Dialectical behavior therapy adapted for bulimia: a case report

Two decades of mindfulness-based interventions for binge eating: A systematic review and meta-analysis

OBJECTIVE

Mindfulness-based interventions (MBIs) are being increasingly used as interventions for eating disorders including binge eating. This systematic review and meta-analysis aimed to assess two decades of research on the efficacy of MBIs in reducing binge eating severity.

METHODS

We searched PubMed, Scopus and Cochrane Library for trials assessing the use of MBIs to treat binge eating severity in both clinical and non-clinical samples. The systematic review and meta-analysis was pre-registered at PROSPERO (CRD42020182395).

RESULTS

Twenty studies involving 21 samples (11 RCT and 10 uncontrolled samples) met inclusion criteria. Random effects meta-analyses on the 11 RCT samples (n = 618: MBIs n = 335, controls n = 283) showed that MBIs significantly reduced binge eating severity (g = -0.39, 95% CI -0.68, -0.11) at end of trial, but was not maintained at follow-up (g = -0.06, 95% CI, -0.31, 0.20, k = 5). No evidence of publication bias was detected. On the Cochrane Risk of Bias Tool 2, trials were rarely rated at high risk of bias and drop-out rates did not differ between MBIs and control groups. MBIs also significantly reduced depression, and improved both emotion regulation and mindfulness ability.

CONCLUSION

MBIs reduce binge eating severity at the end of trials. Benefits were not maintained at follow-up; however, only five studies were assessed. Future well-powered trials should focus on assessing diversity better, including more men and people from ethnic minority backgrounds.

Trial design and methodology for a non-restricted sequential multiple assignment randomized trial to evaluate combinations of perinatal interventions to optimize women's health

Pre-pregnancy overweight/obesity and excessive gestational weight gain (GWG) independently predict negative maternal and child health outcomes. To date, however, interventions that target GWG have not produced lasting improvements in maternal weight or health at 12-months postpartum. Given that interventions solely aimed at addressing GWG may not equip women with the skills needed for postpartum weight management, interventions that address health behaviors over the perinatal period might maximize maternal health in the first postpartum year. Thus, the current study leveraged a sequential multiple assignment randomized trial (SMART) design to evaluate sequences of prenatal (i.e., during pregnancy) and postpartum lifestyle interventions that optimize maternal weight, cardiometabolic health, and psychosocial outcomes at 12-months postpartum. Pregnant women (N = 300; ≤16 weeks pregnant) with overweight/obesity (BMI ≥ 25 kg/m2) are being recruited. Women are randomized to intervention or treatment as usual on two occasions: (1) early in pregnancy, and (2) prior to delivery, resulting in four intervention sequences. Intervention during pregnancy is designed to moderate GWG and introduce skills for management of weight as a chronic condition, while intervention in the postpartum period addresses weight loss. The primary outcome is weight at 12-months postpartum and secondary outcomes include variables of cardiometabolic health and psychosocial well-being. Analyses will evaluate the combination of prenatal and postpartum lifestyle interventions that optimizes maternal weight and secondary outcomes at 12-months postpartum. Optimizing the sequence of behavioral interventions to address specific needs during pregnancy and the first postpartum year can maximize intervention potency and mitigate longer-term cardiometabolic health risks for women.

Deficits in general emotion regulation skills-Evidence of a transdiagnostic factor

OBJECTIVE

Deficits in emotion regulation (ER) skills are discussed as a transdiagnostic factor contributing to the development and maintenance of various mental disorders. However, systematic comparisons of a broad range of ER skills across diagnostic groups that are based on comparable definitions and measures of ER are still rare.

METHOD

Therefore, we conducted two studies assessing a broad range of ER skills with the Emotion Regulation Skills Questionnaire in individuals meeting criteria for mental disorders (N₁  = 1448; N₂  = 137) and in a general population sample (N = 214).

RESULTS

Consistent across the two studies, participants in the clinical samples reported lower general and lower specific ER skills than participants in the general population sample. Also consistent across the two studies, diagnostic subgroups of the clinical samples differed significantly with regard to general and specific ER skills.

CONCLUSION

The studies provide evidence that deficits in ER are associated with various forms of psychopathology. However, mental disorders seem to differ with regard to how strongly they are linked to ER skills.

