The Cognitive‐Behavioural Theory and Treatment of Bulimia Nervosa: An Examination of Treatment Mechanisms and Future Directions

Enhanced cognitive‐behavioural therapy (CBT‐E) is the current treatment of choice for bulimia nervosa. While the cognitive‐behavioural theory and treatment of bulimia nervosa have made a substantial contribution to our understanding of the disorder, approximately half of patients treated with CBT‐E fail to achieve remission of binge eating and purging. There is evidence showing that mechanisms proposed by the CBT‐E model are associated with binge eating and purging symptoms, and therefore likely important targets for treatment. To identify future directions in improving the efficacy of this treatment, and informed by a model of the client change process, we review the evidence for the hypothesised treatment mechanisms of CBT‐E. We conclude that while the proposed treatment mechanisms of CBT‐E largely change over the course of treatment, there is limited evidence that the treatment manipulations of CBT‐E are responsible for the specific changes in the proposed treatment mechanisms. In addition, given a lack of research in this area, we could find no evidence that changes in the additional treatment mechanisms outlined in CBT‐E are associated with changes in the core symptomatology of binge eating and purging. Based on these findings, we recommend that future efforts are directed towards understanding the client change process in CBT‐E and outline three clear directions for research.     

Psychiatric Disorders and Childhood Parental Loss in Obesity: Relationship with the Mode of Weight Gain

We assessed the association between psychiatric disorders, childhood parental loss, and weight gain mode in 150 obese patients seeking bariatric surgery and with a history of sudden or gradual weight gain mode. Subjects with sudden weight gain mode (47%) showed significantly higher bipolar II disorder (p < .001), childhood parental death (p < .01), and separation (p < .01), but lower pure hypomania (p < .001) prevalence than subjects with gradual weight gain mode. We found preliminary evidence that lifetime bipolar spectrum disorders and childhood parental loss may influence weight gain mode in obese subjects. These findings may contribute to predict patients’ weight trajectories and implement preventive interventions.     

Dialectical Behavior Therapy of Anorexia and Bulimia Nervosa Among Adolescents: A Case Series

The aim of this study was to describe a case series of adolescents (mean age = 16.5 years, SD = 1.0) with anorexia nervosa (AN) and bulimia nervosa (BN) who received dialectical behavior therapy (DBT). Twelve outpatients with AN and BN took part in 25 weeks of twice weekly therapy consisting of individual therapy and a skills training group. Family members were involved in the treatment. The patients were compared pre- and posttreatment on behavioral symptoms of AN and BN and symptoms of general psychopathology using standardized instruments (Structured Inventory for Anorectic and Bulimic Syndromes, Eating Disorder Inventory-2, The Symptom Checklist-90-Revised). Posttreatment, significant improvements in behavioral symptoms of eating disorder and symptoms of psychopathology were identified. The application of DBT adapted for the treatment of AN and BN among adolescents was associated with a decrease in behavioral symptoms of eating disorders and symptoms of general psychopathology. However, randomized controlled studies are required to prove the efficacy of this approach.     

Primary Care Provider Familiarity with Binge Eating Disorder and Implications for Obesity Management: A Preliminary Survey

Current guidelines for the evaluation and treatment of obesity recommend referring individuals with binge eating disorder (BED) to a mental health professional. However, it is unclear how familiar primary care providers are with BED. The purpose of this study was to assess providers' familiarity with BED diagnosis and treatment. Providers in two primary care clinics completed a questionnaire, which assessed perceived familiarity with BED and demonstrated familiarity with BED diagnosis and treatment. Results indicated that 61% of respondents demonstrated familiarity with the essential symptoms of BED, and 80% reported familiarity with the diagnosis of BED. However, 35% of respondents who perceived themselves as familiar with BED did not demonstrate familiarity with the most basic symptoms. These results demonstrate that while many providers in primary care are familiar with BED, steps to improve provider familiarity with the disorder and provide appropriate mechanisms to address BED are warranted.     

Making snacking less sinful: (Counter-)moralising obesity in the public discourse differentially affects food choices of individuals with high and low perceived body mass

Objective: As public discourse surrounding obesity highlights the societal costs of obesity and individual’s own responsibility for their weight, being overweight is often framed as immoral. Such ‘moralizing’ messages about being overweight may be a psychological threat for those with high body mass. Attempting to counter-moralise the public discourse (i.e. actively arguing that there is nothing ‘immoral’ about being overweight) may relieve this threat, inducing people, especially those with higher (perceived) weight, to engage in healthier behaviours.

