Group therapy for eating disorders: A step-wise approach

Group therapy is emerging as a favored treatment for eating disorders. Open-ended psychodynamic group therapy is an effective treatment for the underlying conflicts in eating-disordered patients, yet these groups are difficult to form. The authors suggest a specific sequence using time-limited psychoeducational groups initially for symptom control, then offering an open-ended group for patients who are ready to address deeper issues in a group therapy setting.     

Untreated recovery from eating disorders

This retrospective study explored the experience of recovery from anorexia nervosa and bulimia nervosa without professional treatment. A nine-question open-ended electronic survey was posted for a period of four months at a mid-western university. Sixteen female and two male respondents reported recovery from adolescent-onset full syndrome anorexia nervosa or bulimia nervosa. All respondents reported onset factors supporting a sociocultural etiology. Recovery was initiated through the empathic, participatory efforts of parents and friends, or was self-initiated. Respondents with the shortest disorder duration and most complete recovery reported early parental intervention. Onset factors similar to those in research with a clinically treated population were found. Implications of the findings are discussed.     

Group cognitive behavioural therapy for heterogeneous anxiety disorders

Evidence assessing the outcome of cognitive behavioural therapy for anxiety is based on protocols specifically tailored for individual disorders. To date, there is little research that would assess a mode of delivery that is designed for routine service delivery in typical clinical settings, i.e. group cognitive behavioural therapy for unselected, mixed groups of anxiety disorders. The objective of this pilot study is to use program evaluation methods to assess the immediate and enduring improvements following a 12-week Anxiety Management Group. Group participants had any of 5 anxiety disorders and described related avoidance. The weekly 2-hour group sessions and daily homework tasks were guided by a participant handbook. Patients completed questionnaires at baseline and group completion (n = 70); a subset also provided 6-month follow-up data. The results from post-group scores on 2 self-report measures show immediate reductions equivalent to an effect size of eta = 0.73 (p < 0.001). The effect is maintained at 6-month follow-up. This program evaluation suggests that group cognitive behavioural therapy for heterogeneous anxiety disorders may be effective in a routine clinical setting. A more rigorous study of this heterogeneous format appears justified.     

Using group therapy to foster the psychosexual development of patients with eating disorders

When eating-disordered patients participate in long-term eating-dis-order groups, they move through phases of group development that parallel phases of psychosexual development. In the trust (oral) phase, members have an opportunity to experience a positive symbiosis, a suitable holding environment, and optimal frustration. In the control (anal) phase, members learn to identify and express anger constructively. In the intimacy (oedipal) phase, members learn to compete and be intimate. Individual and group movement is facilitated by the group leader being able to identify stages of group development and being able to utilize phase-related techniques.Many thanks to Anne Alonso, Ph.D., Robert Dies, Ph.D., and Geraldine Alpert, Ph.D., for their critiques of the first draft of this paper.     

Saliva DHEAS changes in patients suffering from psychopathological disorders arising from bullying at work

BACKGROUND: Psychological disorders arising from bullying at work (BW) are common. The relationship between these disorders and putative markers is not well established. AIMS: To measure saliva dehydroepiandrosterone sulphate (DHEAS) and saliva cortisol as putative markers in individuals suffering from BW. METHODS: Forty one subjects suffering from BW were screened for mental distress at the institute of occupational health in Clermont-Ferrand, France. They were compared with 28 psychologically healthy controls (group C). The conditions causing BW were recorded. The hospital anxiety and depression (HAD) scale, the Beech questionnaire and the visual analogic scale (VAS) of stress were used to determine the psychological consequences of BW. Saliva samples were collected at awakening (7am), 30 and 60min after awakening, and then every 2h until bed time (11pm). RESULTS: The BW group had significantly higher scores on the HAD scale, higher stress on the VAS, and a higher score on the Beech questionnaire. They also had a significantly higher saliva concentration of DHEAS. There was no significant difference between groups in cortisol levels at any time, nor in area under the curve (AUC) and cortisol awakening response (CAR). There was a significant positive correlation between HAD and VAS scores and DHEAS levels, but not between cortisol levels or AUC or CAR. CONCLUSION: In contrast to saliva cortisol levels, saliva DHEAS levels are modified after psychological distress arising from BW. This discrepancy probably arises from the stability conferred by the very long half life of DHEAS of about 15h.     

Risk factors for eating disorders

The authors review research on risk factors for eating disorders, restricting their focus to studies in which clear precedence of the hypothesized risk factor over onset of the disorder is established. They illustrate how studies of sociocultural risk factors and biological factors have progressed on parallel tracks and propose that major advances in understanding the etiology of eating disorders require a new generation of studies that integrate these domains. They discuss how more sophisticated and novel conceptualizations of risk and causal processes may inform both nosology and intervention efforts.     