Conceptualising Binge Eating: A Review of the Theoretical and Empirical Literature

Binge eating is a distressing symptom common to bulimia nervosa (BN), anorexia nervosa binge/purge subtype (AN-BP) and binge-eating disorder (BED). Over the last 40 years, many attempts have been made to conceptualise this symptom in terms of its antecedents, function, triggers, consequences, and maintaining factors. Cognitive theories of binge eating have evolved as new evidence has emerged. This literature review summarises the main and most influential cognitive models of binge eating across different eating disorder presentations. Many theories have examined binge eating in the context of restriction or compensatory behaviours, as is often observed in cases of BN. Few theories have examined binge eating as it occurs in BED specifically. The long-term efficacy of cognitive behavioural therapy (CBT) treatment based on these models leaves much to be desired, and indicates that there may be maintaining factors of binge eating not addressed in the typical CBT treatment for eating disorders. More recent cognitive models of binge eating propose possible maintaining beliefs, but further study is required to validate these models. Suggestions for future research are presented.

The Use of Dialectical Behavior Therapy (DBT) in Music Therapy: A Sequential Explanatory Study

BACKGROUND

There are published examples of how dialectical behavior therapy (DBT) and music therapy are effectively being used as separate therapies in the treatment of individuals with a variety of mental health disorders. However, research examining DBT-informed music therapy is limited.

OBJECTIVE

The purpose of this study was to determine whether music therapists working in mental health settings are implementing components of DBT in their work, and if so, how and why; and if not, why not and what is their level of interest in such work.

METHODS

We used a sequential explanatory mixed-methods research design implemented in two phases. Phase 1 was a quantitative survey of board-certified music therapists (n=260). Due to a low survey response rate (18%), and to enhance the validity of the findings, Phase 2, an embedded qualitative procedure in the form of interviews with clinicians experienced in the DBT approach, was added to the study. Both survey and interviews inquired about DBT training, use of DBT-informed music therapy, music therapy experiences used to address DBT skills, and experiences of implementing DBT-informed music therapy.

RESULTS

Respondents indicating they implement DBT-informed music therapy (38.3%) are using components and adaptations of the standard DBT protocol. Advantages of implementing DBT-informed music therapy were identified, and more than half of the respondents who do not implement DBT in their music therapy practice also perceived this work as at least somewhat important. Disadvantages were also identified and support the need for further research.

CONCLUSIONS

Components of DBT are used in music therapy and are valued, but there is a lack of empirical evidence to inform, refine, and guide practice.

Discussion of "Eating disorders and attachment: a contemporary psychodynamic perspective:" does the attachment model of eating disorders indicate the need for psychodynamic treatment?

Tasca and Balfour have done admirable work highlighting the importance of attachment security in the psychopathology of eating disorders (EDs), and their contributions are extremely valuable. For their points to be fully appreciated by the research and treatment-research communities, additional data are needed in key areas. Research is needed to help clarify the relative roles and cause-and-effect relationships between attachment insecurity, reflective functioning, and emotion regulation in the development and maintenance of EDs. Tasca and Balfour furthermore call their model "psychodynamic," and call for psychodynamically informed treatment for patients with attachment insecurity. For this call to be heeded, additional research is needed to examine whether the unique elements of psychodynamic psychotherapy have particular benefit for patients with insecure attachment styles. The unique psychodynamic elements considered in this comment include a therapeutic focus on reflective functioning, the patient's developmental history, the "unconscious," and the transference and countertransference. The utility of a non-directive (or patient-directed) therapeutic process is also considered. Investigation of these treatment issues could be extremely useful to practitioners and patients alike.

Review of smartphone applications for the treatment of eating disorders

mHealth tools may be a feasible modality for delivering evidence-based treatments and principles (EBPs), and may enhance treatment for eating disorders (EDs). However, research on the efficacy of mHealth tools for EDs and the extent to which they include EBPs is lacking. The current study sought to (i) review existing apps for EDs, (ii) determine the extent to which available treatment apps utilize EBPs, and (iii) assess the degree to which existing smartphone apps utilize recent advances in smartphone technology. Overall, existing ED intervention apps contained minimal EBPs and failed to incorporate smartphone capabilities. For smartphone apps to be a feasible and effective ED treatment modality, it may be useful for creators to begin taking utilizing the abilities that set smartphones apart from in-person treatment while incorporating EBPs. Before mHealth tools are incorporated into treatments for EDs, it is necessary that the feasibility, acceptability, and efficacy be evaluated.