Method: Two experiments were performed among Dutch and US participants. (Counter-)moralisation was manipulated. Body mass and weight-related self-perceptions were measured. The dependent variable was healthy vs. unhealthy snack choice.

Results: (Counter-)moralisation and (perceived) overweight jointly predicted snack choice: counter-moralising messages induced healthy snacking, but only among those who regarded themselves to have a high body mass.

Conclusions: The effects of moralising vs. counter-moralising obesity depended on one’s (perceived) overweight. This suggests that, for people with relatively high weight, the current moralising public discourse on obesity works in counterproductive ways. Campaigns that ‘counter-moralize’ obesity (i.e. that refute moralising messages) are more productive, although they should be tailored to those who see themselves as being overweight.     

Treatment of Comorbid Pica and Generalized Anxiety Disorder: A Case Study

This case report describes the assessment and treatment of a treatment-naïve 36-year-old Hispanic/Latina female with comorbid pica and generalized anxiety disorder (GAD), and iron-deficiency anemia. At the onset of treatment, the client consumed chalkboard chalk and vermiculite from potting soil approximately three times per week and presented with moderate-severity GAD. Assessment and treatment occurred over 24 weekly outpatient individual sessions. Treatment was delivered in concert with medical intervention to address anemia. A cognitive-behavioral case formulation was developed from multiple assessment sources. A process-based cognitive-behavioral therapy (CBT) intervention approach was used to target GAD and pica simultaneously, which included psychoeducation, self-monitoring, arousal reduction skills, cognitive training (reappraisal, distancing), and behavior modification/stimulus control techniques. Barriers to treatment and their solutions are discussed. At the end of treatment, the client demonstrated increased insight and understanding of her worry symptoms and pica behavior, acquired cognitive skills and arousal reduction strategies for managing GAD, and reported less than one episode of pica per week. The identified assessment and treatment approach is worthy of future investigation to inform empirically based treatment development efforts, especially for pica.     

Interpersonal psychotherapy for eating disorders with co-morbid depression: A pilot study

Objective: Patients with eating disorders (ED) often suffer from co-morbid depression, which may complicate the ED treatment. Previous studies have found that ED interventions seem to have limited capacity to reduce depressive symptoms. Several studies of interpersonal psychotherapy (IPT), have found that when patients have been treated for depression, co-morbid symptoms have diminished. As depression and EDs are commonly co-occurring conditions, this pilot study aimed to examine the effect of an IPT treatment for these conditions, with the focus on the depressive symptoms.

Method: In this multi-centre study, 16 patients with EDs and co-occurring major depression received 16 weeks of depression-focused IPT.

Results: Significant improvements with substantial effect sizes were found for both depression (d = 1.48) and ED (d = .93). Symptom reduction in the two syndromes were strongly correlated (r = .625, p = .004). Patients with a restrictive ED did not improve on either depression or ED symptoms.

Conclusion: These findings point to the usefulness of IPT for concurrent depression and ED with a bingeing/purging symptomatology. Working with negative affect and problem-solving related to current interpersonal problems may alleviate general psychological distress among these patients.     

Typical-Atypical Interactions: One Patient’s Experience of Weight Bias in an Inpatient Eating Disorder Treatment Setting

Abstract

This article examines one patient’s experiences with weigh bias in an inpatient eating disorder treatment setting with a focus on interactions between the patient and her primary therapist. These therapeutic interactions had multiple unintended consequences, including bolstering feelings of denial, modeling of disordered behaviors, and disrupting the therapeutic alliance. Additional instances of weight bias with other treatment professionals, including an inpatient nutritionist and psychiatrist, are briefly discussed. The article ends with several brief recommendations for how clinicians can more skillfully approach issues of weight and size in the therapeutic alliance in order to resist size-related oppressions rather than reinforce them.     

Knowledge and Beliefs about Bulimia Nervosa and its Treatment: A Comparative Study of Three Disciplines

Poor Mental Health Literacy (MHL), i.e. knowledge and beliefs about bulimia nervosa (BN), among health professionals may contribute to low rates of recognition and less optimal management. The aim of this study was to investigate the BN-MHL of health professionals. A total of 534 professionals selected randomly from Internet based lists were surveyed with a MHL questionnaire regarding a fictional vignette of a woman with BN. One hundred and thirty-six dieticians, 68 psychologists and 97 counselors, total 56% (n = 301) responded. The majority of respondents indicated the woman in the vignette suffered from BN (49%) or an eating disorder (20%) and endorsed evidenced based approaches. On post hoc between group analyses there was a trend (p = .02) for dieticians and psychologists to be more likely than counselors to accurately identify the diagnosis of BN. Dieticians and psychologists were also more likely than counselors to endorse a psychologist as the most helpful treatment provider (p<.001) and to be more likely to endorse cognitive behavioral therapy as the most helpful treatment (p<.001). These results indicate a need for greater training and support for non specialist primary care health professionals.     

