Stepped care and cognitive-behavioural therapy for bulimia nervosa: randomised trial

A randomized controlled comparison of integrative cognitive-affective therapy (ICAT) and enhanced cognitive-behavioral therapy (CBT-E) for bulimia nervosa

BACKGROUND

The purpose of this investigation was to compare a new psychotherapy for bulimia nervosa (BN), integrative cognitive-affective therapy (ICAT), with an established treatment, 'enhanced' cognitive-behavioral therapy (CBT-E).

METHOD

Eighty adults with symptoms of BN were randomized to ICAT or CBT-E for 21 sessions over 19 weeks. Bulimic symptoms, measured by the Eating Disorder Examination (EDE), were assessed at baseline, at the end of treatment (EOT) and at the 4-month follow-up. Treatment outcome, measured by binge eating frequency, purging frequency, global eating disorder severity, emotion regulation, self-oriented cognition, depression, anxiety and self-esteem, was determined using generalized estimating equations (GEEs), logistic regression and a general linear model (intent-to-treat).

RESULTS

Both treatments were associated with significant improvement in bulimic symptoms and in all measures of outcome, and no statistically significant differences were observed between the two conditions at EOT or follow-up. Intent-to-treat abstinence rates for ICAT (37.5% at EOT, 32.5% at follow-up) and CBT-E (22.5% at both EOT and follow-up) were not significantly different.

CONCLUSIONS

ICAT was associated with significant improvements in bulimic and associated symptoms that did not differ from those obtained with CBT-E. This initial randomized controlled trial of a new individual psychotherapy for BN suggests that targeting emotion and self-oriented cognition in the context of nutritional rehabilitation may be efficacious and worthy of further study.

Participation and outcome in manualized self-help for bulimia nervosa and binge eating disorder - a systematic review and metaregression analysis

There is a growing body of research on manualized self-help interventions for bulimia nervosa (BN) and binge eating disorder (BED). Study and treatment dropout and adherence represent particular challenges in these studies. However, systematic investigations of the relationship between study, intervention and patient characteristics, participation, and intervention outcomes are lacking. We conducted a systematic literature review using electronic databases and hand searches of relevant journals. In metaregression analyses, we analyzed study dropout as well as more specific measures of treatment participation in manualized self-help interventions, their association with intervention characteristics (e.g. duration, guidance, intervention type [bibliotherapy, CD-ROM or Internet based intervention]) and their association with treatment outcomes. Seventy-three publications reporting on 50 different trials of manualized self-help interventions for binge eating and bulimia nervosa published through July 9th 2012 were identified. Across studies, dropout rates ranged from 1% to 88%. Study dropout rates were highest in CD-ROM interventions and lowest in Internet-based interventions. They were higher in samples of BN patients, samples of patients with higher degrees of dietary restraint at baseline, lower age, and lower body mass index. Between 6% and 88% of patients completed the intervention to which they had been assigned. None of the patient, study and intervention characteristics predicted intervention completion rates. Intervention outcomes were moderated by the provision of personal guidance by a health professional, the number of guidance sessions as well as participants' age, BMI, and eating disorder related attitudes (Restraint, Eating, Weight and Shape Concerns) at baseline (after adjusting for study dropout and intervention completion rates). Guidance particularly improved adherence and outcomes in samples of patients with bulimia nervosa; specialist guidance led to higher intervention completion rates and larger intervention effects on some outcomes than non-specialist guidance. Self-help interventions have a place in the treatment of BN and BED, especially if the features of their delivery and indications are considered carefully. To better determine who benefits most from what kind and "dosage" of self-help interventions, we recommend the use of consistent terminology as well as uniform standards for reporting adherence and participation in future self-help trials.

The Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA): Development, Key Features, and Preliminary Evidence

Anorexia nervosa (AN) is a severe mental disorder that affects mainly young females. In adults with a well-established form of the illness, it is hard to treat. In 2006, we proposed a maintenance model of AN, combining intra- and interpersonal factors and we have recently refined this model. The model encompasses four main maintaining factors (a thinking style characterized by rigidity, detail focus, and a fear of making mistakes; an avoidant emotion processing and relational style; positive beliefs about the use of anorexia for the person [pro-anorexia beliefs]; and a response of close others to the illness characterized by high expressed emotion and enabling of and accommodation to the illness). In this article, we describe how the model has been translated into a novel treatment for AN and the preliminary evidence supporting this. Implications for clinical practice and research are discussed.

Do end of treatment assessments predict outcome at follow-up in eating disorders?

OBJECTIVE

To examine the predictive value of end of treatment (EOT) outcomes for longer term recovery status.

METHOD

We used signal detection analysis to identify the best predictors of recovery based on outcome at EOT using five different eating disorder samples from randomized clinical treatment trials. We utilized a transdiagnostic definition of recovery that included normalization of weight and eating related psychopathology.

RESULTS

Achieving a body weight of 95.2% of expected body weight by EOT is the best predictor of recovery for adolescents with anorexia nervosa (AN). For adults with AN, the most efficient predictor of weight recovery (BMI > 19) was weight gain to greater than 85.8% of ideal body weight. In addition, for adults with AN, the most efficient predictor of psychological recovery was achievement of an eating disorder examination (EDE) weight concerns score below 1.8. The best predictor of recovery for adults with Bulimia Nervosa (BN) was a frequency of compensatory behaviors less than two times a month. For adolescents with BN, abstinence from purging and reduction in the EDE restraint score of more than 3.4 from baseline to EOT were good predictors of recovery. For adults with binge eating disorder, reduction of the Global EDE score to within the normal range (<1.58) was the best predictor of recovery.

DISCUSSION

The relationship between EOT response and recovery remains understudied. Utilizing a transdiagnostic definition of recovery, no uniform predictors were identified across all eating disorder diagnostic groups.

CBT Guided Self-Help Compares Favourably to Gold Standard Therapist-Administered CBT and Shows Unique Benefits Over Traditional Treatment

CBT guided self-help (CBTgsh) can produce treatment outcomes comparable to therapist-administered CBT (CBTta) for the treatment of anxiety and depression. The efficacy of CBTgsh compared to gold standard CBTta, however, remains to be examined. The current article addresses this issue, as well as how CBTgsh may have unique benefits over CBTta. It further highlights ways in which CBTgsh may be used for disorders of increasing severity, using eating disorders and personality pathology for illustrative purposes. A literature review of PsycINFO, PsyARTICLES, and PubMED was conducted to identify relevant studies published since 1990. Studies directly comparing CBTgsh to gold standard CBTta for anxiety and depression, as well as bulimia nervosa, revealed no significant differences between the two interventions. Furthermore, CBTgsh may have unique benefits by encouraging continued improvement over time. Innovative eating disorder studies also show that CBTgsh can be used for more severe disorders as a supplementary treatment, and produces treatment outcomes superior to CBTta or treatment as usual alone. Based on these findings, CBTgsh applications to personality pathology are suggested. Traditional stepped care models, as they pertain to CBTgsh, may gain to be broadened both in their focus and methods of delivery.

Brain responses to body image stimuli but not food are altered in women with bulimia nervosa

BACKGROUND

Research into the neural correlates of bulimia nervosa (BN) psychopathology remains limited.

METHODS

In this functional magnetic resonance imaging study, 21 BN patients and 23 healthy controls (HCs) completed two paradigms: (1) processing of visual food stimuli and (2) comparing their own appearance with that of slim women. Participants also rated food craving and anxiety levels.

RESULTS

Brain activation patterns in response to food cues did not differ between women with and without BN. However, when evaluating themselves against images of slim women, BN patients engaged the insula more and the fusiform gyrus less, compared to HCs, suggesting increased self-focus among women with BN whilst comparing themselves to a 'slim ideal'. In these BN patients, exposure to food and body image stimuli increased self-reported levels of anxiety, but not craving.