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.     

The effect of inpatient cognitive-behavioral therapy for eating disorders on temperament and character

Personality traits seem to have an important role in the development, clinical expression, course, and treatment response in eating disorders (EDs). We investigated the effects of an inpatient cognitive-behavioral treatment (CBT) on the measures of temperament and character (Temperament and Character Inventory (TCI)) in 149 consecutive patients with EDs. Baseline assessment included anthropometry, the Eating Disorder Examination (EDE), the Beck Depression Inventory (BDI), and the TCI. Treatment was based on the transdiagnostic cognitive behavior theory and treatment of ED, adapted for an inpatient setting. Treatment effects were tested by paired ANOVA, adjusted for covariates. No effects were found on Novelty Seeking, Reward Dependence, and Cooperativeness. Harm Avoidance (F=18.17, p<0.001), Persistence (F=7.71, p=0.006), Self-Directedness (F=27.55, p<0.001), and Self Transcendence (F=16.38, p<0.001) significantly changed after treatment. Changes in TCI scores were wholly dependent on the changes in BDI and EDE, and independent of ED diagnosis and behavior and of BMI changes. We conclude that in ED, a few scales of both temperament and character are significantly modified by CBT, in relation to changes in psychopathology and depression, independently of nutrition. These results are relevant for future studies based on TCI.     

Attachment narrative therapy: integrating ideas from narrative and attachment theory in systemic family therapy with eating disorders

This paper proposes that recent developments in attachment theory, especially the move to the study of representations, offers some helpful new directions for systemic family therapy. Some of the findings of a close association between early attachment experiences and the coherence of the narratives are reviewed. It is suggested that this offers a useful link for systemic approaches in showing how early interactions in families promote not only particular emotional attachment patterns, but also shape the content and style of the narratives that are formed. These implications are then explored in the context of work with anorexia nervosa. It is suggested that commonly observed patterns, such as avoidance of conflict and apparent difficulties in discussing relationships and feelings, is consistent with transgenerational experiences of insecure/avoidant attachments. Some implications for systemic therapy with families are outlined and an illustrative case study is offered.     

Cognitive behaviour therapy for eating disorders: a "transdiagnostic" theory and treatment

This paper is concerned with the psychopathological processes that account for the persistence of severe eating disorders. Two separate but interrelated lines of argument are developed. One is that the leading evidence-based theory of the maintenance of eating disorders, the cognitive behavioural theory of bulimia nervosa, should be extended in its focus to embrace four additional maintaining mechanisms. Specifically, we propose that in certain patients one or more of four additional maintaining processes interact with the core eating disorder maintaining mechanisms and that when this occurs it is an obstacle to change. The additional maintaining processes concern the influence of clinical perfectionism, core low self-esteem, mood intolerance and interpersonal difficulties. The second line of argument is that in the case of eating disorders shared, but distinctive, clinical features tend to be maintained by similar psychopathological processes. Accordingly, we suggest that common mechanisms are involved in the persistence of bulimia nervosa, anorexia nervosa and the atypical eating disorders. Together, these two lines of argument lead us to propose a new transdiagnostic theory of the maintenance of the full range of eating disorders, a theory which embraces a broader range of maintaining mechanisms than the current theory concerning bulimia nervosa. In the final sections of the paper we describe a transdiagnostic treatment derived from the new theory, and we consider in principle the broader relevance of transdiagnostic theories of maintenance.     

Changes in alcohol intake in response to transdiagnostic cognitive behaviour therapy for eating disorders

Objective

The aim of this study was to examine how alcohol intake changes during and after transdiagnostic cognitive behaviour therapy for eating disorders (CBT-E). Additionally, the paper considers the relationship between alcohol consumption, eating disorder diagnosis and current major depressive episode at the time of first assessment.

Method

One hundred and forty nine outpatients with an eating disorder (body mass index over 17.5) were divided into high or low alcohol intake groups (HIG and LIG) according to their intake at pre-treatment assessment. Their alcohol intake and eating disorder psychopathology were examined over the course of treatment and follow-up.

Results

There was no difference between the groups on response of the eating disorder to treatment. The HIG significantly reduced their alcohol intake following treatment whilst the intake of the LIG remained stable over the course of treatment and follow-up. There were no group differences in major depression and overall severity of eating disorder at baseline.

Conclusions

The response to CBT-E was not influenced by baseline level of alcohol use. The mean alcohol intake of the heavy drinking subjects decreased without being specifically addressed by the treatment.