Randomized Controlled Trial of an Internet-Based Cognitive-Behavioral Treatment Program for Binge-Eating Disorder

Binge-eating disorder (BED) is a prevalent health condition associated with obesity. Few people with BED receive appropriate treatment. Personal barriers include shame, fear of stigma, geographic distance to mental health services, and long wait-lists. The aims of this study were to examine the efficacy of an Internet-based cognitive-behavioral intervention for adults with threshold BED (DSM-IV) and to examine the stability of treatment effects over 12 months. Participants were randomly assigned to a 16-week Internet-based cognitive-behavioral intervention (n = 69) or a wait-list condition (n = 70). Binge-eating frequency and eating disorder psychopathology were measured with the Eating Disorder Examination–Questionnaire and the Eating Disorder Examination administered over the telephone. Additionally, body weight and body mass index, depression, and anxiety were assessed before and immediately after treatment. Three-, 6-, and 12-month follow-up data were recorded in the treatment group. Immediately after the treatment the number of binge-eating episodes showed significant improvement (d = 1.02, between group) in the treatment group relative to the wait-list condition. The treatment group had also significantly reduced symptoms of all eating psychopathology outcomes relative to the wait-list condition (0.82 ≤ d ≤ 1.11). In the treatment group significant improvement was still observed for all measures 1 year after the intervention relative to pretreatment levels. The Internet-based intervention proved to be efficacious, significantly reducing the number of binge-eating episodes and eating disorder pathology long term. Low-threshold e-health interventions should be further evaluated to improve treatment access for patients suffering from BED.     

A Pilot Study of Acceptance and Commitment Therapy as a Workshop Intervention for Body Dissatisfaction and Disordered Eating Attitudes

Body image dissatisfaction is a source of significant distress among non-eating-disordered women, but because it is subclinical it is generally not treated. It remains stable throughout adulthood, and has proven resistant to many prevention interventions. This study presents a pilot test of a practical alternative: a 1-day Acceptance and Commitment Therapy (ACT) workshop targeting body dissatisfaction and disordered eating attitudes. Women with body dissatisfaction (N = 73) were randomly assigned to the workshop or to a wait list. Participants in both conditions also completed appetite awareness self-monitoring of hunger and satiety. After a brief 2-week follow-up, wait-list participants were also offered the workshop. Eating attitudes, body anxiety, and preoccupation with eating, weight, and shape improved in both arms of the study following the workshop. Participants in the ACT group showed significant reductions in body-related anxiety and significant increases in acceptance when compared to the wait-list control condition. ACT presented as a brief workshop intervention may be applicable for a broad range of women experiencing disordered eating attitudes and distress related to eating and body image; however, larger studies with longer follow-ups are needed.     

Acceptance and Commitment Therapy Group Treatment for Symptoms of Borderline Personality Disorder: A Public Sector Pilot Study

A pilot study of a brief group-based Acceptance and Commitment Therapy (ACT) intervention (12 two-hour sessions) was conducted with clients of public mental health services meeting four or more criteria for borderline personality disorder (BPD). Participants were randomly assigned to receive the ACT group intervention in addition to their current treatment (ACT + TAU; N = 21) or to continue with treatment as usual alone (TAU; N = 20). There was significantly more improvement from baseline for the ACT + TAU condition than the TAU condition on the primary outcome variable—self-rated BPD symptoms. The ACT + TAU gain was both clinically and statistically significant. The ACT + TAU condition also had significantly more positive change on anxiety and hopelessness, and on the following ACT consistent process variables: psychological flexibility, emotion regulation skills, mindfulness, and fear of emotions. For all but anxiety, the improvements for the ACT + TAU condition were significant, while the TAU condition had no significant changes on any measure. Follow-up was possible for only a small number of participants. The improvements gained by the ACT + TAU participants were maintained except for fear of emotions. Anxiety continued to improve, becoming significantly different from baseline at follow-up. Examination of mediators found that psychological flexibility, emotion regulation skills and mindfulness, but not less fear of emotions, mediated BPD symptoms. Psychological flexibility and emotion regulation skills also mediated hopelessness. There is a need for a larger trial, for comparison with other established treatments for BPD, and for conducting a trial of a longer intervention. Nonetheless, this pilot study suggests that a brief group-based ACT intervention may be a valuable addition to TAU for people with BPD symptoms in the public sector.     

