A critical evaluation of the efficacy of self-help interventions for the treatment of bulimia nervosa and binge-eating disorder

The efficacy of internet-based cognitive behavioral therapy for adult binge spectrum eating disorders: A meta-analysis

OBJECTIVE

Internet-Based Cognitive Behavioral Therapy (iCBT) is an innovative modality of cognitive-behavioral intervention that presents a promising therapeutic strategy for individuals diagnosed with binge spectrum eating disorders. This study employed a meta-analysis methodology to assess the clinical effectiveness and acceptability of iCBT.

METHODS

We conducted searches in databases such as PubMed, Embase, Web of Science, Cochrane Library, and PsycINFO, collecting literature that met the inclusion criteria until August 5, 2023.

RESULTS

A comprehensive analysis was conducted, encompassing a total of 11 randomized controlled studies that satisfied the predetermined criteria for inclusion. The summary results demonstrated that iCBT could significantly improve the pathological features related to eating in patients with binge spectrum eating disorders and also significantly reduce the frequency of binge episodes. Additionally, iCBT could ameliorate the depressive and anxious emotions of patients with binge spectrum eating disorders and boost their self-esteem. Furthermore, a notable disparity in dropout rates was seen in comparison to the control group.

LIMITATION

Heterogeneity across studies，limitations of self-assessment scales and potential publication bias.

CONCLUSION

iCBT can effectively assist patients with binge spectrum eating disorders in improving clinical symptoms. However, it is important to use caution when interpreting the findings of this study, as there are limitations pertaining to the quantity and quality of the included studies.

Weight suppression at lowest weight as an indicator of eating disorder clinical severity: A retrospective cohort study

OBJECTIVES

Weight suppression (WS) defines the difference between the highest weight in adulthood and the current weight. WS at lowest weight is the difference between the highest and the lowest ever weight. Weight rebound is the difference between the past lowest weight and current weight. The distinction in the capacities of WS, weight rebound, and WS at the lowest weight remains unclear regarding their efficacy in forecasting clinical endpoints. This study assessed the relationship between WS, WS at lowest weight and/or weight rebound and eating disorder (ED) clinical severity.

METHODS

In this retrospective cohort study, adult participants were selected at the Outpatient Unit for multidisciplinary assessment of ED, Montpellier, France, between February 2012 and October 2014 and May 2017 and January 2020. ED clinical severity was evaluated using the Eating Disorder Examination Questionnaire (EDE-Q).

RESULTS

The sample included 303 patients: 204 with anorexia nervosa (AN) and 99 with bulimia nervosa (BN). The EDE-Q total score was positively correlated with WS at lowest weight in patients with AN (Spearman's rho = 0.181, p = 0.015) and with BN (Spearman's rho = 0.377; p < 0.001). It was also positively correlated with weight rebound (Spearman's rho = 0.319; p = 0.003) in patients with BN. In the multivariate analysis, EDE-Q total score was associated with WS at lowest weight only in patients with BN (β = 0.265; p = 0.03).

CONCLUSION

WS at lowest weight seems to be a good measure of ED clinical severity. More research is needed for better understanding WS at lowest weight in assessment and treatment of patients with ED.

Access to evidence-based care for eating disorders during the COVID-19 crisis

The COVID-19 pandemic has forced an abrupt change in the delivery of clinical services, including for individuals with an eating disorder. We present this Virtual Issue as a resource for the eating disorder community to showcase research published in the International Journal of Eating Disorders that provides information on effective strategies to help address the challenges arising from COVID-19-related disruptions. Articles included describe original research or systematic reviews on obstacles to health services use and strategies to improve access to care; technological tools to provide or enhance interventions; patients' and clinicians' attitudes or perspectives on using digital tools for clinical care; factors influencing therapeutic alliance; and ideas for improving reach and uptake of digital interventions. We hope that readers will find ways to observe and record their own experiences during this global crisis; the experiences of people at risk for developing or exhibiting an eating disorder; and the experiences of those who care for people with an eating disorder. These lived experiences will be invaluable in formulating hypotheses for future studies in service of advancing the understanding of eating disorders and improving interventions and policies for reducing the burden of suffering attributable to eating disorders.