Alexithymia and eating disorders: a critical review of the literature

Alexithymia is characterized by difficulties identifying feelings and differentiating between feelings and bodily sensations, difficulties communicating feelings, and a concrete cognitive style focused on the external environment. Individuals with eating disorders have elevated levels of alexithymia, particularly difficulties identifying and describing their feelings. A number of theoretical models have suggested that individuals with eating disorders may find emotions unacceptable and/or frightening and may use their eating disorder symptoms (i.e., restricting food intake, bingeing, and/or purging) as a way to avoid or cope with their feelings. The current critical review synthesizes the literature on alexithymia and eating disorders and examines alexithymia levels across eating disorders (i.e., anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified), the role of alexithymia in binge eating disorder, and the influence of alexithymia on the development of eating disorders as well as treatment outcome. The clinical implications of the research conducted to date and directions for future research are discussed.

Dating Violence Prevention Programming: Directions for Future Interventions

Dating violence among college students is a widespread and destructive problem. The field of dating violence has seen a substantial rise in research over the past several years, which has improved our understanding of factors that increase risk for perpetration. Unfortunately, there has been less attention paid to dating violence prevention programming, and existing programs have been marred with methodological weaknesses and a lack of demonstrated effectiveness in reducing aggression. In hopes of sparking new research on dating violence prevention programs, the current review examines possible new avenues for dating violence prevention programming among college students. We discuss clinical interventions that have shown to be effective in reducing a number of problematic behaviors, including motivational interventions, dialectical behavior therapy, mindfulness, and bystander interventions, and how they could be applied to dating violence prevention. We also discuss methodological issues to consider when implementing dating violence prevention programs.

Participation in mindfulness-based stress reduction is not associated with reductions in emotional eating or uncontrolled eating

The adverse health effects and increasing prevalence of obesity in the United States make interventions for obesity a priority in health research. Diet-focused interventions generally do not result in lasting reductions in weight. Behavioral interventions that increase awareness of eating cues and satiety have been postulated to result in healthier eating habits. We hypothesized that participation in a program called mindfulness-based stress reduction (MBSR) would positively influence the eating behaviors and nutritional intake of participants through changes in emotional eating (EE), uncontrolled eating (UE), and type and quantity of food consumed. Forty-eight veterans at a large urban Veterans Administration medical center were assessed before MBSR, after MBSR, and 4 months later. For all participants (N = 48), MBSR participation was not associated with significant changes in EE or UE. In addition, there were no significant differences in the intake of energy, fat, sugar, fruit, or vegetables at either follow-up time point as compared with baseline. Enhanced mindfulness skills and reduced depressive symptoms were seen over time with medium to large effect sizes. Changes in mindfulness skills were significantly and negatively correlated with changes in EE and UE over time. Overall, there was no evidence that participation in MBSR was associated with beneficial changes in eating through reductions in disinhibited eating or significant changes in dietary intake. Randomized studies are needed to further define the relationship between mindfulness program participation and eating behaviors.

Emotion regulation deficits in eating disorders: a marker of eating pathology or general psychopathology?

Preliminary evidence indicates that individuals with eating disorders (ED) show emotion regulation (ER) difficulties. However, it is yet unclear whether different types of ED differ in their ER profile and whether certain ER difficulties are specific for ED or rather a transdiagnostic factor. Twenty women with anorexia nervosa (AN), 18 with bulimia nervosa (BN), 25 with binge eating disorder (BED), 15 with borderline personality disorder (BPD), 16 with major depressive disorder (MDD) and 42 female healthy controls (HC) were administered the Emotion Regulation Questionnaire, the Inventory of Cognitive Affect Regulation Strategies, the Difficulties in Emotion Regulation Scale and the Affect Intensity Measure. The ED groups reported significantly higher levels of emotion intensity, lower acceptance of emotions, less emotional awareness and clarity, more self-reported ER problems as well as decreased use of functional and increased use of dysfunctional emotion regulation strategies when compared to HC. No significant differences between the ED groups emerged for most ER variables. However, there were indications that the BED group may show a slightly more adaptive pattern of ER than the two other ED groups. As a whole, all clinical groups performed very similar on most ER variables and reported more difficulties regulating their emotions than HC. The findings suggest that ER difficulties are not linked to a particular diagnostic category. Instead, ER difficulties appear to be a transdiagnostic risk and/or maintenance factor rather than being disorder-specific.