Acceptance and Commitment Therapy for Depression: A Preliminary Randomized Clinical Trial for Unemployed on Long-Term Sick Leave

This preliminary study investigated the feasibility of a brief Acceptance and Commitment Therapy (ACT) in a Swedish sample of unemployed individuals on long-term sick leave due to depression. Participants were randomized to a nonstandardized control condition (N = 16) or to the ACT condition (N = 18) consisting of 1 individual and 5 group sessions. From pretreatment to 18-month follow-up the ACT participants improved significantly on measures of depression, general health, and quality of life compared to participants in the control condition. The conditions did not differ regarding sick leave and employment status at any time point. The results indicate that ACT is a promising treatment for depression. The need for further refinements of future ACT protocols for this population is discussed.     

Body image in social anxiety disorder,obsessive–compulsive disorder,and panic disorder

Body dysmorphic disorder falls under the category of obsessive–compulsive and related disorders, yet research has suggested it may also be highly associated with social anxiety disorder. The current study examined body image variables among 68 outpatients with primary obsessive–compulsive disorder (OCD; n = 22), social anxiety disorder (SAD; n = 25), and panic disorder (PD; n = 21). Participants filled out self-report measures of body image disturbance, attitudes toward one's appearance, and anxiety. Body image disturbance and attitudes toward appearance did not significantly differ between the groups. However, SAD symptoms predicted body image disturbance, Appearance Evaluation and Body Areas Satisfaction, and OCD symptoms predicted Appearance Orientation. These findings suggest that SAD and OCD may be associated with different facets of body image. Implications for the treatment of anxiety disorders and for future research are discussed.     

The effects of aerobic- versus strength-training on body image among young women with pre-existing body image concerns

This experiment compared the effects of aerobic-training (AT) versus strength-training (ST) on body image among young women with pre-existing body image concerns. Theory-based correlates of body image change were also examined. Participants were 46 women (M age = 21.5 years), randomly assigned to an 8-week AT or ST intervention consisting of supervised exercise 3 days/week. Multidimensional measures of body image were administered pre- and post-intervention, along with measures of physical fitness, perceived fitness, and exercise self-efficacy. Women in the AT condition reported greater reductions in social physique anxiety (p = .001) and tended to report greater improvements in appearance evaluation (p = .06) than women in the ST condition. Changes in perceived fatness, perceived aerobic endurance and aerobic self-efficacy were significantly correlated with body image change (ps < .003). Results provide direction for prescribing exercise to improve body image and advancing theory to account for the effects of exercise.     

An Anxiety Sensitivity Reduction Smoking-Cessation Program for Spanish-Speaking Smokers (Argentina)

The present study evaluated a Spanish-language version of an Anxiety Sensitivity Reduction Program for Smoking Cessation among a sample of daily adult smokers from Argentina (n = 6; M_age = 49.4, SD = 15.43) in an open trial methodological design. To be eligible, each participant expressed a current desire to quit smoking and previous difficulties with anxiety/mood symptoms during past quit attempts (e.g., anxiety, stress, depression, irritability). Participants completed a baseline assessment and received eight 90-minute weekly group sessions. The study involved one doctoral-level and two graduate-level therapists. Follow-up visits were scheduled at 1, 2, 4, 8, and 12 weeks post-quit day. Smoking status was confirmed biochemically and via self-report at quit day and each follow-up assessment. The treatment yielded positive results in terms of attendance, positive smoking cessation outcome (5 out of 6 were abstinent at 12-week follow-up), and significant reductions in anxiety sensitivity. The results suggest potential clinical utility among Spanish-speaking smokers for an anxiety-sensitivity smoking cessation program in regard to cessation outcome.     

When the dissolution of perceived body boundaries elicits happiness: The effect of selflessness induced by a body scan meditation

Drawing on the Self-centeredness/Selflessness Happiness Model (SSHM), we hypothesized that a reduction in the salience of perceived body boundaries would lead to increase optimal emotional experience. These constructs were assessed by means of self-report measures. Participants (n = 53) were randomly assigned to either the selflessness (induced by a body scan meditation) condition or the control condition. As expected, the reduction in perceived body salience was greater in the body scan meditation condition than in the control condition. The change in perceived body salience was accompanied by a change in happiness and anxiety. Participants in the body-scan meditation condition reported greater happiness and less anxiety than participants in the control condition. Happiness increased when the salience of body boundaries decreased. Mediation analyses reveal that the change in happiness was mediated by the change in perceived body boundaries, which suggests that selflessness elicits happiness via dissolution of perceived body boundaries.     

