidence that cognitive‐behavioural therapy was superior to non‐cognitive‐behavioural therapy interventions in improving self‐esteem. There was no relationship between symptom improvement and self‐esteem improvement in a meta‐regression. Conclusions Psychotherapy may lead to small improvements in self‐esteem in BN and BED. Additional RCTs with follow‐up assessments are required to make more definitive conclusions about the effects of psychotherapy for eating disorders on self‐esteem in the long‐term.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... Thus, we aim at gaining a better understanding of how and why web-based interventions can reduce eating disorder symptoms by investigating possible mechanisms of change. Theoretical models, such as the transdiagnostic theory of eating disorders, and empirical findings stress the importance of psychopathological processes in the development and maintenance of eating disorders (Fairburn et al., 2003;Linardon et al., 2019;MacDonald and Trottier, 2019;Svaldi et al., 2019). Therefore, we will test selfesteem, emotion regulation, and comorbid psychopathology as possible mechanisms of change to address this research gap and help to improve internet-based interventions in the future. ...
... Considering changes in the quality of life, we will further expect a reduction in psychosocial impairments, a higher increase in well-being, and better restoration of work capacity (Agh et al., 2016). Finally, to better understand possible mechanisms of change, we will explore whether the web-based intervention for BN will lead to a greater decline in comorbid psychopathology and more substantial improvements in global self-esteem as well as the ability to regulate emotions after the treatment (Fairburn et al., 2003;Linardon et al., 2019;Mac-Donald and Trottier, 2019;Svaldi et al., 2019). ...
... • Changes in self-esteem: Self-esteem improvements will be analyzed as essential treatment target in patients with eating disorders (Linardon et al., 2019). For this purpose, the Rosenberg Self-Esteem Scale will be used (RSES; Roth et al., 2008), consisting of 10 items answered on a 4-point scale and showing good internal consistency (α = .88; ...
Article
Full-text available
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).
... The overarching goal of our trial is to evaluate the 12-week webbased self-help intervention Selfapy for BED, which employs CBT methods targeting binge eating pathology directly (Munsch, 2003;Munsch, 2007), as well as processes associated with the maintenance of BED, such as emotion regulation, stress management, and self-esteem (Dingemans et al., 2017;Linardon et al., 2019;Sipos and Schweiger, 2016). The intervention can be used via desktop browsers and mobile devices and has been established alongside a program targeting the treatment of bulimia nervosa in routine care settings (for details, see Hartmann et al., 2022). ...
... Moreover, we assume that there will be a higher decline in global eating disorder symptoms and functional impairments as well as a higher increase in well-being and work capacity in the intervention group compared to the waitlist control group (Ágh et al., 2015;Jenkins et al., 2021;Safi et al., 2022). Finally, we expect that the web-based intervention for BED will be associated with a significantly higher reduction in comorbid psychopathology, increased self-esteem, and an improved ability to regulate negative emotions after treatment (Dingemans et al., 2017;Linardon et al., 2019;Prefit et al., 2019). ...
... • Changes in self-esteem: Possible improvements in self-esteem will be assessed as a core treatment target of eating disorders (Linardon et al., 2019). To address this goal, the Rosenberg Self-Esteem Scale will be used (RSES; Roth et al., 2008), consisting of 10 items answered on a 4-point scale with an internal consistency of Cronbach's α = .88 ...
Article
Full-text available
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).
... These data not only speak to prediction of concurrent EDP but may also have implications for prevention. Third-wave interventions, which emphasize reduction and replacement of avoidance behaviors, are gaining increased support for EDP prevention (Linardon et al., 2019). These data suggest that EDP prevention efforts should target both specific forms body image avoidance along with specific functions of body image avoidance. ...
... College students are at considerably higher risk for EDP than the general population (e.g., Fitzsimmons-Craft et al., 2016;Woodhall et al., 2015. Data on EDP prevention are promising, with recent attention directed increasingly toward third-wave interventions that seek to reduce and replace body image avoidance (e.g., Linardon et al., 2019;Timko et al., 2014). Despite its limitations, the current study contributes to the growing literature on EDP prevention in college students, suggesting that both form and function may be important when conceptualizing, assessing, and intervening on body image avoidance. ...
Article
Models of eating disorder development point to the significant role body image avoidance plays in the development and perpetuation of eating disorder pathology (EDP), highlighting the importance of continued conceptual development. For example, approaches to assessing and conceptualizing body image avoidance vary in the extent to which they emphasize topography (i.e., common forms of avoidance), or their function (i.e., the conditions under which they occur). This study considered four body image avoidance constructs and their relative incremental contribution to predicting concurrent EDP in a college student population (N = 1228). Participants self-reported both the form and function of body image avoidance, including specific behaviors, appearance fixing and avoidant coping, and body image flexibility. A measure of the form of body image avoidance emerged as the best predictor of EDP, both in terms of consistently predicting aspects of disordered eating and in terms of accounting for the largest proportions of unique variance. Body image flexibility also contributed significantly to the prediction of cognitive and emotional aspects of concurrent EDP above and beyond self-report of common forms of avoidance only. Both form and function may be important when assessing and intervening on body image avoidance to prevent EDP.
... The search flow is reported in Fig. 1. Out of 884 articles, 55 MAs and 4 NMAs were included (Albano et al., 2019;Bacaltchuk et al., 1999;Josue Josué Bacaltchuk et al., 2000;Josue Bacaltchuk et al., 2000;Josué Josue Bacaltchuk et al., 2000;Josué Bacaltchuk et al., 2000;Bacaltchuk and Hay, 2003;Barakat et al., 2019;Berkman et al., 2015;Brownley et al., 2016;Cassioli et al., 2020;Claudino et al., 2006;Couturier et al., 2013;Cuijpers et al., 2016;de Vos et al., 2014;Dold et al., 2015;Fisher et al., 2018Fisher et al., , 2010Fornaro et al., 2016;Ghaderi et al., 2018;Ghaderi and Andersson, 1999;Grenon et al., 2018a;Hagan et al., 2020;Hasselbalch et al., 2020;Hay et al., 2019Hay et al., , 2015Hay et al., , 2004Hay et al., , 2001Hay et al., , 2009Hilbert et al., 2019;Kishi et al., 2012;Lebow et al., 2013;Linardon, 2018b;Linardon et al., 2020Linardon et al., , 2019Linardon et al., , 2017aLinardon et al., , 2017bLinardon et al., , 2017cLoucas et al., 2014;Low et al., 2021;Machado and Ferreira, 2014;Murray et al., 2019;Nakash-Eisikovits et al., 2002;Ng et al., 2013;Nourredine et al., 2020;Palavras et al., 2017;Peat et al., 2017;Perkins et al., 2006;Polnay et al., 2014;Reas and Grilo, 2008;Eric Slade et al., 2018;Stefano et al., 2008Stefano et al., , 2006Svaldi et al., 2019;Swift et al., 2017;Thompson-Brenner et al., 2003;Traviss-Turner et al., 2017;van den Berg et al., 2019;Vocks et al., 2010;Zeeck et al., 2018). Publications excluded after full-text assessment, with reason for exclusion are available in supplementary reported on inpatients, and in AN only; eight (13.6%) reported on outpatients; and the others on any or unspecified settings. ...
Article
Full-text available
MONTELEONE, A.M., F. Pellegrino, G. Croatto, M. Carfagno, A. Hilbert, J. Treasure, T. Wade, C. Bulik, S. Zipfel, P. Hay, U. Schmidt, G. Castellini, A. Favaro, F. Fernandez-Aranda, J. Il Shin, U. Voderholzer, V. Ricca, D. Moretti, D. Busatta, G. Abbate-Daga, F. Ciullini, G. Cascino, F. Monaco, C.U. Correll and M. Solmi. Treatment of Eating Disorders: a systematic meta-review of meta-analyses and network meta-analyses. NEUROSCI BIOBEHAV REV 21(1) XXX-XXX, 2022.- Treatment efficacy for eating disorders (EDs) is modest and guidelines differ. We summarized findings/quality of (network) meta-analyses (N)MA of randomized controlled trials (RCTs) in EDs. Systematic meta-review ((N)MA of RCTs, ED, active/inactive control), using (anorexia or bulimia or eating disorder) AND (meta-analy*) in PubMed/PsycINFO/Cochrane database up to December 15th, 2020. Standardized mean difference, odds/risk ratio vs control were summarized at end of treatment and follow-up. Interventions involving family (family-based therapy, FBT) outperformed active control in adults/adolescents with anorexia nervosa (AN), and in adolescents with bulimia nervosa (BN). In adults with BN, individual cognitive behavioural therapy (CBT)-ED had the broadest efficacy versus active control; also, antidepressants outperformed active. In mixed age groups with binge-eating disorder (BED), psychotherapy, and lisdexamfetamine outperformed active control. Antidepressants, stimulants outperformed placebo, despite lower acceptability, as did CBT-ED versus waitlist/no treatment. Family-based therapy is effective in AN and BN (adolescents). CBT-ED has the largest efficacy in BN (adults), followed by antidepressants, as well as psychotherapy in BED (mixed). Medications have short-term efficacy in BED (adults).
... Los trastornos de la conducta alimentaria (tca) se ubican entre las enfermedades mentales de mayor importancia en la población de niños y adolescentes, debido al riesgo para la salud física y mental que representan y al efecto negativo que tienen sobre la calidad de vida de estos (Bautista & Serra, 2015;Bryant-Waugh, 2019;Buelow, 2020;Drieberg et al., 2019;Guarín et al., 2013;Linardon et al., 2019;Ochoa et al., 2013;oms, 2018;Pérez et al., 2018;Solís et al., 2019;Williams-Kerver & Crowther, 2020). ...