Cognitive Behavior Therapy and Dialectical Behavior Therapy for Treating Obese Emotional Eaters

This study describes the treatment of obese individuals who rated high on emotional eating using four case studies that involved 22 sessions of either cognitive behavioral therapy (CBT) or dialectical behavioral therapy (DBT). Outcomes measures relating to weight, body mass index, emotional eating, depression, anxiety, and stress were all assessed with each participant prior to each baseline (three weekly sessions), during treatment and posttherapy. At the 8-week follow-up, the two cases that had received DBT had lost 10.1% and 7.6% of their initial body weight, whereas the two cases that had received CBT had lost 0.7% and 0.6% of their initial body weight. The two DBT cases also exhibited reductions in emotional distress, frequency of emotional eating or quantity of food eating in response to emotions, whereas the two CBT cases showed no overall reductions in these areas. Important processes from all four cases are described as are the implications to clinicians for developing more effective interventions for obese clients who engage in emotional eating.

A systematic review of dialectical behavior therapy for the treatment of eating disorders

Dialectical behavior therapy (DBT) has been proposed as an effective treatment for eating disorders (EDs). We conducted a systematic literature review to locate refereed journal articles testing DBT for the treatment of EDs. We identified 13 studies empirically evaluating treatment efficacy across various settings. Findings, based on mostly uncontrolled trials, indicate that DBT treatments appear effective in addressing ED behaviors and other forms of psychopathology in ED samples. The expectation that improvements in emotion regulation capabilities drive reductions in ED pathology was not fully supported. Further research is necessary to confirm the efficacy of modified DBT treatments for EDs.

Social cognition in bulimia nervosa: a systematic review

OBJECTIVE

Clinical accounts and previous evidence suggest that socio-emotional impairments may be present in people with bulimia nervosa (BN). The aim of this paper was to systematically review studies of social cognition, and to evaluate whether social cognitive deficits exist in BN.

METHOD

Keywords were identified using an existing model of social cognition (Green et al., 2007) [16], and used to search for relevant papers in three online databases. Records were then screened according to a priori inclusion/exclusion criteria.

RESULTS

Five papers reporting seven social cognition tasks were identified as pertinent to the review. All involved either theory of mind ability or emotional processing skills. Participants with BN had impaired performance on the Levels of Emotional Awareness Scale and showed greater attentional bias than controls on an emotional Stroop task. There were no overall group differences for any other tasks, although there were small differences for some specific test items.

CONCLUSIONS

Basic social cognition does not appear to be impaired in people with BN. Future research should make use of more complex, ecologically valid measures, and consider the relationship between task performance and everyday social functioning.

Appetite-focused dialectical behavior therapy for the treatment of binge eating with purging: a preliminary trial

OBJECTIVE

This treatment development study investigated the acceptability and efficacy of a modified version of dialectical behavior therapy (DBT) for bulimia nervosa (BN), entitled appetite focused DBT (DBT-AF).

METHOD

Thirty-two women with binge/purge episodes at least one time per week were randomly assigned to 12 weekly sessions of DBT-AF (n = 18) or to a 6-week delayed treatment control (n = 14). Participants completed the EDE interview and self-report measures at baseline, 6 weeks, and posttreatment.

RESULTS

Treatment attrition was low, and DBT-AF was rated highly acceptable. At 6 weeks, participants who were receiving DBT-AF reported significantly fewer BN symptoms than controls. At posttest, 26.9% of the 26 individuals who entered treatment (18 initially assigned and 8 from the delayed treatment control) were abstinent from binge/purge episodes for the past month; 61.5% no longer met full or subthreshold criteria for BN. Participants demonstrated a rapid rate of response to treatment and achieved clinically significant change.

DISCUSSION

Results suggest that DBT-AF warrants further investigation as an alternative to DBT or cognitive behavior therapy for BN.