Mindfulness-Based Cognitive Therapy for Neuroticism (Stress Vulnerability): A Pilot Randomized Study

Objective: Neuroticism, a characteristic associated with increased stress vulnerability and the tendency to experience distress, is strongly linked to risk of different forms of psychopathology. However, there are few evidence-based interventions to target neuroticism. This pilot study investigated the efficacy and acceptability of mindfulness-based cognitive therapy (MBCT) compared with an online self-help intervention for individuals with high levels of neuroticism. The MBCT was modified to address psychological processes that are characteristic of neuroticism. Method: Participants with high levels of neuroticism were randomized to MBCT (n = 17) or an online self-help intervention (n = 17). Self-report questionnaires were administered preintervention and again at 4 weeks postintervention. Results: Intention-to-treat analyses found that MBCT participants had significantly lower levels of neuroticism postintervention than the control group. Compared with the control group, the MBCT group also experienced significant reductions in rumination and increases in self-compassion and decentering, of which the latter two were correlated with reductions in neuroticism within the MBCT group. Low drop-out rates, high levels of adherence to home practice, and positive feedback from MBCT participants provide indications that this intervention may be an acceptable form of treatment for individuals who are vulnerable to becoming easily stressed. Conclusions: MBCT specifically modified to target neuroticism-related processes is a promising intervention for reducing neuroticism. Results support evidence suggesting neuroticism is malleable and amenable to psychological intervention. MBCT for neuroticism warrants further investigation in a larger study.     

Electrocortical Evidence of Enhanced Performance Monitoring in Social Anxiety

Self-focused attention is thought to be a key feature of social anxiety disorder. Yet few studies have used event-related potentials (ERPs) to examine whether socially anxious individuals display greater monitoring of their performance and attention to their errors. Similarly, only a few studies have used ERPs to examine how social anxiety is related to processing of performance feedback. Individuals with high (n = 26) and low (n = 28) levels of social anxiety completed a trial-and-error learning task. Self-focus was manipulated using false heart-rate feedback during a random subset of trials. Performance feedback was given using emotional and neutral faces in a positive context (correct = happy face; incorrect = neutral face) and negative context (correct = neutral face; incorrect = disgust face) in order to investigate biased interpretation and attention to feedback. Socially anxious subjects displayed enhanced amplitude of the ERN and CRN, suggesting greater response monitoring, and enhanced Pe amplitude, suggesting greater processing of errors relative to the low social anxiety group. No group differences were observed with respect to feedback processing. Before learning stimulus–response mappings in the negative context, the FRN was larger for self-focus compared to standard trials and marginally larger for socially anxious subjects compared to controls. These findings support cognitive models and suggest avenues for future research.     

Multidimensional body image comparisons among patients with eating disorders,body dysmorphic disorder,and clinical controls: A multisite study

Body image disturbance is considered a core characteristic of eating disorders and body dysmorphic disorder (BDD), however its definition has been unclear within the literature. This study examined the multidimensional nature of body image functioning among individuals with either anorexia nervosa (AN; n = 35), bulimia nervosa (BN; n = 26), or BDD (n = 56), relative to female (n = 34) and male (n = 36) psychiatric controls. Participants were recruited from 10 treatment centers in the United States and England and completed psychometrically validated and standardized self-report measures of body image. Overall, the AN, BN, and BDD groups were characterized by significantly elevated disturbances in most body image dimensions relative to their gender-matched clinical controls. There was variability, however, in the comparisons among the three groups of interest, including foci of body dissatisfaction and body image coping patterns. On omnibus indices of body image disturbance and body image quality of life, patients with BDD reported more body image impairment than those with eating disorders. Although AN, BN, and BDD are characterized by body image disturbances, similar and partially distinctive cognitive, behavioral, and emotional elements of body image functioning exist among these groups. The study's empirical and clinical implications are considered.     

A randomized controlled trial of strong minds: A school-based mental health program combining acceptance and commitment therapy and positive psychology

To date, most early intervention programs have been based on emotion regulation strategies that address dysfunctional cognitive appraisals, problem-solving skills, and rumination. Another emotion regulation strategy, ‘acceptance’ training, has largely been overlooked. To examine the efficacy of this strategy, a school-based mental health program combining positive psychology with acceptance and commitment therapy (Strong Minds) was evaluated in a randomized controlled trial with a sample of 267 Year 10 and 11 high-school students in Sydney, Australia. Mixed models for repeated measures examined whether the program led to reductions in symptoms amongst students who commenced the program with high depression, anxiety, and stress scores, and increased wellbeing scores amongst all students. Results demonstrated that compared to controls, participants in the Strong Minds condition with elevated symptom scores (n = 63) reported significant reductions in depression (p = .047), stress (p = .01), and composite depression/anxiety symptoms (p = .02) with medium to strong effect sizes (Cohen's d = 0.53, 0.74, and 0.57, respectively). Increased wellbeing (p = .03) in the total sample and decreased anxiety scores (p = .048) for students with elevated symptoms were significant for Year 10 students with medium effect sizes (Cohen's d = 0.43 and 0.54, respectively). This study tentatively suggests that including the emotion regulation strategy of acceptance in early intervention programs may be effective in reducing symptoms and improving wellbeing in high school students. Further research to investigate the generalizability of these findings is warranted.     