Article
Full-text available
El deseo de cumplir estándares modernos estéticos corporales no alcanzables afecta la salud mental, debido a que las personas internalizan los ideales de belleza y aceptan las presiones sociales acerca de la apariencia corporal incluso por encima de su bienestar. El objetivo del presente estudio instrumental fue evaluar las propiedades psicométricas del Cuestionario de actitudes socioculturales sobre la apariencia (SATAQ-4) en población colombiana, para lo cual se utilizó una muestra estratificada no aleatorizada conformada por 214 personas -138 mujeres y 76 hombres-, con un promedio de edad de 25.13 años (DE = 7.66). Se retomó la versión en español del instrumento validado en Argentina, que fue evaluada por jueces expertos para realizar la adaptación lingüística y que se aplicó a una muestra piloto antes de la aplicación definitiva, hecha bajo las normas éticas exigidas. Se realizó el análisis de las condiciones psicométricas desde la teoría de respuesta al ítem, mediante el modelo Rasch, y por medio del software WINSTEPS. Los resultados indican que la versión en español cumple las condiciones psicométricas adecuadas en las cinco dimensiones que componen el instrumento (.72-.94); y que el grado de dificultad y de habilidad alcanzan valores de ajuste apropiados, lo que indica que el cuestionario cuenta con adecuadas condiciones psicométricas y mantiene su estructura interna original. En conclusión, la versión final de esta adaptación del SATAQ-4 puede ser utilizada en población de similar procedencia, a fin de evaluar el efecto de los aspectos socioculturales en la satisfacción con la imagen corporal.
... We found that the presence of FA in the subsample of patients with BED was associated with a lower likelihood of achieving full remission. Overall, patients with BED tend to show a better prognosis than patients with BN (Agüera et al., 2013;Linardon, Kothe, & Fuller-Tyszkiewicz, 2019). However, this finding suggests that the presence of FA in patients with BED might be acting as a maintenance factor for binge eating episodes, possibly due to its effect on the impaired reward system characteristic of addictive processes. ...
Article
Objectives: The study aimed to examine whether food addiction (FA) was associated with greater severity in both binge eating disorders (BED) and bulimia nervosa and, therefore, to determine if FA was predictive of treatment outcome. Method: Seventy-one adult patients with bulimia nervosa and BED (42 and 29, respectively) participated in the study. FA was assessed by means of the Yale Food Addiction Scale. Results: The results confirmed a high prevalence of FA in patients with binge disorders (around 87%) and also its association with a greater severity of the disorder (i.e., related to an increased eating psychopathology and greater frequency of binge eating episodes). Although FA did not appear as a predictor of treatment outcome in general terms, when the diagnostic subtypes were considered separately, FA was associated with poor prognosis in the BED group. In this vein, FA appeared as a mediator in the relationship between ED severity and treatment outcome. Discussions: Our findings suggest that FA may act as an indicator of ED severity, and it would be a predictor of treatment outcome in BED but not in BN.
... Cognitive behavioral therapy (CBT), the first-line option treatment for BED, has demonstrated partial efficacy with remission rates from binge eating in about 50% of patients (Brownley et al., 2016;Grilo, 2017;Hay, 2013). Other factors such as the comorbidity with personality disorders (Amianto, Ercole, Abbate Daga, & Fassino, 2016), the low self-esteem (Linardon, Kothe, & Fuller-Tyszkiewicz, 2019), and the emotional dysregulation (Chen et al., 2017) may explain the inefficacy of standard treatment for patients with BED. ...
Article
Objective: The present study aimed to (a) assess and compare personological traits and early maladaptive schemas (EMSs) of obese women with and without binge eating disorder (BED) and (b) identify the variables associated with the binge severity. Method: One hundred women (55 BED-obese and 45 non-BED-obese) completed psychopathological and personological self-report questionnaires. A forward stepwise linear regression analysis was performed to assess variables associated with binge eating severity. Results: Not only psychopathological but also personological differences were evident between BED and non-BED-obese women. BED severity was significantly associated with depressivity, emotional deprivation, and defectiveness. Conclusions: Our preliminary findings suggest that BED patients exhibit some EMSs that could be linked to the construct of emotional neglect and specific personological traits closely related to depressive dimensions, emotional lability, and impulsivity. In particular, binge severity is associated with the pervasiveness of depressogenic cognitive schemas, as well as those of emotional deprivation and defectiveness.
... No differences between conditions were found on reduction of perfectionism or interpersonal problems, but CBT-E proved more effective in improving self-esteem than TAU. While it is often thought that amelioration of psychopathology symptoms during psychotherapy is associated with the enhancement of self-esteem (Fennell & Jenkins, 2004), the precise mechanisms underpinning these effects are not known (Linardon, Kothe, & Fuller-Tyszkiewicz, 2019). However, some potential explanations for the overall superior effect of CBT-E on selfesteem can be hypothesized. ...
Article
Full-text available
Objective: Enhanced cognitive behavior therapy (CBT-E) is a transdiagnostic treatment suitable for the full range of eating disorders (EDs). Although the effectiveness of CBT(-E) is clear, it is not being used as widely in clinical practice as guidelines recommend. The aim of the present study was to compare the effectiveness of CBT-E with treatment as usual (TAU), which was largely based on CBT principles. Method: We conducted a randomized controlled trial on a total of 143 adult patients with an ED who received either CBT-E or TAU. The primary outcome was recovery from the ED. Secondary outcome measures were levels of ED psychopathology, anxiety, and depressive symptoms. Self-esteem, perfectionism, and interpersonal problems were repeatedly measured to examine possible moderating effects. We explored differences in duration and intensity between conditions. Results: After 80 weeks, there were no differences between conditions in decrease in ED psychopathology, or symptoms of anxiety and depression. However, in the first six weeks of treatment there was a larger decrease in ED psychopathology in the CBT-E condition. Moreover, when the internationally most widely used definition of recovery was applied, the recovery rate at 20 weeks of CBT-E was significantly higher (57.7%) than of TAU (36.0%). At 80 weeks, this difference was no longer significant (CBT-E 60.9%; TAU 43.6%). Furthermore, CBT-E was more effective in improving self-esteem and was also the less intensive and shorter treatment. Discussion: With broader use of CBT-E, the efficiency, accessibility and effectivity (on self-esteem) of treatment for EDs could be improved.
... The last factor is proposed to be the most susceptible to change due to its focus on individual psychological processes. In the process of enhancing subjective well-being, it is posited that many psychological factors including self-esteem, hope, and optimism act interactively with subjective wellbeing [16][17][18][19]. ...
Preprint
Full-text available
Background Enhancing subjective well-being is an effective way to improve mental health and virtual reality is useful as an intervention tool for cultivating well-being. This preliminary study aimed to probe the usefulness of a virtual reality-based interactive feedback program as an intervention tool for promoting subjective well-being. Methods In the experiment, 36 males participated in this program, consisting of three tasks constructed based on the theories of positive psychology: ‘Experience-based problem recognition task’, ‘Future self-based success story expression task’, and ‘Strength expression task’. Participants rated visual analog scores associated with each of the tasks' contents. The concurrent validity of task scores was evaluated by correlations with scores of the psychological scales, such as the Mental Health Continuum-Short Form, Rosenberg’s Self-Esteem Scale, Dispositional Hope Scale, and Life Orientation Test Revised. Results The total task score was positively correlated with the scores of Mental Health Continuum-Short Form emotional well-being ( r = 0.492, p < 0.001) and psychological well-being ( r = 0.501, p < 0.001), Rosenberg’s Self-Esteem Scale ( r = 0.435, p < 0.001), Dispositional Hope Scale agency dimension ( r = 0.601, p < 0.001) and pathways dimension ( r = 0.451, p < 0.001), and Life Orientation Test Revised ( r = 0.378, p < 0.05), but not with the MHC-SF social well-being scores. After controlling the effects of the other task scores, the task scores had linear relationships with certain psychological assessments. Conclusion The results showed that the total task score was significantly correlated with indicators of well-being, self-esteem, hope, and optimism. The task scores obtained from the individual tasks were closely related to the indicators, depending on the nature of the task. These findings suggest that the program contents are well associated with certain aspects of subjective well-being and thus may be available for training that improves subjective well-being through interactive feedback.
... In the process of enhancing subjective well-being, it is posited that many psychological factors including self-esteem, hope, and optimism act interactively with subjective well-being. [16][17][18][19] A training program to improve mental health should deliver interventions with demonstrated efficacy, accessibility, and sustainability. 20 However, individual or group interventions offered at schools or work places are not always accessible (e.g., rural communities or small businesses) or sustainable (e.g., cost concerns). ...
Article
Full-text available
Objective: Enhancing subjective well-being is an effective way to improve mental health. This study aimed to validate a virtual realitybased interactive feedback program as an intervention tool for promoting subjective well-being. Methods: Thirty-six males participated in this program, consisting of three tasks constructed based on the theories of positive psychology: 'Experience-based problem recognition task', 'Future self-based success story expression task', and 'Strength expression task'. Participants rated visual analog scores associated with each of the tasks' contents. The concurrent validity of task scores was evaluated by correlations with the psychological scale scores. Results: The total task score was positively correlated with scores of Mental Health Continuum-Short Form (MHC-SF) emotional wellbeing and psychological well-being, Rosenberg's Self-Esteem Scale, Dispositional Hope Scale agency dimension and pathways dimension, and Life Orientation Test Revised, but not with MHC-SF social well-being scores. After controlling for the effects of the other task scores, the task scores had linear relationships with certain psychological assessments. Conclusion: Since the task scores are closely related to indicators of well-being, self-esteem, hope, and optimism, the program contents are well associated with certain aspects of subjective well-being and thus may be available for training that improves subjective well-being through interactive feedback.
... Previous meta-analytical evidence suggested that psychotherapy may improve this domain acting on self-esteem (from Cohen's d = 0.34 for one-day workshops to d = 1.12 for weekly sessions ( Kolubinski et al., 2018 )), but we did not confirm superiority of psychotherapy over other types of interventions. Although the ES of our findings was modest (ES = 0.541), we demonstrate that universal and selective interventions to promote self-perceptions are equally effective and should not be reserved only for individuals who suffer from a mental disorder or subthreshold conditions ( Linardon et al., 2019 ). Our finding that universal and selective interventions can comparably improve quality of life (ES = 0.457) extend previous systematic reviews and meta-analyses ( Calver et al., 2018 ;Kolubinski et al., 2018 ) suggesting that this domain can be improved by psychosocial interventions in specific populations with mental and physical health problems. ...