Using mindful eating to treat food restriction: a case study

This case study describes the application of the principles of mindful eating to the treatment of a case of anorexia nervosa. While many clinicians currently use mindful eating in their treatment of binge eating disorder and bulimia, it also may benefit clients who restrict. The client in this case study is a 19-year-old college student with a BMI of 17.9 and daily restriction of approximately 900-1000 calories who exercises 1 hour daily. Over 15 sessions, she was introduced to the principle of mindful eating. There was an overall decline in restriction, her BMI raised to 19.5, and her caloric intake increased to approximately 1,500-2,000.

The application of mindfulness to eating disorders treatment: a systematic review

The present study is an exploratory examination of the efficacy of the application of mindfulness-based interventions to the treatment of eating disorders. It employs a systematic review technique in which terms from the Psychological Index Terms of the American Psychological Association (APA) were chosen and analyzed in conjunction with Boolean operators. Using data obtained by the online consultation of references from 12 different bibliographical databases, 8 studies were included in the systematic review. Each study reported satisfactory results, although trial qualities were variable and sample sizes were small. Nonetheless, the current study found initial evidence supporting the effectiveness of mindfulness-based interventions to the treatment of eating disorders. The application of mindfulness-based interventions to the treatment of eating disorders remains a promising approach worthy of further research.

Psychological inflexibility and symptom expression in anorexia nervosa

The purpose of this article is to outline a model of anorexia nervosa (AN) as a disorder of psychological inflexibility, motivated by an insatiable desire for prediction and control with related intolerance for uncertainty. We describe preliminary data that provide initial support for this conceptualization and point to the ways in which mindfulness and acceptance-based strategies might be particularly useful for treating AN. This article is not intended to be an exhaustive literature review, rather a conceptual framework to guide future research and treatment development.

The functional assessment of maladaptive behaviors: a preliminary evaluation of binge eating and purging among women

This study applied a functional approach to the study of bingeing and purging behaviors. Based on a four-function theoretical model of bingeing and purging, it was hypothesized that these behaviors are performed because of their intrapersonally reinforcing (e.g., emotion regulation) and/or interpersonally reinforcing (e.g., help-seeking, attention-getting behavior) properties. Participants were 298 adult females who had engaged in bingeing or purging in the last 3 months and who provided data via an online survey of these behaviors. Confirmatory factor analyses revealed support for a four-function model of bingeing and purging in which people use these behaviors for intrapersonal reinforcement functions and also for interpersonal reinforcement. Understanding the functions of binge eating and purging has direct implications for assessment and treatment of these behaviors.

Outcome from a randomized controlled trial of group therapy for binge eating disorder: comparing dialectical behavior therapy adapted for binge eating to an active comparison group therapy

Dialectical Behavior Therapy for Binge Eating Disorder (DBT-BED) aims to reduce binge eating by improving adaptive emotion-regulation skills. Preliminary findings have been promising but have only compared DBT-BED to a wait-list. To control for the hypothesized specific effects of DBT-BED, the present study compared DBT-BED to an active comparison group therapy (ACGT). Men and women (n=101) meeting DSM-IV BED research criteria were randomly assigned to 20 group sessions of DBT-BED (n=50) or ACGT (n=51). DBT-BED had a significantly lower dropout rate (4%) than ACGT (33.3%). Linear Mixed Models revealed that posttreatment binge abstinence and reductions in binge frequency were achieved more quickly for DBT-BED than for ACGT (posttreatment abstinence rate=64% for DBT-BED vs. 36% for ACGT) though differences did not persist over the 3-, 6-, and 12-month follow-up assessments (e.g., 12-month follow-up abstinence rate=64% for DBT-BED vs. 56% for ACGT). Secondary outcome measures revealed no sustained impact on emotion regulation. Although both DBT-BED and ACGT reduced binge eating, DBT-BED showed significantly fewer dropouts and greater initial efficacy (e.g., at posttreatment) than ACGT. The lack of differential findings over follow-up suggests that the hypothesized specific effects of DBT-BED do not show long-term impact beyond those attributable to nonspecific common therapeutic factors.