Diagnosing,Conceptualizing, and Treating Eating Disorders Not Otherwise Specified: A Comprehensive Practice Model

This article presents research and evidence‐based practices for identifying, understanding, diagnosing, conceptualizing, and providing a continuum of treatment for the most commonly experienced types of eating‐related counseling concerns—namely, eating disorders not otherwise specified—among the population most likely to present these types of needs: adolescent girls and young adult and adult women.     

An Open Trial Examining Dialectical Behavior Therapy Skills and Behavioral Weight Loss for Adults With Emotional Eating and Overweight/Obesity

Third-wave cognitive behavioral interventions for weight loss have shown promise. However, sparse data exists on the use of dialectical behavior therapy for weight loss. Adapted dialectical behavior therapy skills programs may be especially well suited for adults who engage in emotional eating and are seeking weight loss. Dialectical behavior therapy is skills-based, shares theoretical links to emotional eating, and is effective in treating binge eating. The current study examined the feasibility, acceptability, and preliminary efficacy of Live FREE: FReedom from Emotional Eating, a 16-session group-based intervention. A total of 87 individuals expressed interest in the program, and 39 adults with overweight/obesity (BMI ≥25) and elevated self-reported emotional eating were enrolled. Live FREE targeted emotional eating in the initial sessions 1–9, and sessions 10–16 focused primarily on behavioral weight loss skills while continuing to reinforce emotion regulation training. Assessments were administered at baseline, posttreatment, and 6-month follow up. Enrolled participants were primarily female (97.4%) and Caucasian (91.7%). Treatment retention was strong with participants attending an average of 14.3 sessions and 89.7% of participants completing the intervention. On average, participants lost 3.00 kg at posttreatment, which was maintained at follow-up. Intent-to-treat analyses showed improvements in key outcome variables (self-reported emotional eating, BMI, emotion regulation) over the course of the intervention. Combining dialectical behavior therapy skills with conventional behavioral weight loss techniques may be an effective intervention for adults with overweight/obesity who report elevated emotional eating.     

Counseling and Guided Self‐Help Outcomes for Clients With Bulimia Nervosa: A Meta‐Analysis of Clinical Trials From 1980 to 2010

This meta‐analysis included 111 clinical trials exploring the effectiveness of counseling/psychotherapy and guided self‐help approaches in the treatment of bulimia nervosa. In general, single‐group studies supported higher efficacy of counseling/psychotherapy, whereas wait‐list, treatment‐as‐usual, and placebo studies indicated both approaches were equally effective at termination (posttest) and follow‐up in altering binging, purging, laxative use, and self‐reported bulimia or body dissatisfaction perceptions in nearly all comparisons.     

I'll Start My Diet Tomorrow: A Solution-Focused Approach to Weight Loss

This article illustrates through a personal case example how Solution-Focused Brief Therapy concepts can help people lose weight and keep it off.     

Making sense of being fat: A hermeneutic analysis of adults’ explanations for obesity

This hermeneutic‐phenomenological study of individuals enrolled in a hospital weight management clinic is an account and analysis of the experiences of being overweight, dieting and weight cycling through in‐depth life history interviews. Participants explored their earliest recollections involving family attitudes towards food, multiple experiences with dieting and weight cycling and how they explained their weight problems to themselves. Analysis revealed that mealtimes became the arena within which control battles were waged between parent and child; food became associated with control and eating subsequently became a way to gain control over other aspects of life. Eating also became a way to numb the pain associated with child abuse, to substitute for human needs for relationship and belonging and emotional cycles of eating were identified. Insights emergeing from the interview process suggest the value of considering a psychodynamic approach to understanding emotional eating.     

中西方心理治疗思想之比较

中西方文化中都蕴含着丰富的心理治疗思想,相似之处主要表现在二者都重视心理因素等方面;差异主要表现在文化根基、医学基础、心理问题的起因及治疗的理念、方法与途径等方面。在实际的心理治疗和心理健康教育中,应注意心理治疗的文化依存性,积极挖掘整理本土文化心理治疗的理论与方法,实现心理治疗的本土化。     

Treating a Chronically Depressed Adolescent Female Using the Cognitive Behavioral Analysis System of Psychotherapy: A Case Study

A case is presented of an adolescent female with double depression who was treated using the Cognitive Behavioral Analysis System of Psychotherapy (CBASP). CBASP is designed to teach a social problem-solving procedure called Situational Analysis (SA). Generalized treatment effects were measured through monitoring of diagnostic status, two administrations of the Minnesota Multiphasic Personality Inventory-Adolescent, weekly administrations of the Child Depression Inventory, and acquisition performance ratings on the SA task. The results showed that CBASP appeared to be an effective treatment. The double depressive disorder remitted, and the patient learned to identify behavioral consequences as well as target and attain her interpersonal goals. CBASP can be effective for adolescents, although modifications of the adult form of the therapy may be necessary.     