Article
Full-text available
Promotion of good mental health in young people is important. Our aim was to evaluate the consistency and magnitude of the efficacy of universal/selective interventions to promote good mental health. A systematic PRISMA/RIGHT-compliant meta-analysis (PROSPERO: CRD42018088708) search of Web of Science until 04/31/2019 identified original studies comparing the efficacy of universal/selective interventions for good mental health vs a control group, in samples with a mean age <35 years. Meta-analytical random-effects model, heterogeneity statistics, assessment of publication bias, study quality and sensitivity analyses investigated the efficacy (Hedges’ g=effect size, ES) of universal/selective interventions to promote 14 good mental health outcomes defined a-priori. 276 studies were included (total participants: 159,508, 79,142 interventions and 80,366 controls), mean age=15.0 (SD=7.4); female=56.0%. There was a significant overall improvement in 10/13 good mental health outcome categories that could be meta-analysed: compared to controls, interventions significantly improved (in descending order of magnitude) mental health literacy (ES=0.685, p<0.001), emotions (ES=0.541, p<0.001), self-perceptions and values (ES=0.49, p<0.001), quality of life (ES=0.457, p=0.001), cognitive skills (ES=0.428, p<0.001), social skills (ES=0.371, p<0.001), physical health (ES=0.285, p<0.001), sexual health (ES=0.257, p=0.017), academic/occupational performance (ES=0.211, p<0.001) and attitude towards mental disorders (ES=0.177, p=0.006). Psychoeducation was the most effective intervention for promoting mental health literacy (ES=0.774, p<0.001) and cognitive skills (ES=1.153, p=0.03). Physical therapy, exercise and relaxation were more effective than psychoeducation and psychotherapy for promoting physical health (ES=0.498, p<0.001). In conclusion, several universal/selective interventions can be effective to promote good mental health in young people. Future research should consolidate and extend these findings.
... The other part was characteristic of patients with EDs in our sample and was described as Negative Attitude Towards Self, including Past Failure, Self-Criticalness, Guilty Feelings, Worthlessness, and Self-Dislike. These attributes closely relate to what is called "core low self-esteem" in the transdiagnostic model of EDs [27], which has a trait-like character and hardly responds to specialized treatment [28]. Accordingly, a sequence leading from body dissatisfaction via low self-esteem and depression to ED symptoms has been repeatedly reported in community samples [29][30][31] and low self-esteem was also found to predict the onset of EDs [32,33]. ...
Article
Background: While it is know that depressive symptoms are common in eating disorders (EDs), it is unclear whether these symptoms differ from those in depressive disorders (DDs) with regard to severity and quality. Methods: Beck Depression Inventory II (BDI-II) scores at admission to treatment of 4.895 inpatients with a unipolar DD and 3.302 inpatients with an ED were compared by means of independent t-tests and Cohen's d effect sizes with regard to: (1) overall severity (BDI-II total score), (2) six facets of depression identified by non-metric multidimensional scaling of the German BDI-II validation sample, and (3) individual items. Results: (1) The two groups did not differ with regard to the BDI-II total score. (2) There was no difference in the facet Depressive Core Symptoms. Patients with DDs had higher scores for Diminished Activation (d = 0.40) and patients with EDs had higher scores for Negative View of Self (d = 0.40). (3) Patients with DDs showed higher score on the item Loss of Energy (d = 0.48), while patients with EDs sored higher on Self-Dislike (d = 0.48) and Changes of Appetite (d = 0.48). Conclusions: Depression in EDs seems to be as severe as in DDs and may show similar core aspects (e.g., Sadness, Loss of Pleasure). Qualitative differences suggested that individual additional symptoms of depression need to be differently addressed in therapy. The pronounced Negative View of Self in EDs is in line with the "core low self-esteem", a central component of the prevalent transdiagnostic model of EDs.
... On the other hand, our most central items are in line with several existing models of disordered eating (Pennesi & Wade, 2016), which see weight/shape concerns, emotional regulation difficulties, self-esteem deficits as well as interpersonal issues as common risk factors. Also, our findings converge with recommendations of several researchers who advocate for an integration of additional therapeutic strategies to address self-esteem and ineffectiveness even more (Furtjes et al., 2020;Kästner, Lowe, & Gumz, 2019;Linardon, Kothe, & Fuller-Tyszkiewicz, 2019). ...
Article
Full-text available
Objective: The network theory of mental disorders conceptualizes eating disorders (EDs) as networks of interacting symptoms. Network analysis studies in EDs mostly have examined transdiagnostic and/or mixed age samples. The aim of our study was to investigate similarities and differences of networks in adolescents and adults with anorexia nervosa (AN) or bulimia nervosa (BN). Method: Participants were 2,535 patients (n = 991 adults with AN, n = 821 adolescents with AN, n = 473 adults with BN, and n = 250 adolescents with BN) who completed the Eating Disorder Inventory-2. Twenty-seven items were selected. Cross-sectional networks were estimated via Joint Graphical Lasso. Core symptoms were identified using strength centrality. Spearman correlations and network comparison tests (NCTs) were used to compare groups. Results: Across diagnoses and ages, feeling ineffective, desire to be thinner, worries that feelings will get out of control, guilt after overeating as well as doing things perfectly emerged as most central symptoms. There were moderate to high correlations between symptom profiles (0.62-0.97, mean: 0.78) as well as high correlations between network structures (0.83-0.93, mean: 0.87) and network strengths (0.73-0.95, mean: 0.85). Global strength significantly differed in two of the six NCTs, and 2.5-10% of edges differed between networks. Discussion: Considerable similarities in network structures and strengths across diagnoses and ages speak in favor of the transdiagnostic approach to EDs. Besides drive for thinness, ineffectiveness, emotion regulation difficulties, and perfectionism might be the most consistent factors in ED networks. These symptoms as well as their symptom connections should be especially focused in treatment regardless of age and diagnosis.
... Self-esteem is broadly defined as an individual's overall sense of self-worth or personal value (Rosenberg, 1965) and encapsulates a person's most basic, general and evaluative feelings about themselves (O'Brien & Epstein, 1988). As such, self-esteem has been widely researched in connection to eating pathology (Linardon et al., 2019;Stice, 2002). For both women and men, low self-esteem has been considered a major predictor of, and a strong maintenance factor for, all types of eating disorders (Bardone-Cone et al., 2007;Gila et al., 2005;Schmidt & Treasure, 2006), as well as disordered eating (Courtney et al., 2008). ...
Article
Applying a positive psychology perspective, this study aimed to identify potential intra-individual factors that might protect against the development of disordered eating in a community sample of young women and men (N = 510; 56 % women; Mage = 24.3). Based on existing literature, the study included the general resilience factors of self-esteem and identity coherence as well as two dimensions of positive embodiment (positive body connection and comfort, and agency and functionality). All factors were negatively correlated with disordered eating among women and men. Hierarchical regression analyses indicated that positive embodiment, specifically positive body connection, was a significant predictor of lower degrees of disordered eating symptoms in both women and men, followed by self-esteem. The overall prediction model accounted for 42.6 % in the variation of disordered eating symptoms for women and 23.9 % for men. Prevention and treatment interventions promoting health factors that protect against the development of eating disorders are much needed. The present study informs such efforts by emphasizing the promotion of positive embodiment.
... Past studies showed a mediating role of low self-esteem in the relation between attachment style and depressive symptoms (Fuhr et al., 2017). Meta-analyzes showed a positive effect of psychotherapy on self-esteem as an outcome, whereas psychotherapeutic interventions did lead to an increase in self-esteem compared to an untreated control group (Smith and Glass, 1977;Linardon et al., 2019). The improvement in self-esteem is even higher than the improvement in general symptom reduction and general capability (Smith and Glass, 1977). ...
Article
Full-text available
Objectives: The present naturalistic study aims to investigate the differential effects of the patient’s and the therapist’s attachment representations on the attachment to the therapist as perceived by the patient, and their impact on self-esteem-change through psychotherapy. Methods: Attachment variables of N = 573 patients as well as N = 16 therapists were assessed. Attachment representations were measured for therapists and patients via the Bielefelder Questionnaire for Client Attachment Exploration, the Relationship Specific Attachment to Therapist Scales and the Adult Attachment Interview. The patient’s attachment to therapists was evaluated and patients’ self-esteem was measured via the Frankfurter Selbstkonzeptskalen at the beginning and end of psychotherapy. Results: Although there were significant effects of the patient’s attachment representations on the perceived attachment to the therapist as well as between the perceived attachment to the therapist and the amount of self-esteem-change, the therapist’s attachment style had no significant influence on the perceived attachment to the therapist. Conclusion: Self-esteem-change through psychotherapy is influenced by the actually formed attachment relationship as perceived by the patient. The patient’s attachment representations but not the therapist’s attachment style contributes to the actual patient’s attachment to the therapist.
... Psychological therapy is therefore changing in ways that positively address the current increase of body image-related difficulties and associated negative outcomes (e.g. emotional distress; Linardon, Gleeson, et al., 2019;Linardon, Kothe, et al., 2019;Williams et al., 2004;Zilcha-Mano & Ramseyer, 2020). ...
Article
Full-text available
Positive body image is a contemporary construct, having only received research attention within the past two decades in an effort to elicit a more holistic, comprehensive account of the concept of body image. Nevertheless, emerging literature has suggested its direct and indirect association with improved outcomes, including indicators of well-being (e.g. self-compassion) and feelings towards the self (e.g. self-esteem). Positive body image has therefore been suggested as both a potential technique and a target of actionable therapeutic work for cultivating both physical and psychological well-being. First, through insights from quantitative and qualitative seminal works, this paper demonstrates that positive body image is: (i) a multidimensional construct, distinct from negative body image; (ii) a confluence of theoretical disciplines and influences; (iii) protective, with therapeutic capacities; (iv) a positive outcome; (v) young, yet flourishing; and (vi) socially and politically relevant. Thus, complementing what positive body image is, this paper further situates therapeutic practice within the field of positive body image by delineating and contextualising their reciprocal capacities and relevant techniques.
... Sixth, our statements on BPD specificity are restricted to comparisons with patients with ADs. Therefore, it remains unclear whether self-esteem instability in BPD also differs from that in other clinical control groups, especially those that have been associated with an equally heightened affective instability compared to that of patients with BPD or fragile self-esteem, that is, patients with PTSD, bulimia nervosa, or with other personality disorders (Kashdan et al., 2006;Linardon et al., 2019;Mneimne et al., 2018;Santangelo et al., 2014Santangelo et al., , 2016. Seventh, we acknowledge that improving self-esteem is not always desirable, for example in patients with BPD who score high in narcissistic personality traits. ...
