Short-Term Outcomes of a 12-Step Program among Women with Anorexia,Bulimia, and Eating Disorders

I examined the short-term effectiveness of a 12-Step, inpatient program incorporated into a multimodal approach to the treatment of eating disorders, and the differences among individuals with different types of eating disorders. Results showed that at the 6-month follow-up, all individuals were within the pathological range on all subscales of the EDI-2 instrument. No statistically significant differences were found between the groups on any of the demographic characteristics. Fourteen of the 42 subjects (33.3%) identified themselves as abstinent or devoid of undesirable eating behaviors at the 6-month time period, with 23.8% identified as being at least “somewhat” in relapse.     

A multimodal treatment strategy for behavior problems in toddlers

The article focuses on a multimodal strategy for the treatment of behavior problems commonly associated with toddlers. These problem behaviors, which include temper tantrums, bedtime and sleep difficulties, aggressiveness, not listening, and eating problems, are among the most often presented to mental health professionals who deal with this age group. The treatment approach, which combines clinically pertinent aspects of dynamic, behavioral, and family approaches, includes the following components: data collection (problem clarification, family-of-origin interviews, interactional sessions), formulation of hypotheses, introduction of a behaviorally oriented management program, tracking of problems inherent in the implementation and successful management of the behavioral program, and booster sessions. The treatment strategy is illustrated by a clinical case. Each component of the treatment, along with its inherent clinical problems/difficulties, is discussed.     

Exploring Mechanisms of Action in Exposure-Based Cognitive Behavioral Therapy for Eating Disorders: The Role of Eating-Related Fears and Body-Related Safety Behaviors

Evidence-based cognitive behavioral therapy for eating disorders includes a component of exposure therapy, which involves patients confronting feared eating and body-related stimuli while preventing safety behaviors. With recent research demonstrating that eating-related fears and safety behaviors are central to eating disorder pathology, there is increased emphasis on improving the efficacy of exposure therapy in eating disorders. Doing so will require a better understanding of important mechanisms of action in this treatment. The present study explored how changes during treatment in eating-related fears and avoidance as well as body-related safety behaviors influence overall treatment outcomes. Individuals with eating disorders (N = 71) receiving exposure-based treatment completed measures of global eating disorder severity at admission and discharge. Hypothesized mechanisms of action were also assessed at admission and discharge as well as at a 2-week time point after beginning treatment. Path modeling analyses showed that decreased eating-related cognitions (feared concerns about eating) and emotions (anxiety about eating) at the 2-week time point were prospectively predictive of lowered global eating disorder symptom severity at discharge. Additionally, reduced body checking and avoidance behaviors after 2 weeks of treatment were also associated with lower eating disorder severity at discharge. These findings highlight the importance of exposure-based therapy in eating disorders and the need to uniquely address eating-related fears and safety behaviors.     

Towards effective treatment of eating disorders: nothing is as practical as a good theory

There is much room for improvement in the treatment of eating disorders, anorexia nervosa in particular. It is argued that for more effective treatment a radical change in thinking and doing is needed. First, the wide-spread multicausal model of eating disorders must be abandoned and replaced by (a) fundamental strategic research into the most parsimonious explanation of eating disorders and (b) interventions solely directed on the specific maintaining mechanisms. Second, evidence-based working is needed in mental health care. In daily practice, two of three psychotherapists do not treat their eating disordered patients with the best treatment available, i.e. cognitive behaviour therapy. The Dutch Ministry of Health, Welfare and Sport tried to improve the care for eating disorder patients by the nomination of several specialist hospital units. These units are, however, not selected for their treatment quality or the use of evidence-based treatment protocols. It is argued that this ministerial operation will not increase the supply of effective treatment. The Minister obviously should have done two other things to improve the amount and quality of treatment supply for eating disorders: First, she better could invest in a broad array of workshops, training and supervision programs in cognitive behaviour therapy for all psychotherapists working with eating disorders. Second, since nothing is so practical as a good theory, the facilitation of research into parsimonious models of the relevant mechanisms as well as the experimental tests of interventions on these mechanisms would have been a promising move to effective treatment.     

A receiver operator characteristics analysis of treatment outcome in binge eating disorder to identify patterns of rapid response

The purpose of this study was to perform a receiver operator characteristics (ROC) analysis on a treatment sample from a randomized controlled treatment trial of participants with binge eating disorder (BED). An ROC analysis was completed with 179 adults in a 20-week treatment trial for BED to predict abstinence from binge eating at end of treatment. Percent reductions in binge eating episodes were examined following weeks 1 through 10 of treatment. The rate of percent decrease in binge eating episodes during treatment for BED was a significant predictor of clinical outcome at end of treatment. Participants who demonstrated a 15% reduction in binge eating episodes at week one were more likely to respond positively to treatment and achieve clinical remission. Findings from the current study suggest that a significant reduction in binge eating during the first week of treatment may be predictive of end of treatment remission in those with BED.     

