Efficacy and predictors of long-term treatment success for Cognitive-Behavioral Treatment and Behavioral Weight-Loss-Treatment in overweight individuals with binge eating disorder

ObjectiveThe aim of the study was to assess the long-term efficacy of Cognitive-Behavioral Treatment (CBT) and Behavioral Weight-Loss-Treatment (BWLT) in patients with binge eating disorder (BED) and to identify potential predictors of long-term treatment success.MethodIn a sample of overweight to obese BED patients from a randomized comparative trial we evaluated the efficacy of four months of CBT or BWLT, followed by 12 months extended care, and a final follow-up assessment 6 years after the end of active treatment. Outcomes included binge eating, eating disorder pathology, depressive feelings, and body mass index.ResultsAfter a strong improvement during active treatment, outcomes worsened during follow-up, yet remained improved at 6-year follow-up relative to pretreatment values. Long-term effects between CBT and BWLT were comparable. Rapid response during the early treatment phase was the only characteristic that was predictive of favorable treatment outcome in the long term.ConclusionsBoth CBT and BWLT can be considered to be comparably efficacious in the long-term. Patients not responding strongly enough during the first four therapy sessions might be in need of tailored interventions early during the treatment phase.     

Fundamental Dilemmas in Contemporary Psychodynamic and Insight-Oriented Psychotherapy

Contemporary psychotherapists are being called on to provide treatment with increased degrees of brevity and efficacy. To meet these demands, the practice of brief psychodynamic psychotherapy has turned to (a) the increased emphasis upon a specific psychodynamic focus for treatment versus the more comprehensive goals of longer-term treatment, and (b) the augmented use of confrontation of psychological defenses versus the enhanced use of emotional support as in more nondirective psychotherapy. Other approaches to insight-oriented psychotherapy that have been influenced by this trend include: client-centered psychotherapy with its focus upon the therapeutic relationship; existential psychotherapy with its focus upon death anxiety; and, the revitalization of interpersonal psychotherapy from its original Sullivanian conceptualization. The clinical dilemmas that limitations of time and restricted therapeutic focus place upon each of these methods of treatment are the central issues of this discussion.     

Eating Disorders,Impaired Mentalization,and Attachment: Implications for Child and Adolescent Family Treatment

ABSTRACT

This article reviews the attachment and neuroscience model of Mentalization Based Treatment (MBT) (Allen, Fonagy, & Bateman, 2008) and its application for understanding and treating eating disorders (Skarderud & Fonagy, 2012). Mentalization, or mentalizing, refers to the capacity to apprehend one’s own and others’ behavior in terms of underlying mental states (needs, emotions, desires, beliefs, goals, reasons, and thoughts). Evidence from prospective studies suggests that insecure attachment and poor mentalizing difficulties may be risk factors for the development of eating pathology (Jewell et al., 2015; Rothschild-Yakar, Levy-Shiff, Fridman-Balaban, Gur, & Stein, 2010; Rothschild-Yakar & Stein, 2013). Preliminary research on the use of MBT for treating eating disorders, with nonsuicidal self-injury co-morbidity, suggests some promise for this model (Robinson et al., 2015). The theoretical rationale and key interventions of the MBT eating disorder model (MBT-ED) used in a multicenter research and treatment project are discussed (Skarderud & Fonagy, 2012; Robinson et al., 2015). Modifications of MBT-ED’s structure and techniques are proposed for family treatment of adolescent and child patients with eating disorders. Case example illustrates the impact of problems in the family system with mentalizing capacities on family cohesion, the therapeutic process, and the family’s ability to help the child recover.     

On the Psychoanalytic Treatment of the Depressive Personality

In order to discuss the depressive personality we have first to distinguish between this clinical entity and other types of depressive psychopathology that might also be chronic. The character traits and psychodynamics of the depressive personality confirm that there is a special group of patients, who belong to a depressive disorder continuum. The particular technical problems that depressive personality present are: (1) the inability to enjoy anything and the consequences of this on the therapist's experience and interventions, and (2) the negative therapeutic reaction which threatens the analytic process and the therapist's competence. If we combine transference/extratransference interpretations with an "empathetic understanding" approach to systematic confrontation and interpretation, we can therefore justify the need for a slightly modified psychoanalytic technique in the treatment of the depressive personality.     