Dialektisch Behaviorale Therapie (DBT) und Kognitiv Behaviorale Therapie (CBT) für Jugendliche mit Anorexia und Bulimia nervosa im Vergleich

Ziel der vorliegenden randomisierten kontrollierten Studie war die Überprüfung der Wirksamkeit der Kognitiv Behavioralen Therapie (CBT) sowie der Dialektisch Behavioralen Therapie (DBT-AN/BN) bei Patienten mit einer Anorexia nervosa (AN) und Bulimia nervosa (BN). 50 weibliche Patienten (12;4 – 21;0 Jahre) nahmen an der Untersuchung teil. 19 Patientinnen absolvierten eine 25-wöchige CBT, 16 eine 25-wöchige DBT-AN/BN und 15 wurden für 3 Monate einer Wartekontrollgruppe (WKG) zugeordnet. Am Ende der Behandlung erfüllten in der CBT-Gruppe noch 42.1 %, in der DBT-AN/BN-Gruppe 37.5 % und in der WKG alle Patienten die Kriterien einer Essstörung nach DSM-IV. Sowohl die CBT als auch die DBT-AN/BN führten verglichen mit der WKG zu einer Reduktion der Kalorienvermeidung, der unregelmäßigen Nahrungsaufnahme und der aktuellen psychischen Belastung sowie zu einer Erhöhung des BMI. Bezogen auf die Körperbildstörung, die Autonomieentwicklung, die Emotionsregulation sowie den Perfektionismus konnten nur geringe positive Effekte erzielt werden.

Emotion regulation skills mediate the effects of shame on eating disorder symptoms in women

We examined the impact of negative affectivity, chronic shame, and emotion regulation skills on eating disorder symptoms in undergraduate women (N = 154). We hypothesized that self-reported emotion regulation skills would mediate the well-documented relationship between chronic shame and eating disorder symptoms. Results revealed that chronic shame predicted eating disorder symptoms over and above general negative affectivity. Further, difficulties with emotion regulation mediated the relationship between chronic shame and ED symptoms. These findings suggest that chronic shame's role in eating disorder symptoms can be ameliorated by skillful emotion regulation.

Dialectical behavior therapy for clients with binge-eating disorder or bulimia nervosa and borderline personality disorder

OBJECTIVE

This treatment development study provides summary data for standard Dialectical Behavior Therapy (DBT) with minimal adaptation for 8 women with binge-eating disorder (BED) (5) or bulimia nervosa (BN) (3) and Borderline Personality Disorder (BPD).

METHOD

DBT involved 6 months of weekly skills group, individual DBT, therapist consultation team meeting, and 24-hour telephone coaching. Assessments were conducted at pre-, post-treatment, and 6-months follow-up and utilized standardized clinical interviews including the Eating Disorders Examination (EDE), Personality Disorders Exam, and the Structured Clinical Interview for DSM-IV.

RESULTS

From pre- to post-treatment, effect sizes for objective binge eating, total EDE scores and global adjustment were large and for number of non-eating disorder axis I disorders and for suicidal behavior and self-injury were medium. From pre- to 6-months follow-up, effect sizes were large for all these outcomes.

CONCLUSION

This provides promising pilot data for larger studies utilizing DBT for BED or BN and BPD.

The emotion reactivity scale: development, evaluation, and relation to self-injurious thoughts and behaviors

Prior research has examined the relations between various facets of emotion and psychopathology, with a great deal of recent work highlighting the importance of emotion regulation strategies. Much less attention has been given to the examination of emotion reactivity. This study reports on the development and evaluation of the Emotion Reactivity Scale (ERS), a 21-item self-report measure of emotion sensitivity, intensity, and persistence, among a sample of 87 adolescents and young adults. Factor analysis revealed a single factor of emotion reactivity best characterized the data. The ERS showed strong internal consistency (alpha=.94), convergent and divergent validity via relations with behavioral inhibition/activation and temperament, and criterion-related validity as measured by associations with specific types of psychopathology and self-injurious thoughts and behaviors (SITB). Moreover, emotion reactivity statistically mediated the relation between psychopathology and SITB. These findings provide preliminary support for the ERS and suggest that increased emotion reactivity may help explain the association between psychopathology and SITB.