Evaluating the impact of feedback on elementary aged students' fluency growth in written expression: A randomized controlled trial

The purpose of this randomized controlled trial was to evaluate elementary-aged students' writing fluency growth in response to (a) instructional practices, (b) sex differences, and (c) student's initial level of writing fluency. Third-grade students (n = 133) in three urban elementary schools were randomly assigned to either an individualized performance feedback condition (n = 46), a practice-only condition (i.e., weekly writing practice; n = 39), or an instructional control condition (n = 48) for 8 weeks. Findings included support for use of performance feedback as an instructional component in general education classrooms (Hedges' g = 0.66), whereas simple practice with curriculum-based measurement in written expression did not produce growth significantly greater than standard instructional practices. The hypothesis that girls write significantly more than boys was supported. However, girls and boys did not differ in their rate of growth. Finally, students' initial risk status in writing fluency did not differentially predict growth in writing fluency over the course of the study. Implications for incorporating feedback as a basic component of intervention in writing are discussed.     

Integrative Response Therapy for Binge Eating Disorder

Binge eating disorder (BED), a chronic condition characterized by eating disorder psychopathology and physical and social disability, represents a significant public health problem. Guided self-help (GSH) treatments for BED appear promising and may be more readily disseminable to mental health care providers, accessible to patients, and cost-effective than existing, efficacious BED specialty treatments, which are limited in public health utility and impact given their time and expense demands. No existing BED GSH treatment has incorporated affect regulation models of binge eating, which appears warranted given research linking negative affect and binge eating. This article describes Integrative Response Therapy (IRT), a new group-based guided self-help treatment based on the affect regulation model of binge eating, which has shown initial promise in a pilot sample of adults meeting DSM-IV criteria for BED. Fifty-four percent and 67% of participants were abstinent at posttreatment and 3-month follow-up, respectively. There was a significant reduction in the number of binge days over the previous 28 days from baseline to posttreatment [14.44 (± 7.16) to 3.15 (± 5.70); t = 7.71, p < .001; d = 2.2] and from baseline to follow-up [14.44 (± 7.16) to 1.50 (± 2.88); t = 5.64, p < .001; d = 1.7]. All subscales from both the Eating Disorder Examination–Questionnaire and Emotional Eating Scale were significantly lower at posttreatment compared to baseline. One hundred percent of IRT participants would recommend the program to a friend or family member in need. IRT's longer-term efficacy and acceptability are presently being tested in a NIMH-funded randomized controlled trial.     

Exposure-Based Family Therapy (FBT-E): An Open Case Series of a New Treatment for Anorexia Nervosa

The overlap between anorexia nervosa (AN) and anxiety disorders has led to the development of anxiety-based etiological models of AN and anxiety-based interventions for AN, including exposure treatment. Family-based treatment (FBT) is an efficacious intervention for adolescents with AN; however, it has recently been proposed that FBT accomplishes parent-facilitated exposure and habituation to food and related triggers in the individual's natural environment. FBT was recently altered to include an explicit exposure component that targets the broad construct of anxiety, including fear, worry, and disgust. This case series examines the application of FBT with an exposure component (FBT-E) to a group of adolescents meeting diagnostic criteria for AN (n = 4) and eating disorder not otherwise specified–restricting type (SAN, n = 6). Ten outpatients (ages 12–17, mean age: 15.28) participated in a course of FBT-E. Session-by-session weight was examined, along with BMI at pre- and posttreatment and responses to self-report measures of eating disorder symptoms (Eating Disorder Examination Questionnaire; EDE-Q), depression and anxiety. Parent reports of their adolescents' anxiety were also collected. The results of this study provide preliminary evidence that FBT-E may effectively target disordered eating and anxiety symptoms and may be a viable alternative to traditional FBT. Implications and future directions are discussed.     