CONCLUSIONS

Our findings suggest that women with BN differ from HCs in the way they process body image, but not in the way they process food stimuli.

Perplexities of treatment resistance in eating disorders

BACKGROUND

Treatment resistance is an omnipresent frustration in eating disorders. Attempts to identify the features of this resistance and subsequently develop novel treatments have had modest effects. This selective review examines treatment resistant features expressed in core eating disorder psychopathology, comorbidities and biological features. Novel treatments addressing resistance are discussed.

DESCRIPTION

The core eating disorder psychopathology of anorexia nervosa becomes a coping mechanism likely via vulnerable neurobiological features and conditioned learning to deal with life events. Thus it is reinforcing and ego syntonic resulting in resistance to treatment. The severity of core features such as preoccupations with body image, weight, eating and exercising predicts greater resistance to treatment. Bulimia nervosa patients are less resistant to treatment with treatment failure related to greater body image concerns, impulsivity, depression, severe diet restriction and poor social adjustment. For those with binge eating disorder overweight in childhood and high emotional eating predicts treatment resistance. There is suggestive data that a diagnosis of an anxiety disorder and severe perfectionism may confer treatment resistance in anorexia nervosa and substance use disorders or personality disorders with impulse control problems may produce resistance to treatment in bulimia nervosa. Traits such as perfectionism, cognitive inflexibility and negative affect with likely genetic influences may also affect treatment resistance. Pharmacotherapy and novel therapies have been developed to address treatment resistance. Atypical antipsychotic drugs have shown some effect in treatment resistant anorexia nervosa and topiramate and high doses of SSRIs are helpful for treatment of resistant binge eating disorder patients. There are insufficient randomized controlled trials to evaluate the novel psychotherapies which are primarily based on the core psychopathological features of the eating disorders.

CONCLUSION

Treatment resistance in eating disorders is usually predicted by the severity of the core eating disorder psychopathology which develops from an interaction between environmental risk factors with genetic traits and a vulnerable neurobiology. Future investigations of the biological features and neurocircuitry of the core eating disorders psychopathology and behaviors may provide information for more successful treatment interventions.

Psychological treatments for eating disorders

PURPOSE OF REVIEW

This review summarizes recent evidence on psychological treatments for eating disorders.

RECENT FINDINGS

Eating disorders are serious psychiatric conditions requiring evidence-based intervention. Treatments have been evaluated within each eating disorder diagnosis and across diagnoses. For adults with anorexia nervosa, no one specialist treatment has been shown to be superior. Cognitive behavioral therapy and interpersonal psychotherapy remain the most established treatments for bulimia nervosa and binge eating disorder, with stepped-care approaches showing promise and new behavioral treatments under study. Enhanced cognitive behavioral therapy has improved symptoms in adults and youth. Maudsley family-based therapy is the most established treatment for youth with anorexia nervosa and may be efficacious for youth with bulimia nervosa. Interpersonal psychotherapy for the prevention of excess weight gain may be efficacious for reducing loss of control eating and weight gain in overweight youth.

SUMMARY

Significant advances in treatments have been made, including evaluation of long-term outcomes, novel approaches, and tailored extension for specific patient profiles. However, widespread access to effective eating disorder treatments remains limited. Increasing the potency and expanding the implementation of psychological treatments beyond research settings into clinical practice has strong potential to increase access to care, thereby reducing the burden of eating disorders.

A cost effectiveness analysis of stepped care treatment for bulimia nervosa

BACKGROUND

The cost effectiveness of various treatment strategies for bulimia nervosa (BN) is unknown.

AIMS

To examine the cost effectiveness of stepped care treatment for BN.

METHOD

Randomized trial conducted at four clinical centers with intensive measurement of direct medical costs and repeated measurement of subject quality of life and family/significant other time involvement. Two hundred ninety-three women who met DSM-IV criteria for BN received stepped care treatment or cognitive behavioral therapy. Cost effectiveness ratios were compared.