The role of emotional abuse in the eating disorders: implications for treatment

This paper addresses the clinical links between emotional abuse and the eating disorders. It is argued that the core feature of a range of abusive experiences is emotional invalidation. Emotional abuse is associated with problems in the development of emotional skills, manifesting as alexithymia, poor distress tolerance, and emotional inhibition. Cognitive-behavioral approaches are outlined for work with eating-disordered patients with a history of emotional abuse. As well as addressing the central concerns about eating, weight, and shape (using existing evidence-based methods), the focus of treatment is on addressing the conditional assumptions about the acceptability of emotions and the core beliefs that underpin the emotional difficulties.

Development of a measure to assess invalidating childhood environments in the eating disorders

OBJECTIVE

The role of childhood abuse is well recognised within the eating disorders. However, the impact of parental invalidation of the child's emotional needs has not been investigated. Such invalidation is potentially important because it appears to be associated with the difficulties in tolerating distress that are often seen in adults with eating disorders. This study aims to develop a measure of childhood invalidating environments (Invalidating Childhood Environments Scale; ICES). It also investigated the relationship between childhood experiences, levels of distress tolerance and eating pathology.

METHOD

Seventy-three eating-disordered women and 62 non-eating-disordered women completed a newly developed measure of invalidating environments (ICES), the Eating Disorders Inventory, and a Distress Tolerance Scale.

RESULTS

The ICES had acceptable psychometric and clinical validity. Women who scored highly on the ICES had greater levels of eating disturbance. Within the clinical sample, the data were compatible with a model where difficulties in tolerating distress partially mediate the relationship between perceived invalidation by the father and eating pathology.

CONCLUSIONS

Parental invalidation is a potentially important construct in the eating disorders. This paper demonstrates that the ICES is a valid measure of that construct. This study suggests a clear framework for working with patients, where evidence of an invalidating childhood environment indicates a need to work with patients on their capacity to tolerate distress.

Distress tolerance in the eating disorders

OBJECTIVE

It is commonly noted that patients with eating disorders have difficulties in regulating emotional states. This construct is similar to the concept of distress tolerance, which has been identified as a problem in patients with impulsive disorders. However, the elements that make up distress tolerance are not clearly delineated, making it difficult to target treatment in relevant cases. This study aimed to develop a measure of distress tolerance, and to validate it clinically with the eating disorders.

METHOD

The sample consisted of 72 women with DSM-IV eating disorder diagnoses, and 62 women with no history of eating disorders. Each completed a newly developed measure of distress tolerance (the Distress Tolerance Scale; DTS) and the Eating Disorders Inventory.

RESULTS

The DTS was made up of three scales, each with acceptable psychometric properties. Two of those scales differentiated the groups--the clinical women showed higher levels of 'Avoidance of affect', while the non-clinical women had higher scores in the 'Accept and manage' scale. Avoidance of affect was positively associated with unhealthy eating attitudes.

CONCLUSIONS

It is important to examine both maladaptive and adaptive means of coping with affect in the eating disorders. Treatment strategies for modification of distress tolerance should address both the reduction of avoidance and the development of emotional management skills. Further research is needed to determine whether these findings are relevant to the presence of other impulsive behaviours in the eating disorders.

Spirituality among young women at risk for eating disorders

OBJECTIVE

This study examined the spiritual and religious (S/R) beliefs and practices of college-age women at high-risk for eating disorders, and the relationship between body image distress, coping, and S/R.

METHOD

Two hundred fifty-five college-age women with elevated weight and shape concerns, assessed using the Weight/Shape Concerns Scale and the Eating Disorder Examination (EDE), completed surveys about their S/R beliefs and practices.

RESULTS

Women with strong S/R beliefs and practices cope with body dissatisfaction differently than women without strong S/R beliefs. Participants with strong S/R were significantly more likely to pray, meditate, or read religious/spiritual texts to cope with body image distress. Participants without strong beliefs and practices were more likely to cope utilizing distraction. Women with strong beliefs who prayed found it effective.

DISCUSSION

Study participants were heterogenenous in their S/R beliefs and practices. These beliefs and practices may be underutilized resources for coping with body image concerns.

State dissociation in bulimic eating disorders: an experimental study

BACKGROUND

Dissociation and binge eating appear to have equivalent functions, lowering awareness of generalized threat and negative self-esteem. Dissociation can be a general characteristic of the individual, present in all situations (i.e., a trait), or it can be a time-limited reaction to a specific situation (i.e., a state). Previous studies have shown that the subliminal presentation of threat cues leads to increased bulimic behaviors. This experimental study examines whether dissociation is activated under similar conditions, thus testing whether dissociation is a reactive state in bulimic women, as well as a trait.