Exploring the integration of thin-ideal internalization and self-objectification in the prevention of eating disorders

Analyses of thin-ideal internalization and self-objectification were conducted within the context of a cognitive dissonance based eating disorder prevention program implemented in an undergraduate sorority. Participants completed self-report assessments at baseline (n = 177), post-intervention (n = 169), 5-month (n = 159), and 1-year follow-up (n = 105). Cross-sectional path analysis indicated that thin-ideal internalization and self-objectification predict each other and both predict body dissatisfaction, which in turn, predicts eating disorder symptoms. A longitudinal examination conducted using hierarchical linear modeling indicated that participants showed significant reductions in thin-ideal internalization, self-objectification, body dissatisfaction, and eating disorder symptoms after participating in the prevention program. Reductions of symptoms were maintained 1-year post-intervention, with the exception of self-objectification, which was significantly reduced up to 5-months post-intervention. Collectively, results suggest that targeting both thin-ideal internalization and self-objectification simultaneously within eating disorder prevention programs could increase the reduction of eating disorder symptoms.     

Exploring the Effectiveness of a Mixed-Diagnosis Group Cognitive Behavioral Therapy Intervention Across Diverse Populations

Depression and anxiety are the most common mental health disorders seen in clinical practice and they are highly comorbid. Cognitive behavioral therapy (CBT) has been demonstrated as an effective treatment for both depression and anxiety but is often not available to all individuals who could benefit from it. This paper investigates the effectiveness of a mixed-diagnosis group CBT intervention that incorporates mindfulness meditation for individuals presenting with depression and/or anxiety: CBT Basics II. This intervention was evaluated across two distinct mental health programs to determine both if it can demonstrate positive results and if it is feasible to implement in these types of programs. Sample 1 (n = 42 completers) consisted of higher-functioning individuals in a general mental health program. Sample 2 (n = 53 completers) consisted of individuals with more chronic and severe mental health diagnoses. Overall, intent-to-treat analyses revealed improvements in psychiatric symptoms, and increases in CBT knowledge and mindfulness skill across both programs. This indicates that CBT Basics II is effective across diverse mental health populations and shows promise for improving access to CBT.     

Time Course of Attention in Socially Anxious Individuals: Investigating the Effects of Adult Attachment Style

Theoretical models of social anxiety propose that attention biases maintain symptoms of social anxiety. Research findings regarding the time course of attention and social anxiety disorder have been mixed. Adult attachment style may influence attention bias and social anxiety, thus contributing to the mixed findings. This study investigated the time course of attention toward both negative and positive stimuli for individuals diagnosed with social anxiety disorder (SAD) and assessed whether attachment style moderates this relationship.One hundred and thirty participants (age: M = 29.03) were assessed using a semistructured clinical interview. Those meeting eligibility criteria for the clinical sample met DSM-IV criteria for SAD (n = 90, age: M = 32.18), while those in the control sample did not meet criteria for any mental disorder (n = 23, age: M = 26.04, 11 females). All participants completed self-report measures examining depression, social anxiety, adult attachment style, and completed an eye-tracking task used to measure the time course of attention. Eye-tracking data were analysed using growth curve analysis.The results indicate that participants in the control group overall displayed greater vigilance towards emotional stimuli, were faster at initially fixating on the emotional stimulus, and had a greater percentage of fixations towards the emotional stimulus as the stimulus presentation time progressed compared to those in the clinical group. Thus, the clinical participants were more likely to avoid fixating on emotional stimuli in general (both negative and positive) compared to those in the control group.These results support the Clark and Wells (1995) proposal that socially anxious individuals avoid attending to emotional information. Attachment style did not moderate this association, however anxious attachment was related to greater vigilance toward emotional compared to neutral stimuli.     

The role of intergroup disgust in predicting negative outgroup evaluations

We introduce intergroup disgust as an individual difference and contextual manipulation. As an individual difference, intergroup disgust sensitivity (ITG-DS) represents affect-laden revulsion toward social outgroups, incorporating beliefs in stigma transfer and social superiority. Study 1 (5 samples, N = 708) validates the ITG-DS scale. Higher ITG-DS scorers demonstrated greater general disgust sensitivity, disease concerns, authoritarian/conservative ideologies, and negative affect. Greater ITG-DS correlated with stronger outgroup threat perceptions and discrimination, and uniquely predicted negative outgroup attitudes beyond well-established prejudice-predictors. Intergroup disgust was experimentally manipulated in Study 2, exposing participants (n = 164) to a travel blog concerning contact with a disgust-evoking (vs. neutral) outgroup. Manipulated disgust generated negative outgroup evaluations through greater threat and anxiety. This mediation effect was moderated: Those higher (vs. lower) in ITG-DS did not experience stronger disgust, threat, or anxiety reactions, but demonstrated stronger translation of aversive reactions (especially outgroup threat) into negative attitudes. Theory development and treatment implications are considered.