The Opioid System and Food Intake: Use of Opiate Antagonists in Treatment of Binge Eating Disorder and Abnormal Eating Behavior

Eating disorders (EDs) and substance use disorders (SUDs) commonly co-occur, especially in conjunction with affective syndromes, yet little is known about opiate abuse and ED symptoms in patients on naltrexone-bupropion therapy. Moreover, evidence suggests that the opioid system can also be regarded as one of the major systems regulating the anticipatory processes preceding binge eating episodes. The lack of evidence in the effectiveness of psychotherapy treatment in addition to psychotropic mediations compounds the difficulties in stabilizing individuals with EDs. This article aims to exhaustively review literature relating to the use of opioid antagonists in the management of binge eating disorder (BED) and other abnormal eating habits and how this can be augmented by the use of psychological approaches to come up with the most effective therapy or combination of therapies to manage these conditions. Although this approach is promising, it has not been evaluated. A review of the literature pertaining to the use of naltrexone in patients with EDs was performed through PubMed, PsycINFO and MEDLINE. We selected 63 relevant articles published between 1981 and 2018 and those written in English. Search terms included “Opioid antagonists”, “naltrexone”, “bupropion” and “Psychotherapy” each combined with “Binge Eating Disorder”, “Bulimia Nervosa”, “Anorexia Nervosa”, “Eating Disorder”, “EDNOS” and “Obesity”. While working with these articles, we also identified several problems related to use of these methods in real clinical practice. Seventy-seven articles were reviewed, and 63 were selected for inclusion. Data obtained from these sources confirmed that the blockade of opioid receptors diminishes food intake. More recent findings also indicate that the combination of bupropion and naltrexone can induce weight loss. Augmentation of this by introducing psychotherapy may lead to better outcomes. Cognitive behavioral therapy (CBT) was the most frequently recommended psychotherapy intervention, showing efficacy for EDs and chemical addictions as documented by most of the studies, but with uncertain efficacy when utilized as augmentation strategy. There are limited data supporting the use of psychotherapy in augmentation of standard therapy in ED; however, there is evidence to support that psychotherapy is safe in this population and has been effective in cases of patients with opiate addiction with and without psychiatric comorbidities as well as BED. More research is needed to establish treatment guidelines. Combining pharmacotherapeutic and psychotherapeutic interventions leads to the achievement of a better outcome in managing patients with EDs. Involving families or the use of support groups increases chances of adherence to the prescribed interventions resulting in higher rates of remission. However, it is clear that all of these interventions must occur in the context of a comprehensive treatment program. We believe that patient-specific psychotherapy may not only facilitate the treatment process, but also cause significant alterations in eating pattern. This approach for BED may lead to more significant treatment outcomes, but this possibility must be tested in larger samples.

Comparing a Tailored Self-Help Mobile App With a Standard Self-Monitoring App for the Treatment of Eating Disorder Symptoms: Randomized Controlled Trial

BACKGROUND

Eating disorders severely impact psychological, physical, and social functioning, and yet, the majority of individuals with eating disorders do not receive treatment. Mobile health apps have the potential to decrease access barriers to care and reach individuals who have been underserved by traditional treatment modalities.

OBJECTIVE

The objective of this study was to evaluate the effectiveness of a tailored, fully automated self-help version of Recovery Record, an app developed for eating disorders management. We examined differences in eating disorder symptom change in app users that were randomized to receive either a standard, cognitive behavioral therapy-based version of the app or a tailored version that included algorithmically determined clinical content aligned with baseline and evolving user eating disorder symptom profiles.

METHODS

Participants were people with eating disorder symptoms who did not have access to traditional treatment options and were recruited via the open-access Recovery Record app to participate in this randomized controlled trial. We examined both continuous and categorical clinical improvement outcomes (measured with the self-report Eating Disorder Examination Questionnaire [EDE-Q]) in both intervention groups.

RESULTS

Between December 2016 and August 2018, 3294 Recovery Record app users were recruited into the study, out of which 959 were considered engaged, completed follow-up assessments, and were included in the analyses. Both study groups achieved significant overall outcome improvement, with 61.6% (180/292) of the tailored group and 55.4% (158/285) of the standard group achieving a clinically meaningful change in the EDE-Q, on average. There were no statistically significant differences between randomized groups for continuous outcomes, but a pattern of improvement being greater in the tailored group was evident. The rate of remission on the EDE-Q at 8 weeks was significantly greater in the group receiving the tailored version (d=0.22; P≤.001).

CONCLUSIONS

This is the first report to compare the relative efficacy of two versions of a mobile app for eating disorders. The data suggest that underserved individuals with eating disorder symptoms may benefit clinically from a self-help app and that personalizing app content to specific clinical presentations may be more effective in promoting symptomatic remission on the EDE-Q than content that offers a generic approach.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02503098; https://clinicaltrials.gov/ct2/show/NCT02503098.