METHOD

The participants were 24 bulimic and 26 nonclinical women, each of whom completed the Eating Disorders Inventory and the Dissociative Experiences Scale. Each woman was exposed to subliminal neutral and threat cues, before completing the subjective component of the Clinician-Administered Dissociation Scale and a measure of anxiety and mood (the Hospital Anxiety and Depression Scale).

RESULTS

The subliminal threat cue significantly increased state dissociation (particularly derealization levels) in the bulimic women but had no effect on the nonclinical group. There was no impact on mood.

DISCUSSION

State dissociation appears to play an integral role in the bulimic process, but further studies are needed to determine the causal structure in that relationship and whether it applies in other disorders. Future clinical practice should be directed towards the identification and treatment of state dissociation in therapy.

Survey of regional health care providers on selection of treatment for bulimia nervosa

OBJECTIVE

To determine which treatments clinicians currently recommend for patients with bulimia nervosa (BN), to find out if they recommended evidence-based treatments, and to assess availability and clinician satisfaction with treatment options.

METHODS

Surveys were sent to 1,263 health care providers in Minnesota, Iowa, and Wisconsin who were likely to encounter patients with BN. These health care providers comprised all primary care clinicians, physician assistants, advanced practice nurses, and all mental health/chemical dependency clinicians (MDs, Clinical Nurse Specialist (CNS), social workers, doctoral and masters-level therapists, and chemical dependency (CD) counselors) affiliated with the Mayo Clinic in Rochester, Minnesota.

RESULTS

Evidence-based treatments for BN are recommended consistently and are generally perceived to be available, at least to practitioners affiliated with a large medical center in the Midwest. Clinician satisfaction with treatment options is modest.

DISCUSSION

Clinicians are recommending evidence-based treatments for BN patients and find them to be generally available. Modest satisfaction with available treatments may reflect a realistic understanding of treatment options, which need further development.

Management of child and adolescent eating disorders: the current evidence base and future directions

Although eating disorders in children and adolescents remain a serious cause of morbidity and mortality, the evidence base for effective interventions is surprisingly weak. The adult literature is growing steadily, but this is mainly with regard to psychological therapies for bulimia nervosa and to some extent in the field of pharmacotherapy. This review summarises the recent research literature covering management in three areas, namely physical management, psychological therapies, and service issues, and identifies prognostic variables. Findings from the adult literature are presented where there is good reason to believe that these might be applied to younger patients. Evidence-based good practice recommendations from published clinical guidelines are also discussed. Suggestions for future research are made, focusing on 1) the need for trials of psychological therapies in anorexia nervosa, 2) applications of evidence-based treatments for adult bulimia nervosa to the treatment of adolescents, and 3) clarification of the benefits and costs of different service models.

A dialectical behavior therapy program for people with an eating disorder and borderline personality disorder--description and outcome

OBJECTIVE

To describe and evaluate a full dialectical behavior therapy (DBT) program for people with comorbid eating disorder and borderline personality disorder. The program included a novel skills training module written especially for eating-disordered patients.

METHOD

The program was run for 18 months. Days in hospital and major acts of self-harm were counted for the 18 months before and after DBT.

RESULTS

There were no dropouts from the program. The patients seemed to benefit. Most patients were neither eating disordered nor self-harming at follow-up.

DISCUSSION

Full DBT is an expensive and demanding treatment but deserves consideration for patients with an eating disorder and co-morbid borderline personality disorder and self-harm. There is a need for a more systematic and thorough evaluation.

Individual psychotherapy for children and adolescents with an eating disorder from historical precedent toward evidence-based practice

This article reviews the place of individual therapy in the suite of treatment services required by children and adolescents with an eating disorder. Individual therapy is defined and traced from historical origins in psychoanalytic practice with later important modifications by Hilda Bruch and Arthur Crisp. More recent developments, based primarily on cognitive and learning theory are discussed, as is the timing of individual therapy with respect to illness stage and patient motivation. Evidence for therapy effectiveness is reviewed where possible. At present, treatment evidence in the pediatric mental health field must be inferred from adult research.