The effectiveness of enhanced cognitive behavioural therapy for eating disorders: an open trial

The aim of this study was to examine the effectiveness of Enhanced Cognitive Behaviour Therapy (CBT-E) for eating disorders in an open trial for adults with the full range of eating disorders found in the community. The only previously published trial of CBT-E for eating disorders was a randomised controlled trial (RCT) conducted in the U.K. for patients with a BMI ≥ 17.5. The current study represents the first published trial of CBT-E to include patients with a BMI < 17.5. The study involved 125 patients referred to a public outpatient clinic in Perth, Western Australia. Patients attended, on average, 20–40 individual sessions with a clinical psychologist. Of those who entered the trial, 53% completed treatment. Longer waiting time for treatment was significantly associated with drop out. By the end of treatment full remission (cessation of all key eating disorder behaviours, BMI ≥ 18.5 kg/m², not meeting DSM-IV criteria for an eating disorder) or partial remission (meeting at least 2 these criteria) was achieved by two thirds of the patients who completed treatment and 40% of the total sample. The results compared favourably to those reported in the previous RCT of CBT-E, with one exception being the higher drop-out rate in the current study. Overall, the findings indicated that CBT-E results in significant improvements, in both eating and more general psychopathology, in patients with all eating disorders attending an outpatient clinic.     

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.     

Peer-facilitated cognitive dissonance versus healthy weight eating disorders prevention: A randomized comparison

Research supports the efficacy of both cognitive dissonance (CD) and healthy weight (HW) eating disorders prevention, and indicates that CD can be delivered by peer-facilitators, which facilitates dissemination. This study investigated if peer-facilitators can deliver HW when it is modified for their use and extended follow-up of peer-facilitated CD as compared to previous trials. Based on pilot data, we modified HW (MHW) to facilitate peer delivery, elaborate benefits of the healthy-ideal, and place greater emphasis on consuming nutrient dense foods. Female sorority members (N = 106) were randomized to either two 2-h sessions of CD or MHW. Participants completed assessment pre- and post-intervention, and at 8-week, 8-month, and 14-month follow-up. Consistent with hypotheses, CD decreased negative affect, thin-ideal internalization, and bulimic pathology to a greater degree post-intervention. Both CD and MHW reduced negative affect, internalization, body dissatisfaction, dietary restraint, and bulimic pathology at 14 months.     

Psychological treatment of eating disorders

Significant progress has been achieved in the development and evaluation of evidence-based psychological treatments for eating disorders over the past 25 years. Cognitive behavioral therapy is currently the treatment of choice for bulimia nervosa and binge-eating disorder, and existing evidence supports the use of a specific form of family therapy for adolescents with anorexia nervosa. Important challenges remain. Even the most effective interventions for bulimia nervosa and binge-eating disorder fail to help a substantial number of patients. A priority must be the extension and adaptation of these treatments to a broader range of eating disorders (eating disorder not otherwise specified), to adolescents, who have been largely overlooked in clinical research, and to chronic, treatment-resistant cases of anorexia nervosa. The article highlights current conceptual and clinical innovations designed to improve on existing therapeutic efficacy. The problems of increasing the dissemination of evidence-based treatments that are unavailable in most clinical service settings are discussed.     

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.     

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.     

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.     

Remote treatment of bulimia nervosa and binge eating disorder: a randomized trial of Internet-assisted cognitive behavioural therapy

The present study investigated the efficacy of self-help based on cognitive behaviour therapy in combination with Internet support in the treatment of bulimia nervosa and binge eating disorder. After confirming the diagnosis with an in-person interview, 73 patients were randomly allocated to treatment or a waiting list control group. Treated individuals showed marked improvement after 12 weeks of self-help compared to the control group on both primary and secondary outcome measures. Intent-to-treat analyses revealed that 37% (46% among completers) had no binge eating or purging at the end of the treatment and a considerable number of patients achieved clinically significant improvement on most of the other measures as well. The results were maintained at the 6-month follow-up, and provide evidence to support the continued use and development of self-help programmes.     

A method for the control of eating rate: A potential intervention in eating disorders

A method for the control of eating rate gave subjects feedback from a computer screen on how much and at what rate to eat during a meal. The method also allowed us to record the development of satiety during the meal. Linear eaters—that is, women selected for eating at an approximately constant rate—underate when challenged to eat at a lower rate and overate when challenged to eat at a higher rate, thereby modeling the eating behavior of patients with anorexia nervosa and binge eating disorder, respectively. In both cases, the women’s postmeal perception of satiety mimicked that of the respective patient group. The results provide support for the notion that linear eaters have the capacity to exhibit disordered eating.     

Longitudinal treatment mediation of traditional cognitive behavioral therapy and acceptance and commitment therapy for anxiety disorders

ObjectiveTo assess the relationship between session-by-session putative mediators and treatment outcomes in traditional cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT) for mixed anxiety disorders.MethodSession-by-session changes in anxiety sensitivity and cognitive defusion were assessed in 67 adult outpatients randomized to CBT (n = 35) or ACT (n = 32) for a DSM-IV anxiety disorder.ResultsMultilevel mediation analyses revealed significant changes in the proposed mediators during both treatments (p < .001, d = .90–1.93), with ACT showing borderline greater improvements than CBT in cognitive defusion (p = .05, d = .82). Anxiety sensitivity and cognitive defusion both significantly mediated post-treatment worry; cognitive defusion more strongly predicted worry reductions in CBT than in ACT. In addition, cognitive defusion significantly mediated quality of life, behavioral avoidance, and (secondary) depression outcomes across both CBT and ACT (p < .05, R² change = .06–.13), whereas anxiety sensitivity did not significantly mediate other outcomes.ConclusionsCognitive defusion represents an important source of therapeutic change across both CBT and ACT. The data offered little evidence for substantially distinct treatment-related mediation pathways.