To Know Another Inside and Out: Linking Psychic and Somatic Experience in Eating Disorders

ABSTRACT

This article explores the role of the body in the psychoanalytic treatment of eating disorders from a relational and developmental perspective. Many who struggle with eating disorders and related issues have had early experiences that adversely affected the development of flexible, adaptive self-regulation, including the ability to experience affects as psychic states that can be safely shared in the context of a relationship. Because of their difficulty symbolizing and expressing feelings, patients with eating disorders often experience affects as somatic problems, for which they seek somatic solutions. Tuning in to patients’ bodily experience can open up pathways for accessing and, eventually, verbalizing and reflecting on internal states in the therapeutic relationship. As shown through a detailed case illustration, the therapist can discover and engage aspects of the intersubjective matrix that may not meet the eye by attending to his or her own bodily experiences and associations in and out of sessions.     

Spirituality and Ten False Beliefs and Pursuits of Women With Eating Disorders: Implications for Counselors

Women with eating disorders often struggle with deep spiritual conflicts that can be a major impediment to their recovery. On the basis of clinical experience with more than 350 women in an inpatient eating disorder treatment facility, the authors describe 10 false beliefs that women with eating disorders may hold; the authors explain how the pursuit of these beliefs can prevent the women from connecting with God and with others in genuine ways. The authors also suggest some therapeutic strategies that may help women with eating disorders find a healing and helpful spiritual perspective.     

The Therapist’s Needs: Beyond Mutual Recognition

Abstract

As early as 1965, Harold Searles argued that therapists’ needs for healing and growth are part and parcel of their work with patients. Since then, the relational movement has corroborated this idea by articulating the healing function of treatment for both patient and clinician. In this article, the authors examine therapists’ needs that have been overlooked or those that have not been considered fully in the literature. Using various ideas related to the concept of what the authors call therapeutic freedom, this article argues that clinicians must strive to adopt a therapeutic vision that aims to loosen their own ties to safe, familiar modes of engaging with patients, particularly in moments of enactment or impasse. The authors elucidate these ideas with case material from their clinical work and show how embracing various forms of therapeutic freedom results in a type of mutual surrender on the part of both patient and therapist, creating opportunistic conditions that generate therapeutic action and new possibilities for the dyad.     

On Targeting Emotion Regulation Deficits in Eating Disorders through Defense Analysis

ABSTRACT

Psychodynamic approaches to the treatment of individuals with eating disorders are underrepresented in research and in academia. This will increasingly deprive patients of a viable therapeutic alternate to the dominant behavioral family-based models. As psychodynamic approaches may have unique benefits, there is value in resolving this loss. Recent models of dynamic therapies for eating disorders within modern, empirically derived theory show promise for future psychodynamic viability. An attachment-focused approach targeting disordered attachment patterns that are common in individuals with eating disorders has recently been introduced. To complement this model, this article proposes an approach for individuals with eating disorders that is hypothesized to target emotion regulation deficits that are also commonly found in individuals with eating disorders. Observed parallels between the implicit branch of the emotion regulation system and that of contemporary constructs of defense mechanisms guide this proposal. Developmental considerations reveal important connections between this biologically based model and a two-person model based in attachment theory. In this way, this proposal offers a flexible psychodynamic approach that integrates with the existing literature. Further development of this approach could one day help patients to have a greater range of therapeutic options for recovery from eating disorders.     