Increased wait-list time predicts dropout from outpatient enhanced cognitive behaviour therapy (CBT-E) for eating disorders

Between 30 and 70% of patients with eating disorders drop out from outpatient treatment. However, research has been unable to identify factors that consistently predict dropout from eating disorder treatment. Most studies have exclusively investigated the role that individual patient characteristics play in dropout and have ignored more process-based factors such as expectations about treatment, the therapeutic alliance, or time spent on a treatment waiting list. This study aimed to investigate the roles of both individual patient characteristics and process-based factors in dropout from outpatient treatment for eating disorders. The study involved data collected from consecutive eating disorder referrals to the only public specialist eating disorder service for youth and adults in Perth, Western Australia. The standard treatment provided at this service is Enhanced Cognitive Behaviour Therapy on an individual basis. The study involved 189 patients referred to the service between 2005 and 2010. Forty five percent of this sample dropped out of treatment. Results showed that, in this sample, two individual factors, lowest reported weight and the tendency to avoid affect, and one process-based factor, time spent on the wait list for treatment, were significant predictors of dropout. These findings are valuable because a process-based factor, such as wait-list time, may be easier to address and modify than a patient's weight history or the trait of mood intolerance. Increased resources for eating disorder services may reduce waiting list times which would help to reduce dropout and maximize treatment outcomes.     

Family therapy and systemic interventions for child‐focused problems: the current evidence base

This review updates previous similar papers published in JFT in 2000, 2009 and 2014. It presents evidence from meta‐analyses, systematic literature reviews, narrative literature reviews and controlled trials for the effectiveness of systemic interventions for families of children and adolescents with common mental health problems and other difficulties. In this context, systemic interventions include both family therapy and other family‐based approaches such as parent training, or parent implemented behavioural programmes. The evidence supports the effectiveness of systemic interventions either alone or as part of multimodal programmes for sleep, feeding and attachment problems in infancy; recovery from child abuse and neglect; conduct problems, emotional problems, eating disorders, somatic problems, and first episode psychosis.     

Heavenly Bodies: Religious Issues in Cognitive Behavioral Treatment of Eating Disorders

Minimal attention has been given to the role that religion may play in the development, maintenance, and treatment of eating disorders. Many religions espouse specific doctrines about the nature and purpose of the body as well as prescribe particular body grooming and eating practices. These doctrines and practices influence individuals' schemas and experiences of the body and eating, which can either contribute to or provide protection from eating disorders. This paper describes pathways through which religious beliefs and practices may impact risk for and maintenance of eating disorders. Methods for integrating religious concepts, practices, and resources into standard cognitive-behavioral treatment for eating disorders are discussed, including interventions that address purported religiously oriented contributory and protective factors. Treatment of a religious client with an eating disorder is described to illustrate the incorporation of religiously oriented interventions in practice.     

Developing an Acceptance-Based Behavioral Treatment for Binge Eating Disorder: Rationale and Challenges

Binge eating disorder (BED), characterized by recurrent eating episodes in which individuals eat an objectively large amount of food within a short time period accompanied by a sense of loss of control, is the most common eating disorder. While existing treatments, such as cognitive behavioral therapy (CBT), produce remission in a large percentage of individuals with BED, room for improvement in outcomes remains. Two reasons some patients may continue to experience binge eating after a course of treatment are: (a) Difficulty complying with the prescribed behavioral components of CBT due to the discomfort of implementing such strategies; and (b) a lack of focus in current treatments on strategies for coping with high levels of negative affect that often drive binge eating. To optimize treatment outcomes, it is therefore crucial to provide patients with strategies to overcome these issues. A small but growing body of research suggests that acceptance-based treatment approaches may be effective for the treatment of binge eating. The goal of the current paper is to describe the development of an acceptance-based group treatment for BED, discuss the structure of the manual and the rationale and challenges associated with integrating acceptance-based strategies into a CBT protocol, and to discuss clinical strategies for successfully implementing the intervention.     

Dialectical Behavior Therapy: Does It Bring About Improvements in Affect Regulation in Individuals with Eating Disorders?

The current investigation sought to determine whether a standard outpatient dose of dialectical behavior therapy (DBT) skills training (2 h per week) coupled with standard CBT treatment would be sufficient to produce changes in affect regulation over the course of day hospitalization treatment. In an uncontrolled pre-post treatment design, 65 women diagnosed with anorexia nervosa or bulimia nervosa were assessed at the beginning of treatment and at the end of treatment on affect regulation. Findings indicated that participants demonstrated a significant improvement in their ability to regulate affect, suggesting that weekly DBT treatment may play an important role in producing changes in affect regulation. Secondary analyses on eating disorder outcomes revealed a significant increase in weight gain as well as a significant reduction in restriction, bingeing, purging and eating disordered cognitions. Findings are discussed in the context of clinical and treatment implications for those with severe eating disorders.     