Article
Borderline personality disorder (BPD) is commonly characterized by pervasive instability. Affective instability, despite being a diagnostic criterion in the DSM-5, is commonly seen as a transdiagnostic feature, but recent studies have brought new attention to the importance of self-esteem instability as a potential defining feature of BPD. However, evidence is lacking regarding whether heightened self-esteem instability is a specific feature of BPD when patients with BPD are compared to clinical controls. Using ambulatory assessment, we examined self-esteem instability and affective instability in participants' daily lives. We assessed momentary self-esteem and affective state 12 times daily for 4 consecutive days in 71 patients with BPD, 121 patients with anxiety disorders (ADs), and 74 healthy controls (HCs). To determine group differences, we used established instability indices and analyzed multilevel models. Compared to HCs, patients with BPD and those with ADs exhibited heightened self-esteem instability and affective instability. Importantly, the clinical groups did not differ in affective instability, whereas self-esteem instability was significantly higher in patients with BPD than in those with ADs across all instability indices. Beyond the influence of mean self-esteem, patients with BPD had the highest general instability, the most frequent extreme changes, and the largest decreases in self-esteem, especially from high levels of self-esteem. Our results support previous findings on affective instability, which may constitute a transdiagnostic feature, and they provide the first evidence that heightened self-esteem instability is particularly prominent in BPD, underscoring the importance of self-esteem for the understanding of dysregulation in BPD. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
... These problems can be prevented by applying a rigorous methodology. In terms of meta-analyses, publication bias (Driessen et al., 2015;Flint et al., 2015;Fonagy et al., 2017;Linardon et al., 2019;Niemeyer et al., 2012) and the inclusion of low-quality studies in meta-analyses (Coyne & Kok, 2014;Hengartner, 2018) deflate the validity of the results of meta-anaylses. Therefore, a new publishing paradigm is needed to overcome publication bias (Bradley et al., 2017). ...
Article
Full-text available
Son 10 yıldır psikoloji alanında kendini gösteren ve alanı derinden sarsan tekrarlama krizi, psikolojinin her alt alanını, araştırma bulgularını ve genel kabullerini yeniden değerlendirmesi için harekete geçirmiştir. Klinik psikoloji alanının geç de olsa tekrarlama krizi tartışmalarına katılmaya başladığı görülmektedir. Uzun yıllardır gerçekleştirilen psikoterapi etkililik (efficacy) çalışmaları, klinik psikoloji içindeki başlıca deneysel alanlardan birini oluşturmaktadır. Psikoterapi etkililik çalışmaları çeşitli psikolojik tedavilerin psikolojik rahatsızlıklar üzerindeki etkilerini değerlendirmek için gerçekleştirilmektedir. Tekrarlama krizi bağlamında ortaya çıkan bulgular, psikoterapilerin etkililiklerini değerlendirmek için sıkça kullanılan seçkisiz kontrollü çalışmaların ve bu çalışmaların sonuçlarının toplu olarak değerlendirilmesine yardımcı olan meta-analizlerin pek çok yöntemsel problem ve yanlılık içerdiğini ortaya çıkarmıştır. Seçkisiz kontrollü çalışmalar düşük örneklem sayısı, bağlılık yanlılığı, seçici sonuç raporlama, örnekleme dahil etme ya da dışarıda bırakma kriterlerinin katılığı, kontrol grubu olarak bekleme listesi kullanımı, seçkisizleştirme ve körleştirme sorunları, çalışmayı bırakan katılımcıların analizlere dahil edilmemesi ve psikoterapist etkilerinin ihmal edilmesi gibi problemler ve yanlılıklar içermektedir. Meta-analizler ile ilişkili başlıca sorunlar ise yayın yanlılığı ve düşük kaliteli çalışmaların metaanalizlere dahil edilmesidir. Tüm bu durumlar psikoterapilerin olumlu etkilerini olduğundan daha yüksek gösterirken, edinilen bulguların sağlıklı bir şekilde değerlendirilmesini engellemektedir. Uzun yıllardır gerçekleştirilen çalışmalar, psikoterapilerin çeşitli psikolojik rahatsızlıkların tedavisinde tercih edilebilecek etkili araçlar olduğunu göstermektedir. Ancak dikkat edilmesi gereken iki önemli husus vardır. Bunlardan ilki psikoterapilerin etkililiğini gösteren çalışmaların yöntemsel anlamda güncel bilimsel standartları yakalamakta zorlanmasıdır. İkinci önemli husus ise psikoterapilerin gerçek etkilerinin çalışmalarda bulunan etkilerden daha az olabileceğidir. Bu derleme makalesinin amacı, psikoterapi etkililik çalışmalarını ve meta-analizleri etkileyen yöntemsel problemlere ve onların çözümlerine değinerek klinik psikoloji alanında bu konuda ortaya çıkan farkındalığın arttırılmasına ve gerçekleştirilecek çalışmaların yöntemsel olarak güçlendirilmesine yardımcı olmaktır.
Article
Body image flexibility refers to the ability to openly experience thoughts or feelings about the body without acting on them or trying to change them. Accumulating evidence has demonstrated that body image flexibility is connected to numerous adaptive processes, and that it is sensitive to change during psychological interventions. However, a quantitative synthesis of empirical research on body image flexibility is lacking. We conducted the first meta-analysis on body image flexibility and its correlates. Sixty-two studies were included. Random effects meta-analyses were conducted on 19 psychological correlates, divided into three clusters: eating and body image disturbances, positive body-related and general psychological constructs, and general psychopathology. Meta-analyses showed inverse correlations between body image flexibility and each construct within the eating and body image disturbances cluster (rs= −.45 to −.67), and the general psychopathology cluster (rs= −.37 to −.58). Body image flexibility was positively associated with each positive psychology construct (rs = .23 – .58). Men reported higher levels of body image flexibility than women (d = 0.32). Psychological interventions were more effective than control groups at enhancing body image flexibility in randomized controlled trials (d = 0.42). Findings confirm that body image flexibility is consistently connected to indices of mental health, and that it can be enhanced during psychological interventions.
Chapter
Körperbildprobleme sind ein Kernsymptom der Essstörungen Anorexia und Bulimia nervosa. So leiden Patientinnen (Da es sich bei der Mehrzahl der Betroffenen um Patientinnen handelt, haben wir die weibliche Form gewählt. Selbstverständlich sind damit auch männliche Patienten gemeint.) mit diesen Essstörungen unter ausgeprägten Ängsten vor einer Gewichtszunahme und Störungen in der Art und Weise, wie die Figur und das Gewicht wahrgenommen und bewertet werden. Zudem können das Gewicht und die Figur ausgeprägten Einfluss auf die Selbstbewertung haben. Auch bei der Binge-Eating-Störung können Körperbildstörungen vorkommen, z. B. im Hinblick auf die Bewertung des Körpers und der Figur oder im Hinblick auf affektive Reaktionen gegenüber dem Körper. In dem Beitrag werden Befunde der Grundlagenforschung vorgestellt, die zu einem besseren Verständnis von Körperbildstörungen beitragen können und Implikationen für die Psychotherapie bieten.
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.
Preprint
Full-text available
Eating disorders are associated with one of the highest mortality rates among all mental disorders, yet there is very little research about them within the newly emerging and promising field of computational psychiatry. As such, we focus on investigating a previously unexplored, yet a core aspect of eating disorders – body image preoccupation. We continue a freshly opened debate about model-based learning in eating disorders and perform a study that utilises a two-step decision-making task and a reinforcement learning model to understand the effect of body image preoccupation on model-based learning in a subclinical eating disorder population, as recruited using Prolific. We find a significantly reduced model-based contribution in the body image disturbance task condition in the eating disorder group as compared to a healthy control. We propose a new digital biomarker that significantly predicts disordered eating, and body image issues.
Article
Objective: Self-esteem is a core aspect of eating disorder symptomatology. This study aims to examine whether method effects associated with negatively worded items of the Rosenberg Self-Esteem Scale (RSES) may interact the negative self-evaluations experienced by patients with obesity and binge eating disorder (BED). We also examined whether negatively worded items were associated with psychological distress and eating symptoms. Method: Five hundred thirty three female outpatients (mean age: 42.59) with BED (n = 160) or obesity without BED (n = 373) completed the RSES and measures of interpersonal problems, psychological distress, and eating symptoms. Results: Patients with BED responded more strongly to the negatively worded items of the RSES than those with obesity. The RSES negatively worded item factor was negatively associated with higher interpersonal problems, psychological distress, and binge eating. Conclusions: Patients with BED may be more responsive to negatively phrased items on the RSES consistent with their negative self-evaluations and self-perceptions.
Article
Full-text available
Eating disorders are serious psychiatric illnesses with high rates of morbidity and mortality. Effective treatments have traditionally included behaviorally focused therapies as well as several medication strategies. Recent years have seen promising developments in these treatments, including additional support for family-based approaches for children and adolescents, new evidence for “third-wave” behavioral therapies, and new support for the use of lisdexamfetamine for binge eating disorder and olanzapine for anorexia nervosa. Case study and pilot data are beginning to show limited support for neuromodulatory interventions targeting brain regions thought to be involved in eating disorders. This review summarizes treatment developments over the last several years and points towards future directions for the field.
Article
Objective: There are no generally accepted definitions or markers of treatment nonresponse in eating disorders (EDs). The aim of this paper was to examine how the duration of illness and other potential prognostic markers impacted on nonresponse and drop-out from treatment across different EDs subtypes. Methods: A total sample of 1199 consecutively treated patients with EDs, according to Diagnostic and Statistical Manual of Mental Disorders, fifth edition criteria, participated in this study. Kaplan-Meier curves were calculated for each ED diagnosis in which the probability of recovery was plotted against the duration of illness. Results: Full remission was more likely for people with binge eating disorder (BED; 47.4%) and anorexia nervosa (AN; 43.9%) compared to bulimia nervosa (BN; 25.2%) and other specified feeding and EDs (OSFED; 23.2%). The cut-off points for the duration of the illness related with high likelihoods of poor response was 6-8 years among OSFED, 12-14 years among AN and BN and 20-21 years among BED. Other variables predicting nonresponse included dysfunctional personality traits. Conclusions: Nonresponse to treatment is associated with duration of illness which is in turn associated with poor response to previous treatment. However, there was no evidence for staging the illness using specific duration of illness criteria. Nevertheless, the shorter temporal trajectory for OSFED suggests that early interventions may be of importance for this group.