RESULTS

The cost per abstinent subject was $12,146 for stepped care, and $20,317 for cognitive behavioral therapy. Quality of life ratings improved significantly with treatment, and family/significant other time burden diminished substantially.

DISCUSSION

In this trial, stepped care for BN appeared cost effective in comparison to cognitive behavioral therapy. Treatment was associated with improved quality of life and diminished time costs of illness.

Step one within stepped care trauma-focused cognitive behavioral therapy for young children: a pilot study

This pilot study explored the preliminary efficacy, parent acceptability and economic cost of delivering Step One within Stepped Care Trauma-Focused Cognitive Behavioral Therapy (SC-TF-CBT). Nine young children ages 3-6 years and their parents participated in SC-TF-CBT. Eighty-three percent (5/6) of the children who completed Step One treatment and 55.6 % (5/9) of the intent-to-treat sample responded to Step One. One case relapsed at post-assessment. Treatment gains were maintained at 3-month follow-up. Generally, parents found Step One to be acceptable and were satisfied with treatment. At 3-month follow-up, the cost per unit improvement for posttraumatic stress symptoms and severity ranged from $27.65 to $131.33 for the responders and from $36.12 to $208.11 for the intent-to-treat sample. Further research on stepped care for young children is warranted to examine if this approach is more efficient, accessible and cost-effective than traditional therapy.

Internet-delivered cognitive-behavioural therapy v. conventional guided self-help for bulimia nervosa: long-term evaluation of a randomised controlled trial

BACKGROUND

Cognitive-behavioural therapy (CBT)-based guided self-help is recommended as a first step in the treatment of bulimia nervosa.

AIMS

To evaluate in a randomised controlled trial (Clinicaltrials.gov registration number: NCT00461071) the long-term effectiveness of internet-based guided self-help (INT-GSH) compared with conventional guided bibliotherapy (BIB-GSH) in females with bulimia nervosa.

METHOD

A total of 155 participants were randomly assigned to INT-GSH or BIB-GSH for 7 months. Outcomes were assessed at baseline, month 4, month 7 and month 18.

RESULTS

The greatest improvement was reported after 4 months with a continued reduction in eating disorder symptomatology reported at month 7 and 18. After 18 months, 14.6% (n = 7/48) of the participants in the INT-GSH group and 25% (n = 7/28) in the BIB-GSH group were abstinent from binge eating and compensatory measures, 43.8% (n = 21/48) and 39.2% (n = 11/28) respectively were in remission. No differences regarding outcome between the two groups were found.

CONCLUSIONS

Internet-based guided self-help for bulimia nervosa was not superior compared with bibliotherapy, the gold standard of self-help. Improvements remain stable in the long term.

Defining recovery in adult bulimia nervosa

To examine how different definitions of recovery lead to varying rates of recovery, maintenance of recovery, and relapse in bulimia nervosa (BN), end-of-treatment (EOT) and follow-up data were obtained from 96 adults with BN. Combining behavioral, physical, and psychological criteria led to recovery rates between 15.5% and 34.4% at EOT, though relapse was approximately 50%. Combining these criteria and requiring abstinence from binge eating and purging when defining recovery may lead to lower recovery rates than those found in previous studies; however, a strength of this definition is that individuals who meet this criteria have no remaining disordered behaviors or symptoms.

Early intervention in eating disorders: a parent group approach

AIM

Early intervention in eating disorders (EDs) has been a neglected area. Peak onset is in adolescence, suggesting that early intervention should include parents. We synthesize findings from five key theoretical domains, and present pilot data from a phase-specific early intervention for new onset EDs in young people.

METHODS

From literature searches, we reviewed current knowledge on risk factors for EDs; ED prevention in young people; the evidence base for treatment for young people with EDs; early intervention in other mental health fields; and parenting interventions. Based on these findings, we devised and piloted a parent group intervention.