Differential association between food craving,food addiction and eating-related characteristics in persons at risk for eating disorders

IntroductionFood craving is a key feature of eating disorders, but its association with medical and psychological outcome might depend on the type of eating disorder.ObjectivesThis study investigated the factors associated with food craving in individuals at risk for DSM-5 eating disorder.MethodSeventy-six women were recruited from a non-clinical population (n = 372) based on their positive screening (EDDS, QEWP-R) for binge eating disorder (BED; n = 29), anorexia nervosa (AN; n = 28) or bulimia nervosa (BN; n = 19). They completed self-administered questionnaires assessing food craving (FCQ- T-r), Body Mass Index (BMI), eating behaviour (DEBQ), food addiction (YFAS 2.0), and anxiety and depressive symptoms (HADS).ResultsIndividuals at risk for BED or BN had higher food craving than those at risk for AN. Food craving was associated with BMI only in the BED group. Food craving was positively correlated with external eating in all groups, and with emotional eating in the AN and BED groups and correlated with anxiety only in BN. Food addiction prevalence was higher in the BN group than in the AN or BED groups (respectively 94.7%, 46.4% and 65.5%; p < 0.01). In this non-clinical population, we demonstrated that food craving was differentially associated with BMI and eating-related characteristics according to the type of eating disorder.ConclusionThis suggests that food craving is a transdiagnostic dimension that should be differentially targeted depending on the type of eating disorder; future studies should test this hypothesis in clinical populations.     

Eating Disorders Among Urban and Rural African American and European American Women

Abstract

It is alleged that eating disorders are nonexistent in African American women and that eating disorder symptomatology occurs predominantly among White middle class women (Kumanyika, Wilson, & Guilford-Davenport, 1993; Smolak & Striegel-Moore, 2001). This research attempted to identify differences in eating disorder symptomatology in African American and White American women. An eating disorder is a disability because it can damage the person physically, emotionally and socially. It can be undetected for years and society may reinforce the hidden disorder by being complimentary regarding the thin appearance of the person. The Eating Disorder Inventory (EDI) was used to measure psychological traits and symptom clusters associated with the understanding and treatment of eating disorders (Garner, 1990). Measures of self-esteem, depression and coping were also examined. Findings indicated differences between African American and White women on the Ineffectiveness scale of the EDI, differences between the urban/rural women on Ineffectiveness and Perfectionism, and differences in coping strategies and education among this sample group of women. Successful treatment usually involves psychotherapy and/or medication for depression.     

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.     

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.     

Eating disorders in elite female distance runners: Effects of nationality and running environment

ObjectivesTo compare UK and Kenyan athletes and to examine the influence of nationality and involvement in elite distance running on the presence of eating disorders, eating disorder psychopathology and menstrual dysfunction, in young women.DesignIndependent groups, with nationality and running status as independent variables.MethodsElite female distance runners were identified based on their performances in track, road and cross-country events. Questionnaire packs were sent to UK athletes and Kenyan athletes were approached at race meetings or a training camp. In all, 82 UK and 75 Kenyan athletes participated (70% and 90% of those invited) along with 97 and 101 non-athlete, age-matched controls from the two countries. All participants completed the Eating Disorder Examination Questionnaire (EDE-Q) and assessments of dieting, mental health, self-esteem and menstrual function.ResultsUK women had significantly higher levels of eating disorder psychopathology and more probable present and past eating disorders than enyan women. Overall, 19.5% of the UK runners had a probable present or past eating disorder, confirming the results of our earlier study (Hulley & Hill, 2001). Kenyan runners had the lowest proportion of probable cases compared with all other groups and the least eating disorder psychopathology. Athletic participation was associated with less regular menstrual periods, regardless of nationality.ConclusionThese findings confirm that participation in distance running at an elite level does not in itself predispose to an eating disorder. Eating disorder risk is better represented as a combination of cultural values, elite sporting environment and person variables.     

Dr John Hunter Padel 1913–1999

SUMMARY

With the help of clinical material from two female patients with whom acting out was a major feature of their treatment I have examined the connection between acting out behaviour and separation anxiety.

To begin with, I have drawn on Freud's conception of acting out and have shown that this kind of behaviour can be closely associated with transference in that both can act as a resistance as well as an aid to the psychoanalytic process.

The link between acting out and preverbal experience is commented on and attention is given to the defensive splitting of the primary object during early development.

It is then suggested that one of the essential roots associated with acting out behaviour is that of object loss and separation.

The clinical examples show that if the child separates in a strongly hostile manner from the mother then acting out associated with separations during analysis is going to be greater.