Guided and unguided self-help for binge eating

This study compared the relative short- and longer-term efficacy of therapist-guided and unguided use of a cognitive behavioral self-help manual for binge eating [Fairburn, C. G. (1995). Overcome binge eating. New York: The Guilford Press.] Forty women (82.5% with binge eating disorder) were randomized to one of the two treatment levels. Results indicate that both conditions represent viable means of treating binge eating. Overall, patients improved their eating behavior, eliminated any inappropriate compensatory behaviors, reduced their shape concern, weight concern, and other symptoms of eating-related psychopathology, and improved their general psychological functioning. The guided self-help condition was notably superior in reducing the occurrence of binge eating and its associated symptomatology, as well as lowering interpersonal sensitivity. A high degree of general psychopathology was a negative prognostic indicator. The implications for a stepped-care approach to treating binge eating are discussed.     

Adjunctive mirror exposure for eating disorders: A randomized controlled pilot study

Mirror exposure therapy has proven efficacious in improving body image among individuals with shape/weight concerns and eating disorders. No randomized controlled trials have examined the effect of mirror exposure in a healthy-weight clinical sample of eating disordered individuals. The purpose of the current study was to test the efficacy of a five-session acceptance based mirror exposure therapy (A-MET) versus a non directive body image therapy (ND) control as an adjunctive treatment to outpatient eating disorder treatment. Thirty-three males and females aged 14–65 with a body mass index of 18.5–29.9 were randomized to five sessions of A-MET or ND with a 1-month follow-up. Results indicated large to moderate effect size differences for efficacy of A-MET across measures of body checking, body image dissatisfaction, and eating disorder symptoms (d = ?0.38 to ?1.61) at end of treatment and follow-up. Baseline measures of social comparison and history of appearance-related teasing were predictive of treatment response. There were also differential effects of treatment on participants' perceived homework quality, but no differences in therapeutic alliance. Results suggest that A-MET is a promising adjunctive treatment for residual body image disturbance among normal and overweight individuals undergoing treatment for an eating disorder. Future research and clinical implications are discussed.     

The effectiveness of family therapy and systemic interventions for child-focused problems

This review updates a similar paper published in the Journal of Family Therapy in 2001. It presents evidence from meta-analyses, systematic literature reviews and controlled trials for the effectiveness of systemic interventions for families of children and adolescents with various difficulties. In this context, systemic interventions include both family therapy and other family-based approaches such as parent training. The evidence supports the effectiveness of systemic interventions either alone or as part of multimodal programmes for sleep, feeding and attachment problems in infancy; child abuse and neglect; conduct problems (including childhood behavioural difficulties, ADHD, delinquency and drug abuse); emotional problems (including anxiety, depression, grief, bipolar disorder and suicidality); eating disorders (including anorexia, bulimia and obesity); and somatic problems (including enuresis, encopresis, recurrent abdominal pain, and poorly controlled asthma and diabetes).     

Dialectical Behavior Therapy Modified for Adolescent Binge Eating Disorder: A Case Report

Given the lack of empirically supported treatments available for adolescents with eating disorders, it is important to investigate the clinical utility of extending treatments for adults with eating disorders to younger populations. Dialectical behavior therapy for binge eating disorder, based on the affect-regulation model, conceptualizes binge eating as a behavioral attempt to influence, change, or control painful emotional states. With promising research findings in adult women, it is of clinical interest whether the dialectical behavior therapy for binge eating disorder treatment manual could be usefully adapted for an adolescent population. This report describes adolescent-specific modifications (including the use of family sessions) to standard dialectical behavior therapy for binge eating disorder, with an illustrative case study. While more rigorous case studies are needed prior to establishing justification for a randomized trial, this pilot case provides preliminary support for a modified version of dialectical behavior therapy for binge eating disorder as a therapeutic option for adolescents with binge eating disorder.     