Pathways to specialist care for eating disorders: An Italian multicentre study

Two hundred forty six patients with eating disorders (EDs) recruited from eight Italian specialized treatment centres were administered with the World Health Organization "Encounter Form," a standardized schedule that makes it possible to characterize the clinical pathways that patients follow to reach specialized care. The median time from symptoms onset to specialized care was 114 weeks. Primary "points of access to care" were general practitioners (25%), psychiatrists (18%), and clinical nutritionists (17%), followed by various other carers. All patients received specific psychotherapy, whereas only 11% of them were given psychotropic drugs. EDs are characterized by complex care pathways, with low rates of direct access to specialized care. Although the role of general practitioners remains crucial, they tend to follow different clinical routes to refer ED patients. Educational programmes on EDs should be addressed to general practitioners and clinical nutritionists, in order to ease the transition of ED patients to a mental health care setting.

A single-arm pilot study of guided self-help treatment based cognitive behavioral therapy for bulimia nervosa in Japanese clinical settings

Objective

Guided self-help treatments based on cognitive behavioral therapy (CBT-GSH) are regarded as a first-line effective treatment for bulimia nervosa (BN). With limited application for CBT-GSH in Japanese clinical settings, we conducted a single arm pilot study in order to confirm the acceptability and availability of CBT-GSH in Japan.

Results

25 women with BN received 16–20 sessions of face-to-face CBT-GSH. Primary outcomes were the completion rate of intervention and abstinence rates from objective bingeing and purging as assessed by the Eating Disorder Examination. Secondary outcomes were other self-report measurements of the frequency of bingeing and purging, and characteristic psychopathologies of eating disorders. Assessments were conducted before CBT as baseline as well as after CBT. 92% (23/25) of the participants completed the CBT sessions. After CBT-GSH, 40% (10/25) of the participants (intention-to-treat) achieved symptom abstinence. The mean binge and purge episodes during the previous 28 days improved from 21.88 to 10.96 (50% reduction) and from 22.44 to 10.88 (52% reduction), each (before CBT-GSH to after CBT-GSH), and the within-group effect sizes were medium (Cohen’s d = 0.67, 0.65, each). Our study provided a preliminary evidence about the feasibility of CBT-GSH in Japanese clinical settings for the future.

Trial registration This study was registered retrospectively in the national UMIN Clinical Trials Registry on July 10, 2013 (registration ID: UMIN000011120)

Randomized controlled trial comparing smartphone assisted versus traditional guided self-help for adults with binge eating

OBJECTIVE

Guided self-help treatments based on cognitive-behavior therapy (CBT-GSH) are efficacious for binge eating. With limited availability of CBT-GSH in the community, mobile technology offers a means to increase use of these interventions. The purpose of this study was to test the initial efficacy of Noom Monitor, a smartphone application designed to facilitate CBT-GSH (CBT-GSH + Noom), on study retention, adherence, and eating disorder symptoms compared to traditional CBT-GSH.

METHOD

Sixty-six men and women with DSM-5 binge-eating disorder (BED) or bulimia nervosa (BN) were randomized to receive eight sessions of CBT-GSH + Noom (n = 33) or CBT-GSH (n = 33) over 12 weeks. Primary symptom outcomes were eating disorder examination objective bulimic episodes (OBEs), subjective bulimic episodes (SBEs), and compensatory behaviors. Assessments were collected at 0, 4, 8, 12, 24, and 36 weeks. Behavioral outcomes were modeled using zero-inflated negative-binomial latent growth curve models with intent-to-treat.

RESULTS

There was a significant effect of treatment on change in OBEs (β = -0.84, 95% CI = -1.49, -0.19) favoring CBT-GSH + Noom. Remission rates were not statistically different between treatments for OBEs (βlogit  = -0.73, 95% CI = -1.86, 3.27; CBT-GSH-Noom = 17/27, 63.0% vs. CBT-GSH 11/27, 40.7%, NNT = 4.5), but CBT-GSH-Noom participants reported greater meal and snack adherence and regular meal adherence mediated treatment effects on OBEs. The treatments did not differ at the 6-month follow-up.

DISCUSSION

Smartphone applications for the treatment binge eating appear to have advantages for adherence, a critical component of treatment dissemination.