Article
Full-text available
BACKGROUND: Several meta-analyses have shown that psychotherapy is effective for reducing depressive symptom severity. However, the impact on quality of life (QoL) is as yet unknown. AIMS: To investigate the effectiveness of psychotherapy for depression on global QoL and on the mental health and physical health components of QoL. METHOD: We conducted a meta-analysis of 44 randomised clinical trials comparing psychotherapy for adults experiencing clinical depression or elevated depressive symptoms with a control group. We used subgroup analyses to explore the influence of various study characteristics on the effectiveness of treatment. RESULTS: We detected a small to moderate effect size (Hedges' g = 0.33, 95% CI 0.24-0.42) for global QoL, a moderate effect size for the mental health component (g = 0.42, 95% CI 0.33-0.51) and, after removing an outlier, a small but statistically significant effect size for the physical health component (g = 0.16, 95% CI 0.05-0.27). Multivariate meta-regression analyses showed that the effect size of depressive symptoms was significantly related to the effect size of the mental health component of QoL. The effect size of depressive symptoms was not related to global QoL or the physical health component. CONCLUSIONS: Psychotherapy for depression has a positive impact on the QoL of patients with depression. Improvements in QoL are not fully explained by improvements in depressive symptom severity.
Article
Full-text available
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.
Article
Full-text available
Systematic reviews and meta-analyses have become increasingly important in health care. Clinicians read them to keep up to date with their field [1],[2], and they are often used as a starting point for developing clinical practice guidelines. Granting agencies may require a systematic review to ensure there is justification for further research [3], and some health care journals are moving in this direction [4]. As with all research, the value of a systematic review depends on what was done, what was found, and the clarity of reporting. As with other publications, the reporting quality of systematic reviews varies, limiting readers' ability to assess the strengths and weaknesses of those reviews. Several early studies evaluated the quality of review reports. In 1987, Mulrow examined 50 review articles published in four leading medical journals in 1985 and 1986 and found that none met all eight explicit scientific criteria, such as a quality assessment of included studies [5]. In 1987, Sacks and colleagues [6] evaluated the adequacy of reporting of 83 meta-analyses on 23 characteristics in six domains. Reporting was generally poor; between one and 14 characteristics were adequately reported (mean = 7.7; standard deviation = 2.7). A 1996 update of this study found little improvement [7]. In 1996, to address the suboptimal reporting of meta-analyses, an international group developed a guidance called the QUOROM Statement (QUality Of Reporting Of Meta-analyses), which focused on the reporting of meta-analyses of randomized controlled trials [8]. In this article, we summarize a revision of these guidelines, renamed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses), which have been updated to address several conceptual and practical advances in the science of systematic reviews (Box 1). Box 1: Conceptual Issues in the Evolution from QUOROM to PRISMA Completing a Systematic Review Is an Iterative Process The conduct of a systematic review depends heavily on the scope and quality of included studies: thus systematic reviewers may need to modify their original review protocol during its conduct. Any systematic review reporting guideline should recommend that such changes can be reported and explained without suggesting that they are inappropriate. The PRISMA Statement (Items 5, 11, 16, and 23) acknowledges this iterative process. Aside from Cochrane reviews, all of which should have a protocol, only about 10% of systematic reviewers report working from a protocol [22]. Without a protocol that is publicly accessible, it is difficult to judge between appropriate and inappropriate modifications.
Article
Full-text available
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
Article
Full-text available
Background: Individuals with eating disorders show deficits in neuropsychological functioning which might preexist and underlie the etiology of the eating disorders and influence relapse. Deficits in cognitive flexibility, i.e., set-shifting and central coherence, might perpetuate the symptoms. Cognitive remediation therapy (CRT) was developed to improve cognitive flexibility, thereby increasing the likelihood of improved outcome. The focus of CRT is on how patients think, rather than on what patients think. The present study investigated the effectiveness of CRT for patients with a severe or enduring eating disorder by means of a randomized controlled trial comparing intensive treatment as usual (TAU) to CRT plus TAU. Methods: Eighty-two patients were randomly assigned to CRT plus TAU (n = 41) or TAU alone (n = 41). Outcome measures were set-shifting, central coherence, eating disorder and general psychopathology, motivation, quality of life and self-esteem. Assessments were performed at baseline (n = 82) and after 6 weeks (T1; n = 75) and 6 months (T2; n = 67). Data were analyzed by means of linear mixed model analyses. Results: Patients who received CRT in addition to TAU improved significantly more with regard to eating disorder-related quality of life at the end of treatment (T1) and eating disorder psychopathology at follow-up (T2), compared to those who received TAU only. Moreover, moderator analyses revealed that patients with poor baseline set-shifting abilities benefited more from CRT than patients with no deficits in set-shifting abilities at baseline; the quality of life of the former group was higher than that of the latter at follow-up. Conclusions: CRT seems to be promising in enhancing the effectiveness of concurrent treatment.
Article
Full-text available
Background: The purpose of this investigation was to compare a new psychotherapy for bulimia nervosa (BN), integrative cognitive-affective therapy (ICAT), with an established treatment, 'enhanced' cognitive-behavioral therapy (CBT-E). Method: Eighty adults with symptoms of BN were randomized to ICAT or CBT-E for 21 sessions over 19 weeks. Bulimic symptoms, measured by the Eating Disorder Examination (EDE), were assessed at baseline, at the end of treatment (EOT) and at the 4-month follow-up. Treatment outcome, measured by binge eating frequency, purging frequency, global eating disorder severity, emotion regulation, self-oriented cognition, depression, anxiety and self-esteem, was determined using generalized estimating equations (GEEs), logistic regression and a general linear model (intent-to-treat). Results: Both treatments were associated with significant improvement in bulimic symptoms and in all measures of outcome, and no statistically significant differences were observed between the two conditions at EOT or follow-up. Intent-to-treat abstinence rates for ICAT (37.5% at EOT, 32.5% at follow-up) and CBT-E (22.5% at both EOT and follow-up) were not significantly different. Conclusions: ICAT was associated with significant improvements in bulimic and associated symptoms that did not differ from those obtained with CBT-E. This initial randomized controlled trial of a new individual psychotherapy for BN suggests that targeting emotion and self-oriented cognition in the context of nutritional rehabilitation may be efficacious and worthy of further study.
Article
Full-text available
Cognitive behavioral therapy (CBT) is the leading evidence-based treatment for bulimia nervosa. A new "enhanced" version of the treatment appears to be more potent and has the added advantage of being suitable for all eating disorders, including anorexia nervosa and eating disorder not otherwise specified. This article reviews the evidence supporting CBT in the treatment of eating disorders and provides an account of the "transdiagnostic" theory that underpins the enhanced form of the treatment. It ends with an outline of the treatment's main strategies and procedures.
Article
Full-text available
This study evaluates a short stepwise cognitive-behavioral intervention for the treatment of low self-esteem in patients with eating disorders. Competitive memory training (COMET) for low self-esteem is based on insights and findings from experimental psychology. A total of 52 patients with eating disorders and low self-esteem were treated with COMET in a routine mental health center in addition to their regular treatment. These patients were randomized to receive 8 weeks of COMET + therapy as usual (TAU) or to receive TAU only. Differential effects in favor of COMET + TAU were found for 2 indexes of self-esteem and for 1 index of depressive mood. Shortcomings of this study and possible clinical implications are discussed.
Article
Full-text available
Predictors and moderators of outcomes were examined in 75 overweight patients with binge-eating disorder (BED) who participated in a randomized clinical trial of guided self-help treatments. Age variables, psychiatric and personality disorder comorbidity, and clinical characteristics were tested as predictors and moderators of treatment outcomes. Current age and age of BED onset did not predict outcomes. Key dimensional outcomes (binge frequency, eating psychopathology, and negative affect) were predominately predicted, but not moderated, by their respective pretreatment levels. Presence of personality disorders, particularly Cluster C, predicted both posttreatment negative affect and eating disorder psychopathology. Negative affect, but not major depressive disorder, predicted attrition, posttreatment negative affect, and eating disorder psychopathology. Despite the prognostic significance of these findings for dimensional outcomes, none of the variables tested were predictive of binge remission (i.e., a categorical outcome). No moderator effects were found. The present study found poorer prognosis for patients with negative affect and personality disorders, suggesting that treatment outcomes may be enhanced by attending to the cognitive and personality styles of these patients.
Article
Full-text available
The aim of this quasi-experimental study was to examine the effectiveness of group interpersonal therapy (IPT) in treating overweight patients with binge eating disorder who did not stop binge eating after 12 weeks of group cognitive-behavioral therapy (CBT). Participants in this study were randomly allocated to either group CBT or to an assessment-only control group. After 12 weeks of treatment with CBT, 55% of participants met criteria for improvement and began 12 weeks of weight loss therapy, whereas the nonresponders began 12 weeks of group IPT. Over the 24-week period, participants who received treatment reduced binge eating and weight significantly more than the waiting-list control group. However, IPT led to no further improvement for those who did not improve with CBT. Predictors of poor outcome were early onset of, and more severe, binge eating.
Article
Full-text available
Seventy-five patients with bulimia nervosa were treated with 1 of 3 short-term psychological treatments and were then entered into a closed 1-year period of follow-up. Pretreatment predictors of 3 measures of outcome were sought. Only 2 variables were significantly associated with outcome: attitudes toward shape and weight, and self-esteem. The nature of the relation between attitudinal disturbance and outcome was complex and unexpected. The data set was also used to test the major prediction of the cognitive view of bulimia nervosa, namely that among patients who have responded to treatment, the residual level of attitudinal disturbance will predict subsequent outcome. This prediction was confirmed.