The (Extremely) Picky Eaters Clinic: A Pilot Trial of a Seven-Session Group Behavioral Intervention for Parents of Children With Avoidant/Restrictive Food Intake Disorder

Excessive and impairing picky eating is a common problem among children for which there is little published research on efficacious psychosocial treatment. Extant research largely concerns single-case studies, or small samples of very young children, who are typically treated in hospital settings. This paper reports on outcomes of 21 children (ages 4–11) described by their parents as extremely picky eaters who met criteria for avoidant/restrictive food intake disorder not associated with a developmental disorder, other eating disorder, or other eating-related anxiety disorder (e.g., specific phobia of vomiting or choking). Seven cohorts of two to four families each took part in a seven-session manualized parent-only group treatment in an outpatient setting. This group treatment focused on training parents to serve as effective coaches for daily in-home exposures to nonpreferred foods, as well as in components of parent management training to reduce problematic mealtime behaviors. Parents completed standardized feeding measures to assess picky eating and associated problem mealtime behaviors at pretreatment, posttreatment, and at 3-month follow-up, as well as a satisfaction measure at posttreatment. Results showed excellent feasibility and adherence by parents and high parent satisfaction with treatment. Paired t tests to measure within-group change showed significant pre–post treatment reductions in picky eating scales with moderate to large effect sizes. Gains were maintained at 3-month follow-up. Findings indicate that a relatively brief group treatment that focuses specifically on training parents to facilitate and carry out food exposures and contingency management procedures in their homes is associated with reductions in functionally impairing picky eating and related negative mealtime behaviors in elementary school-age children.     

The relationship between basic need satisfaction and emotional eating in obesity

Emotional eating has been identified as a factor that promotes the development and maintenance of obesity and hinders its treatment. This study investigated the relationship between unsatisfied basic needs and emotional eating, including the mediating factors of self‐esteem and coping strategies. The results from a survey of 136 obese individuals indicated support for a significant relationship between basic need satisfaction and emotional eating, with a mediating effect of negative coping strategies. These findings extend previous research and provide guidance on how to help individuals who engage in emotional eating by focusing on developing more adaptive coping strategies.     

Process Analyses of Impulsive Behavior in Binge-Eating Disorder During the Randomized Controlled IMPULS Trial

Impulsivity represents a risk factor for patients with binge-eating disorder, and we therefore investigated the treatment process of impulsive behaviors including binge-eating episodes in the randomized controlled IMPULS trial. Using 8 weekly online questionnaires throughout the assessment period, we compared 41 patients participating in the IMPULS program, which emphasized impulsive eating behavior (IG), with 39 control patients who received no intervention (CG). We assessed the frequency of binge eating, other impulsive behaviors, situations in which such behaviors could be inhibited, and the execution of alternative behaviors. Results indicate a stronger binge-eating reduction in the IG compared to the CG at the fifth, seventh, and eighth treatment weeks. Overall, both groups reduced other impulsive behaviors. They did not differ in the amount of inhibited impulsive behaviors and showed similar alternative behaviors, “distraction” most frequently used. IG patients evaluated the IMPULS program as very helpful. The stronger reduction of binge eating in the IG and positive evaluation of the treatment indicate a specific treatment effect regarding impulsive eating behavior. The reduction of other impulsive behaviors across both groups, and the initial reduction of binge eating within the CG, could be explained by an increased degree of self-observation.     

A PRELIMINARY EVALUATION OF EMPIRICALLY DERIVED CONSEQUENCES FOR THE TREATMENT OF PICA

Individualized treatment packages were developed for 3 children with high-rate severe pica using a discrimination training paradigm and a behavioral assessment-based procedure known as empirically derived consequences. Children received empirically derived reinforcers for eating under appropriate stimulus conditions (i.e., eating food only from a plate and placemat that served as a discriminative stimulus) and empirically derived punishers for attempts to engage in pica. This treatment package resulted in marked reductions in pica and an increase in appropriate eating for all 3 children in a “baited” analogue condition. In addition, low rates of pica were maintained for 9 months for all 3 children. These results suggest that treatment effectiveness may be enhanced when behavioral assessment data are used to identify potent consequences.     

Bulimic Eating Disorders in Primary Care: Hidden Morbidity Still?

The current study examined the features of women with bulimic-type eating disorders (n = 24) attending primary care in two smaller urban regions of the USA. The assessment included measures of eating disorder psychopathology, medical comorbidity, impairment in role functioning, potential barriers to treatment and actual use of health services. Eating disorders, primarily variants of bulimia nervosa and binge eating disorder not meeting formal diagnostic criteria, were associated with marked impairment in psychosocial functioning. Although two-thirds of participants recognized a problem with their eating, less than 40% had ever sought treatment from a health professional for an eating or weight problem and only one in ten had sought such treatment from a mental health specialist. Only one-third had ever been asked about problems with eating by a primary care practitioner or other health professional. However, more than 80% had sought treatment from a health professional for symptoms of anxiety or depression. Most reported some degree of discomfort in discussing eating problems with others, and half reported that they would not be truthful about such problems if asked. Having an eating disorder was associated with several chronic medical conditions, including joint pain, gastrointestinal problems and fatigue. Although the small sample size limits any firm conclusions, the findings suggest that the health burden of bulimic-type eating disorders is substantial but remains largely hidden. Efforts may be needed to improve the eating disorders “mental health literacy” of both patients and primary care practitioners in order to facilitate early, appropriate intervention.