Parenting after Weight Loss Surgery: A Conceptual Model and Two Case Reports

The ways families approach eating, shape, and weight can result in stress for individual family members and challenge the overall functioning of the family. This is further complicated among families with a parent who has history of obesity or undergone weight loss surgery (WLS). Although WLS can positively impact other family members, it can also exacerbate conflicts regarding feeding and weight. Such conflicts can involve uncertainty regarding the extent to which the entire family should make the dietary changes recommended for the post-WLS parent. Conflict might also center on the appropriate level of concern regarding the children’s risk of developing (or maintaining) obesity. This paper uses two case examples to describe the application of a specialized, time-limited intervention: Parent-Based Prevention following Bariatric Surgery (PBP-B). The program was developed to address the unique challenges and concerns that arise after, or are exacerbated by, WLS. Each detailed case example illustrates a common child-feeding challenge and the employment of key PBP-B strategies throughout the course of treatment. In the first case, the parent who had undergone WLS believed the family’s current eating behaviors were the same as those that had led to her own overeating, obesity, and co-occurring psychiatric symptoms, while her husband disagreed. In the second case, both parents were concerned about their son’s weight, yet due to their prior eating histories, they felt unable to construct boundaries around the feeding experience. Both cases follow families through the entire intervention and illustrate key points and challenges. These cases underscore the need for novel treatment modalities to support families following parental WLS.     

Eating disorder pathology among overweight treatment-seeking youth: clinical correlates and cross-sectional risk modeling

Preliminary research suggests that pediatric overweight is associated with increased eating disorder pathology, however, little is known about which overweight youth are most vulnerable to eating disorder pathology. We therefore investigated 122 overweight treatment-seeking youth to describe eating disorder pathology and mental health correlates, and to identify psychopathological constructs that may place overweight youth at increased risk for eating disorder pathology. Youth participated in a comprehensive assessment of eating disorders, mood and anxiety disorders, general psychopathology, and risk variables involving semi-structured clinical interviews and self- and parent-report questionnaires prior to the initiation of weight-loss treatment. Ten youth met criteria for an eating disorder, and over one-third endorsed recent binge eating. Eating disorder pathology was associated with depressive and anxious symptoms (p's<0.001). Structural equation modeling indicated increased negative affect, teasing experience, and thin-ideal internalization, and decreased perfectionism were associated with increased eating disorder pathology. Findings corroborate earlier work indicating that eating disorder pathology is elevated and clinically significant in overweight treatment-seeking youth, bolstering the need for mental health assessment of such individuals. Cross-sectional modeling proposed key variables that relate to eating disorder pathology in overweight treatment-seeking youth, which following prospective replication, may inform the development of effective interventions for overweight and eating disorders.     

Compassion-Focused Therapy to Reduce Body Weight Shame for Individuals With Obesity: A Randomized Controlled Trial

Adults living in larger bodies (Body Mass Index > 30) often experience body weight shame, are highly self-critical, and are at increased risk for anxiety and depression. To date, there have been no RCTs examining the efficacy of Compassion-Focused Therapy (CFT) to help those experiencing body weight shame. The aim of the current study was to investigate the efficacy of CFT as a 12-session group intervention to reduce body weight shame for individuals living in larger bodies. The study used an RCT design with participants randomized to the CFT (n = 28) or waitlist control (n = 27) condition. Participants in both groups were assessed at pre- and postintervention, with the CFT group alone assessed at 3- and 6-month follow-up intervention. Both self-report and a physiological measure of parasympathetic nervous system activity were used (i.e., heart rate variability). Results indicated that CFT had a significant positive impact at postintervention compared to the control group for body weight shame (internal and external), increasing self-compassion, reducing fears of compassion (self, other, and receiving), reducing self-criticism, and reducing external shame. Although there were no significant group effects at postintervention on depression and anxiety, 66% of participants had clinical improvement on depression in the CFT group compared to 8% in the control group at postintervention. CFT did not shift baseline heart rate variability at postintervention. The evidence from this RCT supports CFT as an efficacious intervention to reduce body weight shame for individuals with obesity.