RESULTS

Presenting features are typically parental concern about changes in eating behaviour and/or weight loss. There is a delay between symptom onset and help seeking, by which time the illness is well established. Early intervention should therefore target parents and be delivered at secondary rather than primary care. Effective treatments favour family-focused interventions with parental responsibility for symptom management. We hypothesized that a parents' group might be effective for addressing the specific emotional experience of parents in the early stages and their relative lack of knowledge and understanding. Pilot data show significant improvements in knowledge, skills, confidence, understanding and their child's adherence to meal plans as a result of a 6-week parent group intervention.

CONCLUSION

A parent group intervention addressing themes identified from risk factor, prevention and treatment research is a potentially promising approach to early intervention for EDs. The impact of the intervention on patient outcome needs evaluation.

Emotional and social mind training: a randomised controlled trial of a new group-based treatment for bulimia nervosa

Objective

There is a need to improve treatment for individuals with bulimic disorders. It was hypothesised that a focus in treatment on broader emotional and social/interpersonal issues underlying eating disorders would increase treatment efficacy. This study tested a novel treatment based on the above hypothesis, an Emotional and Social Mind Training Group (ESM), against a Cognitive Behavioural Therapy Group (CBT) treatment.

Method

74 participants were randomised to either ESM or CBT Group treatment programmes. All participants were offered 13 group and 4 individual sessions. The primary outcome measure was the Eating Disorder Examination (EDE) Global score. Assessments were carried out at baseline, end of treatment (four months) and follow-up (six months).

Results

There were no differences in outcome between the two treatments. No moderators of treatment outcome were identified. Adherence rates were higher for participants in the ESM group.

Discussion

This suggests that ESM may be a viable alternative to CBT for some individuals. Further research will be required to identify and preferentially allocate suitable individuals accordingly.

Trial Registration

ISRCTN61115988

Train-the-trainer: implementation of cognitive behavioural guided self-help for recurrent binge eating in a naturalistic setting

OBJECTIVE

The present study evaluated the feasibility and acceptability of cognitive behavioural guided self-help (CBTgsh) for recurrent binge eating using the train-the-trainer implementation strategy.

METHOD

After receiving expert-led training in CBTgsh, a master's-level graduate student in clinical psychology subsequently trained and supervised less experienced graduate students to implement the treatment in an open clinical trial. Participants were 38 treatment-seeking students at a university counselling centre with recurrent binge eating, featuring cases of bulimia nervosa, binge eating disorder, or eating disorder not otherwise specified.

RESULTS

Intent-to-treat (ITT) analyses revealed 42.1% abstinence from binge eating at post-treatment and 47.4% at one-month follow-up. Participants reported significant pretreatment to post-treatment reductions on measures of specific eating disorder psychopathology, general psychopathology, and functional impairment and high levels of treatment acceptability.

CONCLUSIONS

These results provide 'proof-of-concept' for the train-the-trainer implementation strategy and add to the evidence supporting the feasibility and effectiveness of CBTgsh in routine clinical care.

Prospective association of common eating disorders and adverse outcomes

OBJECTIVE

Anorexia nervosa and bulimia nervosa (BN) are rare, but eating disorders not otherwise specified (EDNOS) are relatively common among female participants. Our objective was to evaluate whether BN and subtypes of EDNOS are predictive of developing adverse outcomes.

METHODS

This study comprised a prospective analysis of 8594 female participants from the ongoing Growing Up Today Study. Questionnaires were sent annually from 1996 through 2001, then biennially through 2007 and 2008. Participants who were 9 to 15 years of age in 1996 and completed at least 2 consecutive questionnaires between 1996 and 2008 were included in the analyses. Participants were classified as having BN (≥ weekly binge eating and purging), binge eating disorder (BED; ≥ weekly binge eating, infrequent purging), purging disorder (PD; ≥ weekly purging, infrequent binge eating), other EDNOS (binge eating and/or purging monthly), or nondisordered.