In view of the deficits in the early mother child relationships of the two patients described I adopted a therapeutic strategy based less on confrontation and limit setting and more on a consistent attempt to understand what was being communicated in the acting out behaviour.     

Early Onset Binge Eating and Purging Eating Disorders: Course and Outcome in a Population-Based Study of Adolescents

This study aimed to describe the course of early onset eating disorders in a population-based sample followed from 14 to 20 years; identify variables that could account for the persistence of eating disorders from 14 to 20 years; and describe outcome of early onset eating disorders with reference to general and psychological functioning at age 20. Participants (N?=?1,383; 49 % male) were drawn from the Western Australian Pregnancy Cohort (Raine) Study, which has followed children from pre-birth to young adulthood. Eating disorder symptoms were assessed using an adapted version of the Eating Disorder Examination-Questionnaire, at ages 14, 17 and 20. At age 14, 70 participants met DSM-IV criteria for a binge eating or purging eating disorder. Nearly half (44 %) of these adolescents ceased to meet criteria for an eating disorders at ages 17 and 20, whilst one-quarter still met criteria for an eating disorder at age 20 and one-fifth met criteria for an eating disorder at all three time points. Purging at age 17 and externalising behaviour problems at age 14 were the strongest predictors of eating disorder persistence to age 20. Participants who experienced a persistent eating disorder were less likely to complete high school than other participants, and reported pronounced depressive and anxiety symptoms at age 20. This study provides new data the course and outcome of early onset eating disorders at a population level. Behavioural difficulties in early adolescence and purging in middle adolescence may predict persistent eating pathology to young adulthood.     

Perceived acceptability of anorexia and bulimia in women with and without eating disorder symptoms

Perceptions of the acceptability of eating‐disordered behaviour were examined in young adult women with (n = 44) and without (n = 268) eating disorder symptoms. All participants viewed vignettes of anorexia nervosa (AN) and bulimia nervosa (BN) and responded to the same series of questions—addressing different possible ways in which the conditions described might be seen to be acceptable—in relation to each vignette. Participants with eating disorder symptoms perceived eating‐disordered behaviour to be more acceptable than asymptomatic participants, and this was the case for both AN and BN vignettes and for a range of different items. Differences on items tapping the perception that it ‘might not be too bad’ to have an eating disorder and that an eating disorder is ‘nothing to be concerned about’ were particularly pronounced. The findings could not be accounted for by between‐group differences in body weight. The findings indicate the ambivalence towards eating‐disordered behaviour that exists among a subgroup of young women in the community and the clear association between such ambivalence and actual eating disorder symptoms. The perceived acceptability of eating‐disordered behaviour may need to be addressed in prevention and early‐intervention programs for eating disorders.     

A Description of the Continuum of Eating Disorders: Implications for Intervention and Research

Many authors have proposed the notion of an eating disorder continuum to aid in the understanding of similarities and differences among various types of eating disturbances and disorders. The purpose of this article is to present an eating disorders continuum and to describe groups on the continuum by highlighting differences among the groups on behavioral, cognitive-attitudinal, and self-esteem issues. The relationship of the continuum to the developmental course of eating disorders is discussed. Prevention, early intervention, and treatment programs for various groups on the continuum are presented. Recommendations for future research on the continuum of eating disorders are provided.     

Eating disorder NOS (EDNOS): an example of the troublesome "not otherwise specified" (NOS) category in DSM-IV

The “Not Otherwise Specified” (NOS) category within DSM-IV is designed for disorders of clinical severity that are not specified within broad diagnostic classes. “NOS” diagnoses are intended to be residual categories and they tend to be neglected by researchers. This can be inappropriate. The problems associated with certain NOS diagnoses are well illustrated by “Eating Disorder NOS” (sometimes termed EDNOS), which is the most common category of eating disorder encountered in routine clinical practice yet it has barely been studied. Indeed, there has been no research on its treatment. Interim and longer-term conceptual and practical solutions to the anomalous status of eating disorder NOS are proposed including the creation of a new diagnosis termed “mixed eating disorder”. Several of these solutions are of relevance to NOS categories in general. All the solutions should fulfil criteria for clinical utility.     

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.     

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.