Article
Objective Standardized effect sizes reported in previous meta‐analyses of binge‐eating disorder (BED) treatment are sometimes difficult to interpret and are criticized for not being a useful indicator of the clinical importance of a treatment. Abstinence from binge eating is a clinically relevant component of a definition of a successful treatment outcome. This meta‐analysis estimated the prevalence of patients with BED who achieved binge eating abstinence following psychological or behavioral treatments. Method This meta‐analysis included 39 randomized controlled trials, with 65 treatment conditions and 2,349 patients. Most conditions comprised cognitive‐behavioral therapy (n = 40). Pooled event rates were calculated at posttreatment and follow‐up using random effects models. Results The total weighted percentage of treatment‐completers who achieved abstinence at posttreatment was 50.9% (95% CI = 43.9, 57.8); this estimate was almost identical at follow‐up (50.3%; 95% CI = 43.6, 56.9). The total weighted percentage of patients who achieved abstinence at posttreatment in the intention‐to‐treat analysis (all randomized patients) was 45.1% (95% CI =40.7, 49.5), and at follow‐up it was 42.3% (95% CI =37.5, 47.2). Interpersonal psychotherapy (IPT) produced the highest abstinence rates. Clinician‐led group treatments produced significantly higher posttreatment (but not follow‐up) abstinence estimates than guided self‐help treatments. Neither timeframe for achieving abstinence, assessment type (interview/questionnaire), number of treatment sessions, patient demographics, nor trial quality, moderated the abstinence estimates. Discussion The present findings demonstrate that 50% of patients with BED do not fully respond to treatment. Continued efforts toward improving eating disorder treatments are needed.
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.
Article
Objective: This meta-analysis examined the efficacy of cognitive-behavioral therapy (CBT) for eating disorders. Method: Randomized controlled trials of CBT were searched. Seventy-nine trials were included. Results: Therapist-led CBT was more efficacious than inactive (wait-lists) and active (any psychotherapy) comparisons in individuals with bulimia nervosa and binge eating disorder. Therapist-led CBT was most efficacious when manualized CBT-BN or its enhanced version was delivered. No significant differences were observed between therapist-led CBT for bulimia nervosa and binge eating disorder and antidepressants at posttreatment. CBT was also directly compared to other specific psychological interventions, and therapist-led CBT resulted in greater reductions in behavioral and cognitive symptoms than interpersonal psychotherapy at posttreatment. At follow-up, CBT outperformed interpersonal psychotherapy only on cognitive symptoms. CBT for binge eating disorder also resulted in greater reductions in behavioral symptoms than behavioral weight loss interventions. There was no evidence that CBT was more efficacious than behavior therapy or nonspecific supportive therapies. Conclusions: CBT is efficacious for eating disorders. Although CBT was equally efficacious to certain psychological treatments, the fact that CBT outperformed all active psychological comparisons and interpersonal psychotherapy specifically, offers some support for the specificity of psychological treatments for eating disorders. Conclusions from this study are hampered by the fact that many trials were of poor quality. Higher quality RCTs are essential. (PsycINFO Database Record
Article
Objective: 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
A low-intensity 4-week intervention that included components of compassion, mindfulness, and acceptance was delivered to women diagnosed with binge eating disorder. Participants were randomly assigned to 1 of 2 conditions: intervention (n = 11) or waiting list control (n = 9). Participants in the intervention condition were invited to practise mindfulness, soothing rhythm breathing, and compassionate imagery practices with a focus on awareness and acceptance of emotional states and triggers to binge eating and engagement in helpful actions. Results revealed that, in the intervention group, there were significant reductions in eating psychopathology symptoms, binge eating symptoms, self-criticism, and indicators of psychological distress; there were significant increases in compassionate actions and body image-related psychological flexibility. Data suggest that developing compassion and acceptance competencies may improve eating behaviour and psychological well-being in individuals with binge eating disorder. Key practitioner message A low-intensity 4-week intervention for BED was tested. The intervention included components of compassion, mindfulness, and acceptance. Results showed efficacy in reduced binge eating and eating psychopathology. Participants showed reductions in self-criticism and psychological distress. Participants increased in self-compassion and body image psychological flexibility.
Article
Objective: Rapid response to cognitive behavior therapy (CBT) for eating disorders (i.e., rapid and substantial change to key eating disorder behaviors in the initial weeks of treatment) robustly predicts good outcome at end-of-treatment and in follow up. The objective of this study was to determine whether rapid response to day hospital (DH) eating disorder treatment could be facilitated using a brief adjunctive CBT intervention focused on early change. Method: 44 women (average age 27.3 [8.4]; 75% White, 6.3% Black, 6.9% Asian) were randomly assigned to 1 of 2 4-session adjunctive interventions: CBT focused on early change, or motivational interviewing (MI). DH was administered as usual. Outcomes included binge/purge frequency, Eating Disorder Examination-Questionnaire and Difficulties in Emotion Regulation Scale. Intent-to-treat analyses were used. Results: The CBT group had a higher rate of rapid response (95.7%) compared to MI (71.4%; p = .04, V = .33). Those who received CBT also had fewer binge/purge episodes (p = .02) in the first 4 weeks of DH. By end-of-DH, CBT participants made greater improvements on overvaluation of weight and shape (p = .008), and emotion regulation (ps < .008). Across conditions, there were no significant baseline differences between rapid and nonrapid responders (ps > .05). Conclusions: The results of this study demonstrate that rapid response can be clinically facilitated using a CBT intervention that explicitly encourages early change. This provides the foundation for future research investigating whether enhancing rates of rapid response using such an intervention results in improved longer term outcomes. (PsycINFO Database Record
Article
Objective: Meta-analyses have documented the efficacy of cognitive-behavioral therapy (CBT) for reducing symptoms of eating disorders. However, it is not known whether CBT for eating disorders can also improve quality of life (QoL). This meta-analysis therefore examined the effects of CBT for eating disorders on subjective QoL and health-related quality of life (QoL). Method: Studies that assessed QoL before and after CBT for eating disorders were searched in the PsycInfo and Medline database. Thirty-four articles met inclusion criteria. Pooled within and between-groups Hedge's g were calculated at post-treatment and follow-up for treatment changes on both subjective and HRQoL using a random effects model. Results: CBT led to significant and modest improvements in subjective QoL and HRQoL from pre to post-treatment and follow-up. CBT led to greater subjective QoL improvements than inactive (i.e., wait-list) and active (i.e., a combination of bona fide therapies, psychoeducation) comparisons. CBT also led to greater HRQoL improvements than inactive, but not active, comparisons. Prepost QoL improvements were larger in studies that delivered CBT individually and by a therapist or according to the cognitive maintenance model of eating disorders (CBT-BN or CBT-E); though this was not replicated at follow-up CONCLUSIONS: Findings provide preliminary evidence that CBT for eating disorders is associated with modest improvements in QOL, and that CBT may be associated with greater improvements in QOL relative to comparison conditions.
Article
This systematic review synthesised the literature on predictors, moderators, and mediators of outcome following Fairburn's CBT for eating disorders. Sixty-five articles were included. The relationship between individual variables and outcome was synthesised separately across diagnoses and treatment format. Early change was found to be a consistent mediator of better outcomes across all eating disorders. Moderators were mostly tested in binge eating disorder, and most moderators did not affect cognitive-behavioural treatment outcome relative to other treatments. No consistent predictors emerged. Findings suggest that it is unclear how and for whom this treatment works. More research testing mediators and moderators is needed, and variables selected for analyses need to be empirically and theoretically driven. Future recommendations include the need for authors to (i) interpret the clinical and statistical significance of findings; (ii) use a consistent definition of outcome so that studies can be directly compared; and (iii) report null and statistically significant findings.
Article
Background: The best treatment options for binge-eating disorder are unclear. Purpose: To summarize evidence about the benefits and harms of psychological and pharmacologic therapies for adults with binge-eating disorder. Data sources: English-language publications in EMBASE, the Cochrane Library, Academic OneFile, CINAHL, and ClinicalTrials.gov through 18 November 2015, and in MEDLINE through 12 May 2016. Study selection: 9 waitlist-controlled psychological trials and 25 placebo-controlled trials that evaluated pharmacologic (n = 19) or combination (n = 6) treatment. All were randomized trials with low or medium risk of bias. Data extraction: 2 reviewers independently extracted trial data, assessed risk of bias, and graded strength of evidence. Data synthesis: Therapist-led cognitive behavioral therapy, lisdexamfetamine, and second-generation antidepressants (SGAs) decreased binge-eating frequency and increased binge-eating abstinence (relative risk, 4.95 [95% CI, 3.06 to 8.00], 2.61 [CI, 2.04 to 3.33], and 1.67 [CI, 1.24 to 2.26], respectively). Lisdexamfetamine (mean difference [MD], -6.50 [CI, -8.82 to -4.18]) and SGAs (MD, -3.84 [CI, -6.55 to -1.13]) reduced binge-eating-related obsessions and compulsions, and SGAs reduced symptoms of depression (MD, -1.97 [CI, -3.67 to -0.28]). Headache, gastrointestinal upset, sleep disturbance, and sympathetic nervous system arousal occurred more frequently with lisdexamfetamine than placebo (relative risk range, 1.63 to 4.28). Other forms of cognitive behavioral therapy and topiramate also increased abstinence and reduced binge-eating frequency and related psychopathology. Topiramate reduced weight and increased sympathetic nervous system arousal, and lisdexamfetamine reduced weight and appetite. Limitations: Most study participants were overweight or obese white women aged 20 to 40 years. Many treatments were examined only in single studies. Outcomes were measured inconsistently across trials and rarely assessed beyond end of treatment. Conclusion: Cognitive behavioral therapy, lisdexamfetamine, SGAs, and topiramate reduced binge eating and related psychopathology, and lisdexamfetamine and topiramate reduced weight in adults with binge-eating disorder. Primary funding source: Agency for Healthcare Research and Quality.
Article
The development and validation of a new measure, the Eating Disorder Inventory (EDI) is described. The EDI is a 64 item, self-report, multiscale measure designed for the assessment of psychological and behavioral traits common in anorexia nervosa (AN) and bulimia. The EDI consists of eight subscales measuring: Drive for Thinness, Bilimia, Body Dissatisfaction, Ineffectiveness, Perfectionism, Interpersonal Distrust, Interoceptive Awareness and Maturity Fears. Reliability (internal consistency) is established for all subscales and several indices of validity are presented. First, AN patients (N=113) are differentiated from femal comparison (FC) subjects (N=577) using a cross-validation procedure. Secondly, patient self-report subscale scores agree with clinician ratings of subscale traits. Thirdly, clinically recovered AN patients score similarly to FCs on all subscales. Finally, convergent and discriminant validity are established for subscales. The EDI was also administered to groups of normal weight bulimic women, obese, and normal weight but formerly obese women, as well as a male comparison group. Group differences are reported and the potential utility of the EDI is discussed.