RESULTS

BN affected ∼1% of adolescent girls; 2% to 3% had PD and another 2% to 3% had BED. Girls with BED were almost twice as likely as their nondisordered peers to become overweight or obese (odds ratio [OR]: 1.9 [95% confidence interval: 1.0-3.5]) or develop high depressive symptoms (OR: 2.3 [95% confidence interval: 1.0-5.0]). Female participants with PD had a significantly increased risk of starting to use drugs (OR: 1.7) and starting to binge drink frequently (OR: 1.8).

CONCLUSIONS

PD and BED are common and predict a range of adverse outcomes. Primary care clinicians should be made aware of these disorders, which may be underrepresented in eating disorder clinic samples. Efforts to prevent eating disorders should focus on cases of subthreshold severity.

Current and emerging directions in the treatment of eating disorders

Eating disorders are a significant source of psychiatric morbidity in young women and demonstrate high comorbidity with mood, anxiety, and substance use disorders. Thus, clinicians may encounter eating disorders in the context of treating other conditions. This review summarizes the efficacy of current and emerging treatments for anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). Treatment trials were identified using electronic and manual searches and by reviewing abstracts from conference proceedings. Family based therapy has demonstrated superiority for adolescents with AN but no treatment has established superiority for adults. For BN, both 60 mg fluoxetine and cognitive behavioral therapy (CBT) have well-established efficacy. For BED, selective serotonin reuptake inhibitors, CBT, and interpersonal psychotherapy have demonstrated efficacy. Emerging directions for AN include investigation of the antipsychotic olanzapine and several novel psychosocial treatments. Future directions for BN and BED include increasing CBT disseminability, targeting affect regulation, and individualized stepped-care approaches.

Cognitive-behavioral guided self-help for eating disorders: effectiveness and scalability

Given the well-documented shortage of cognitive-behavioral therapy (CBT) for eating disorders, there is a compelling need for advances in dissemination. Guided self-help based on cognitive-behavioral principles (CBTgsh) provides a robust means of improving implementation and scalability of evidence-based treatment for eating disorders. It is a brief, cost-effective treatment that can be implemented by a wide range of mental health providers, including non-specialists, via face-to-face contact and internet-based technology. Controlled studies have shown that CBTgsh can be an effective treatment for binge eating disorder and bulimia nervosa, although it is contraindicated for anorexia nervosa. Several studies have shown that CBTgsh can be as effective as more complex specialty therapies and that it is not necessarily contraindicated for patients with comorbid conditions. Mental health providers with relatively minimal professional credentials have in some studies obtained results comparable to specialized clinicians. Establishing the nature of optimal "guidance" in CBTgsh and the level of expertise and training required for effective implementation is a research priority. Existing manuals used in CBTgsh are outdated and can be improved by incorporating the principles of enhanced transdiagnostic CBT. Obstacles to wider adoption of CBTgsh are identified.

Long-term efficacy of psychological treatments for binge eating disorder

BACKGROUND

The long-term efficacy of psychological treatments for binge eating disorder remains largely unknown.

AIMS

To examine the long-term efficacy of out-patient group cognitive-behavioural therapy (CBT) and group interpersonal psychotherapy (IPT) for binge eating disorder and to analyse predictors of long-term non-response.

METHOD

Ninety people with binge eating disorder were assessed 4 years after treatment cessation within a randomised trial (trial registration: NCT01208272).

RESULTS

Participants showed substantial long-term recovery, partial remission, clinically significant improvement and significant reductions in associated psychopathology, despite relapse tendencies in single secondary outcomes. Body mass index remained stable. While the IPT group demonstrated an improvement in eating disorder symptoms over the follow-up period, the CBT group reported a worsening of symptoms, but treatments did not differ at any time point.

CONCLUSIONS

The results document the long-term efficacy of out-patient CBT and IPT for binge eating disorder. Further research is warranted to elucidate the time course and mechanisms of change of these treatments for binge eating disorder.