Article
Understanding the factors that predict a favourable outcome following specialist treatment for an eating disorder may assist in improving treatment efficacy, and in developing novel interventions. This review and meta-analysis examined predictors of treatment outcome and drop-out. A literature search was conducted to identify research investigating predictors of outcome in individuals treated for an eating disorder. We organized predictors first by statistical type (simple, meditational, and moderational), and then by category. Average weighted mean effect sizes (r) were calculated for each category of predictor. The most robust predictor of outcome at both end of treatment (EoT) and follow-up was the meditational mechanism of greater symptom change early during treatment. Simple baseline predictors associated with better outcomes at both EoT and follow-up included higher BMI, fewer binge/purge behaviors, greater motivation to recover, lower depression, lower shape/weight concern, fewer comorbidities, better interpersonal functioning and fewer familial problems. Drop-out was predicted by more binge/purge behaviors and lower motivation to recover. For most predictors, there was large interstudy variability in effect sizes, and outcomes were operationalized in different ways. There were generally insufficient studies to allow analysis of predictors by eating disorder subtype or treatment type. To ensure that this area continues to develop with robust and clinically relevant findings, future studies should adopt a consistent definition of outcome and continue to examine complex multivariate predictor models. Growth in this area will allow for stronger conclusions to be drawn about the prediction of outcome for specific diagnoses and treatment types. © 2015 Wiley Periodicals, Inc.
Article
• Previous research on the treatment of outpatients with bulimia nervosa has focused on two treatment strategies: (1) drug therapy, primarily using tricyclic antidepressants, and (2) psychotherapy, often employing behavioral and cognitive behaviorantechniques. We report here the short-term treatment outcome of a 12-week comparison trial of bulimic outpatients who were randomly assigned to one of four treatment cells: (1) imipramine hydrochloride treatment, (2) placebo treatment, (3) imipramine treatment combined with intensive group psychotherapy, and (4) placebo treatment combined with intensive group psychotherapy. All three active treatment cells resulted in significant reductions in target-eating behaviors and in a significant improvement in mood relative to placebo treatment. However, the results also suggested that the amount of improvement obtained with the intensive group psychotherapy component was superior to that obtained with antidepressant treatment alone. The addition of antidepressant treatment to the intensive group psychotherapy component did not significantly improve outcome over intensive group psychotherapy combined with placebo treatment in terms of eating behavior, but did result in more improvement in the symptoms of depression and anxiety.
Article
IntroductionIndividual studiesThe summary effectHeterogeneity of effect sizesSummary points
Article
Background Standardised effect sizes have been criticized because they are difficult to interpret and offer little clinical information. This meta-analyses examine the extent of actual improvement, the absolute numbers of patients no longer meeting criteria for major depression, and absolute rates of response and remission. Methods We conducted a meta-analysis of 92 studies with 181 conditions (134 psychotherapy and 47 control conditions) with 6937 patients meeting criteria for major depressive disorder. Within these conditions, we calculated the absolute number of patients no longer meeting criteria for major depression, rates of response and remission, and the absolute reduction on the BDI, BDI-II, and HAM-D. Results After treatment, 62% of patients no longer met criteria for MDD in the psychotherapy conditions. However, 43% of participants in the control conditions and 48% of people in the care-as-usual conditions no longer met criteria for MDD, suggesting that the additional value of psychotherapy compared to care-as-usual would be 14%. For response and remission, comparable results were found, with less than half of the patients meeting criteria for response and remission after psychotherapy. Additionally, a considerable proportion of response and remission was also found in control conditions. In the psychotherapy conditions, scores on the BDI were reduced by 13.42 points, 15.12 points on the BDI-II, and 10.28 points on the HAM-D. In the control conditions, these reductions were 4.56, 4.68, and 5.29. Discussion Psychotherapy contributes to improvement in depressed patients, but improvement in control conditions is also considerable.
Article
Binge eating is characterized by significant imbalance in food intake regulation and is often comorbid with obesity and depression. Mindfulness-based approaches may reduce compulsive overeating, address associated behavioral and emotional dysregulation, and promote internalization of change. This randomized trial explored the efficacy of Mindfulness-Based Eating Awareness Training (MB-EAT), a 12-session group treatment, in comparison to a psychoeducational/cognitive–behavioral intervention (PECB) and a wait list control. MB-EAT incorporates sitting and guided mindfulness practices to cultivate greater awareness of hunger and fullness cues, sensory-specific satiety, and emotional and other triggers for eating. The two-site study randomized 150 overweight or obese (body mass index = 40.3) individuals (12 % men; 14 % African-American/Hispanic; average age = 46.6 years), 66 % of whom met the full DSM-IV-R criteria for binge eating disorder (BED). Compared to the wait list control, MB-EAT and PECB showed generally comparable improvement after 1 and 4 months post-intervention on binge days per month, the Binge Eating Scale, and depression. At 4 months post-intervention, 95 % of those individuals with BED in MB-EAT no longer met the BED criteria vs. 76 % receiving PECB; furthermore, binges that occurred were likely to be significantly smaller. Amount of mindfulness practice predicted improvement on a range of variables, including weight loss (r = −0.38, p < 0.05). Results suggest that MB-EAT decreased binge eating and related symptoms at a clinically meaningful level, with improvement related to the degree of mindfulness practice.
Article
Patients (N=135) with binge eating disorder (BED) were randomized to a control condition or to one of two 16-session group treatments: Group cognitive-behavioral therapy (GCBT) or group psychodynamic interpersonal psychotherapy (GPIP). The two treatments performed equally well, and each resulted in reduced days binged compared with the wait-list control condition. Twelve-month follow-up indicated that improvements were maintained in days binged and in other outcome variables. For women who completed GPIP, higher attachment anxiety was related to improvements in days binged by posttreatment. On the other hand, for women who completed GCBT, lower attachment anxiety was associated with improvements in days binged by posttreatment. Higher attachment avoidance was related to dropping out of GCBT. Although both GPIP and GCBT reduced binge eating, the results indicated that individual outcomes differ across treatments based on level of attachment anxiety and avoidance.
Article
The present study was designed to test the relative effectiveness of behavioral (B) and cognitive-behavioral (CB) group therapy programs in the treatment of 41 bulimic women. Subjects were randomly assigned to the two treatment conditions and a waiting list control (WLC). Multiple behavioral and psychological measures were administered at pretreatment, posttreatment, and 1- and 3-month follow-up. Results indicated that both treatments were superior to the WLC in decreasing the frequency of binge eating and the use of extreme weight control methods at post-treatment. However, only the B group was able to maintain reductions in binge eating throughout the follow-up period. In terms of psychological measures, both treatments evidenced significantly decreased bulimic tendencies and body dissatisfaction and significantly increased feelings of adequacy, security, and control which were maintained at follow-up. Only the CB group evidenced additional psychological changes in preoccupation with dieting and severity of psychopathologi-cal symptoms which were maintained at follow-up. The implications of these findings are discussed.
Article
Objective: The prognosis for eating disorders (ED) is unsatisfactory, and the literature about outcome indicators is controversial. The present study evaluates the roles of self-esteem, personality disorders (PD), and dissociation as outcome predictors. Method: Fifty-seven ED outpatients were recruited from a population beginning a Cognitive Behavioral Therapy-Enhanced (CBT-E) treatment. All patients received the Structured Clinical Interview for DSM-IV Axis I (SCID-I), the Structured Clinical Interview for DSM-IV Axis II (SCID-II), and completed the Eating Disorder Examination Questionnaire (EDE-Q), the Dissociation Questionnaire (DIS-Q), and the Rosenberg Self-Esteem Scale (RSES). One month after the end of treatment, recovery was evaluated as meeting the DSM-IV criteria for EDs. Results: A small group of patients recovered (42.2%). Low self-esteem and dissociation results correlated with a negative outcome. Discussion: Dissociation may be an important moderator of psychotherapy and treatment success, as already suggested by previous studies on non-eating-related disorders.
Article
Background: Although treatment guidelines suggest that suicidal patients with depression should be treated for depression with psychotherapy, it is not clear whether these psychological treatments actually reduce suicidal ideation or suicide risk. Methods: We conducted a systematic review and meta-analysis of studies on psychotherapy for depression in which outcomes on suicidality were reported. We also focused on outcomes on hopelessness because this is strongly associated with suicidal behavior in depression. Results: Thirteen studies (with 616 patients) were included, three of which examined the effects of psychotherapy for depression on suicidal ideation and suicide risk, and eleven on hopelessness. No studies were found with suicide attempts or completed suicides as the outcome variables. The effects on suicidal ideation and suicide risk were small (g=0.12; 95% CI: -0.20-0.44) and not statistically significant. A power calculation showed that these studies only had sufficient power to find an effect size of g=0.47. The effects on hopelessness were large (g=1.10; 95% CI: 0.72-1.48) and significant, although heterogeneity was very high. Furthermore, significant publication bias was found. After adjustment of publication bias the effect size was reduced to g=0.60. Discussion: At this point, there is insufficient evidence for the assumption that suicidality in depressed patients can be reduced with psychotherapy for depression. Although psychotherapy of depression may have small positive effects on suicidality, available data suggest that psychotherapy for depression cannot be considered to be a sufficient treatment. The effects on hopelessness are probably higher.
Article
The study reports the pre-post findings from a controlled comparative evaluation of treatments for bulimia nervosa. These pre-post results allow comparison of the hypnobehavioural and cognitive behavioural treatments with a waiting list control group and a comparison of the immediate effects of the two modalities. One hundred and thirty subjects were screened to enter the study. Seventy-eight subjects entered the investigation after being randomly allocated to either a waiting list control group, or to hypnobehavioural or cognitive behavioural groups. The treatments were delivered individually and matched in duration (8 weeks) and the number of sessions. Pre to posttreatment outcome indicated significant differences between the control group and the two treatments in reductions in bulimic behaviours and related eating pathology. The immediate effects of both treatments were equal. There were no differences at posttreatment between the treatments in abstinence from either bingeing or purging. The treatment effects were also similar to the immediate effects obtained by longer therapeutic approaches.
Article
Objective Cognitive therapy (CT) has been used in anorexia nervosa, but little is known about its effectiveness. A randomized controlled trial was undertaken comparing dietary advice (DA) with cognitive therapy in the outpatient treatment of AN.Method Thirty-five patients were randomly allocated to either cognitive therapy (n=25) or dietary advice (n=10). There were no significant differences in the groups pre-treatment. Twenty sessions of cognitive therapy or dietary advice were offered.ResultsAt 6 months 23 cognitive therapy patients remained engaged whereas all the dietary advice controls dropped out. Cognitive therapy patients showed significant changes in Body Mass Index (p=0.001), Eating Disorder Inventory Scores (p=0.035), Beck Depression Inventory Scores (p<0.0001) and Locus of Control of Behaviour Scores (p=0.017).Conclusions Significant improvements were observed in patients allocated to cognitive therapy, but not in those allocated to dietary advice on an intention to treat analysis. Cognitive therapy has advantages of promoting engagement and facilitating recovery. Copyright © 1999 John Wiley & Sons, Ltd and Eating Disorders Association.
Article
Twenty-nine women meeting criteria for Binge Eating Disorder (BED) were randomly assigned to Appetite Awareness Training (AAT; an 8-week cognitive-behavioral intervention) or a wait-list control. The goal of AAT is to establish an eating pattern in which: (a) the individual responds primarily to moderate (rather than strong) hunger and fullness cues; and (b) eating in response to non-appetite cues is minimized. The intervention uses an innovative form of self-monitoring based on appetite ratings rather than recording food intake. Compared to controls, AAT participants reported significantly greater reductions in both binge eating and overeating episodes; they did not report increased hunger nor did they gain weight. They also reported decreased urges to eat in several high-risk situations, and decreased symptoms of depression and social anxiety. Results provide initial support for the effectiveness of a form of cognitive behavior therapy utilizing appetite monitoring (AAT) and suggest that additional investigation of this intervention is warranted.
Article
Dialectical Behavior Therapy for Binge Eating Disorder (DBT-BED) aims to reduce binge eating by improving adaptive emotion-regulation skills. Preliminary findings have been promising but have only compared DBT-BED to a wait-list. To control for the hypothesized specific effects of DBT-BED, the present study compared DBT-BED to an active comparison group therapy (ACGT). Men and women (n=101) meeting DSM-IV BED research criteria were randomly assigned to 20 group sessions of DBT-BED (n=50) or ACGT (n=51). DBT-BED had a significantly lower dropout rate (4%) than ACGT (33.3%). Linear Mixed Models revealed that posttreatment binge abstinence and reductions in binge frequency were achieved more quickly for DBT-BED than for ACGT (posttreatment abstinence rate=64% for DBT-BED vs. 36% for ACGT) though differences did not persist over the 3-, 6-, and 12-month follow-up assessments (e.g., 12-month follow-up abstinence rate=64% for DBT-BED vs. 56% for ACGT). Secondary outcome measures revealed no sustained impact on emotion regulation. Although both DBT-BED and ACGT reduced binge eating, DBT-BED showed significantly fewer dropouts and greater initial efficacy (e.g., at posttreatment) than ACGT. The lack of differential findings over follow-up suggests that the hypothesized specific effects of DBT-BED do not show long-term impact beyond those attributable to nonspecific common therapeutic factors.
Article
Interpersonal psychotherapy (IPT) is an effective specialty treatment for binge eating disorder (BED). Behavioral weight loss treatment (BWL) and guided self-help based on cognitive behavior therapy (CBTgsh) have both resulted in short-term reductions in binge eating in obese patients with BED. To test whether patients with BED require specialty therapy beyond BWL and whether IPT is more effective than either BWL or CBTgsh in patients with a high negative affect during a 2-year follow-up. Randomized, active control efficacy trial. University outpatient clinics. Two hundred five women and men with a body mass index between 27 and 45 who met DSM-IV criteria for BED. Intervention Twenty sessions of IPT or BWL or 10 sessions of CBTgsh during 6 months. Binge eating assessed by the Eating Disorder Examination. At 2-year follow-up, both IPT and CBTgsh resulted in greater remission from binge eating than BWL (P < .05; odds ratios: BWL vs CBTgsh, 2.3; BWL vs IPT, 2.6; and CBTgsh vs IPT, 1.2). Self-esteem (P < .05) and global Eating Disorder Examination (P < .05) scores were moderators of treatment outcome. The odds ratios for low and high global Eating Disorder Examination scores were 2.8 for BWL, 2.9 for CBTgsh, and 0.73 for IPT; for self-esteem, they were 2.4 for BWL, 1.9 for CBTgsh, and 0.9 for IPT. Interpersonal psychotherapy and CBTgsh are significantly more effective than BWL in eliminating binge eating after 2 years. Guided self-help based on cognitive behavior therapy is a first-line treatment option for most patients with BED, with IPT (or full cognitive behavior therapy) used for patients with low self-esteem and high eating disorder psychopathology. clinicaltrials.gov Identifier: NCT00060762.
Article
The purpose of this investigation was to compare three types of treatment for binge eating disorder to determine the relative efficacy of self-help group treatment compared to therapist-led and therapist-assisted group cognitive-behavioral therapy. A total of 259 adults diagnosed with binge eating disorder were randomly assigned to 20 weeks of therapist-led, therapist-assisted, or self-help group treatment or a waiting list condition. Binge eating as measured by the Eating Disorder Examination was assessed at baseline, at end of treatment, and at 6 and 12 months, and outcome was assessed using logistic regression and analysis of covariance (intent-to-treat). At end of treatment, the therapist-led (51.7%) and the therapist-assisted (33.3%) conditions had higher binge eating abstinence rates than the self-help (17.9%) and waiting list (10.1%) conditions. However, no between-group differences in abstinence rates were observed at either of the follow-up assessments. The therapist-led condition also showed more reductions in binge eating at end of treatment and follow-up assessments compared to the self-help condition, and treatment or waiting period completion rates were higher in the therapist-led (88.3%) and waiting list (81.2%) conditions than in the therapist-assisted (68.3%) and self-help (59.7%) conditions. Therapist-led group cognitive-behavioral treatment for binge eating disorder led to higher binge eating abstinence rates, greater reductions in binge eating frequency, and lower attrition compared to group self-help treatment. Although these findings indicate that therapist delivery of group treatment is associated with better short-term outcome and less attrition than self-help treatment, the lack of group differences at follow-up suggests that self-help group treatment may be a viable alternative to therapist-led interventions.
Article
The aim of this study was to compute and compare mean effects of various treatments for binge eating disorder. A total of 38 studies with 1973 participants fulfilled the defined inclusion criteria. Effect sizes, odds ratios, and simple rates were integrated in fixed and random (mixed) effects categorical models. From randomized controlled trials, psychotherapy and structured self-help, both based on cognitive behavioral interventions, were found to have large effects on the reduction of binge eating. Regarding pharmacotherapy, mainly comprising antidepressants, randomized controlled trials revealed medium effects for the reduction of binge eating. Uncontrolled studies on weight-loss treatments demonstrated moderate reductions of binge eating. Combination treatments did not result in higher effects compared with single-treatment regimens. Except for weight-loss treatment, none of the interventions resulted in a considerable weight reduction. Psychotherapy and structured self-help, both based on cognitive-behavioral interventions, should be recommended as the first-line treatments.
Article
The purpose of the present study was to evaluate reducing perfectionism as a potential treatment target for individuals with Bulimia Nervosa (BN). Forty-eight individuals meeting DSM-IV criteria for BN or eating disorder - not otherwise specified with binge eating [objective or subjective] or purging at least once per week were recruited. Participants were randomly assigned to receive 8 sessions of manual-based guided self-help (GSH) over a 6-week period that was focused on either cognitive behaviour therapy (CBT) for perfectionism, CBT for BN, or a placebo. Individuals were assessed at baseline, pre-treatment, post-treatment and at six-month follow-up on 12 outcome variables, including diagnostic criteria and psychological variables. There was no significant change in any of the outcome variables over a 6-week no-treatment period but at post-treatment and 6-month follow-up there were significant main effects of time for 10 and 8 outcome variables respectively, suggesting that all groups reported significant reductions in bulimic symptomatology and related psychopathology at post-treatment and follow-up. These findings show potential for the use of novel interventions in GSH for BN.
Article
Outcome predictors of a cognitive behavioural group treatment for bulimia nervosa were examined. Pre-treatment self-esteem, binge frequency and ineffectiveness, but not duration of disorder, significantly predicted outcome on at least one measure (binge frequency or overall eating pathology) at post-treatment and/or three-month follow-up. The results are related to previous studies and to theories of maintenance of the disorder.
Article
Synopsis In constructing a new self-report questionnaire for measuring self esteem, the aim has been to satisfy psychometric requirements without sacrificing the intuitive meaning of the concept. Self esteem is seen as a composite, and examination of its components may have more analytic or predictive value than ‘ global’ scores. Preliminary reliability and validity data are encouraging.
Article
Preliminary results are reported on the efficacy of a 4-month group (n = 8) therapy compared with waiting-list controls (n = 9) in women with DSM-III bulimia. Treatment consisted of a standard behaviorally oriented stress management program and of basic nutritional management. A significantly greater decrease in binge frequency and specific psychopathology was found in the treated compared with the waiting-list group. The treated subjects showed further improvement 3 months after treatment termination. The usefulness of the different treatment components is briefly discussed.
Article
A psychotherapy study for bulimia is described. The preliminary results of a random allocation control trial comparing cognitive behaviour therapy, behaviour therapy and group psychotherapy with a waiting list control are presented. The results of the first 60 subjects in active treatment are shown. They indicate that all three treatments are effective in dramatically reducing the behavioural symptoms of the bulimia syndrome. There is evidence that cognitive therapy has a greater effect on symptoms of depression and self-esteem. No evidence is yet available on the longterm outcome of the three treatments.
Article
This study examined the relative efficacy of cognitive-behavioral and behavioral treatment approaches for bulimia nervosa. Female bulimic Ss were randomly assigned to cognitive-behavioral, behavioral, or attention placebo conditions. At posttreatment, 92% of the cognitive-behavioral group, 100% of the behavioral group, and 69% of the nonspecific self-monitoring group were abstinent from binge eating-purging. At 6-month follow-up, 69% of the cognitive-behavioral group, 38% of the behavioral group, and 15% of the nonspecific self-monitoring group were abstinent from binge eating and purging. The results support the conceptualization of bulimia nervosa as a multifaceted disorder best treated with an approach that directly addresses maladaptive cognitions, problematic behaviors, and the development of more adaptive coping skills.