Overview of the treatment of binge eating disorder

We performed a qualitative review of treatment studies of binge eating disorder (BED), focusing on randomized clinical trials (RCTs). Limited effectiveness has been demonstrated for self-help strategies, and substantial effectiveness has been shown for cognitive behavioral therapy (CBT) and interpersonal therapy (IPT). CBT and IPT may each be more effective than behavior weight loss therapy (BWLT) for reducing binge eating over the long term. The stimulant pro-drug lisdexamfetamine dimesylate (LDX) is the only drug approved by the FDA for the treatment of BED in adults based on 2 pivotal RCTs. Topiramate also decreases binge eating behavior, but its use is limited by its adverse event profile. Antidepressants may be modestly effective over the short term for reducing binge eating behavior and comorbid depressive symptoms, but are not associated with clinically significant weight loss. A RCT presented in abstract form suggests that intranasal naloxone may decrease time spent binge eating. There is no RCT of obesity surgery in BED, but many patients with BED seek and receive such surgery. While some studies suggest patients with BED and obesity do just as well as patients with obesity alone, other studies suggest that patients with BED have more post-operative complications, less weight loss, and more weight regain. This evidence suggests that patients with BED would benefit from receiving highly individualized treatment.

Mexican American women's perspectives on a culturally adapted cognitive-behavioral therapy guided self-help program for binge eating

The prevalence of bulimia nervosa (BN) and binge eating disorder (BED) among Latinas is comparable to those of the general population; however, few interventions and treatment trial research have focused on this group. Cognitive-behavioral therapy (CBT) is the treatment of choice for binge eating related disorders. CBT-based guided self-help (CBTgsh)-a low-cost minimal intervention-has also been shown effective in improving binge eating related symptom, but the effectiveness of the CBTgsh among ethnic minority women is not well understood. Cultural adaptation of evidence-based treatments can be an important step for promoting treatment accessibility and engagement among underserved groups. This qualitative study was part of a larger investigation that examined the feasibility and efficacy of a culturally adapted CBTgsh program among Mexican American women with binge eating disorders. Posttreatment focus groups were conducted with 12 Mexican American women with BN or BED who participated in the intervention. Data were analyzed with the grounded theory methodology (Corbin & Strauss, 2008). Three themes emerged from the data: (a) eating behavior and body ideals are socially and culturally constructed, (b) multifaceted support system is crucial to Mexican American women's treatment engagement and success, and (c) the culturally adapted CBTgsh program is feasible and relevant to Mexican American women's experience, but it can be strengthened with increased family and peer involvement. The findings provide suggestions for further adaptation and refinement of the CBTgsh, and implications for future research as well as early intervention for disordered eating in organized care settings.

Perceptions of the feasibility and acceptability of a smartphone application for the treatment of binge eating disorders: Qualitative feedback from a user population and clinicians

BACKGROUND

Binge eating, a major public health problem, is characterized by recurrent episodes of out-of-control eating in which an individual consumes an unusually large amount of food in a discrete time period. Limitations of existing treatments for binge eating (both in-person psychotherapy and guided self-help) indicate that smartphone applications (apps) may be an ideal alternative or enhancement. An app for binge eating could aid treatment dissemination, engagement, and/or compliance. However, no research to date has examined user perceptions of a therapeutic app for binge eating, which is critical for development.

OBJECTIVES

The purposes of the current study were to conceptualize a potential app for binge eating and obtain feedback regarding feasibility and acceptability from target users (i.e., individuals with binge eating) and clinicians specializing in the treatment of binge eating.

METHODS

Our team conceptualized a smartphone app that contained self-help material, functions to monitor behavior, and provisions of in-the-moment interventions. We presented this app (e.g., feature explanations, mock screen shots) through phone interviews with clinicians who specialize in the treatment of binge eating (n=10), and focus groups with individuals experiencing binge eating (n=11). Participants were asked to discuss customization, user burden, terminology, attrition, data visualization, comprehensiveness, reminders, feasibility, acceptability, and perceived effectiveness of the proposed app. Thematic analyses were conducted from qualitative data (e.g., audio recordings and interview notes) obtained via the focus groups and interviews.

RESULTS

Results indicated that our proposed app would be highly feasible and acceptable to users and clinicians, though concerns about the degree of personalization and customizability were noted.

CONCLUSIONS

The current study details highly specific feedback and ideas regarding essential app features from target users and clinicians. This information is critical for the development of future apps to treat binge eating. Ways in which data obtained from the current study may be generalized to the development of therapeutic apps for other psychological disorders is discussed.

Disseminating evidence-based psychological treatments for eating disorders

The research-practice gap is of concern in the treatment of eating disorders. Despite the existence of empirically supported treatments, few receive them. The barriers to wider dissemination and implementation of evidence-based treatment include clinician attitudes towards such treatments and the lack of sufficient numbers of suitably trained therapists to provide treatment. In this review we discuss these barriers in the context of the wider issue of the dissemination and implementation of psychological treatments and review the research with regard to the treatment of eating disorders. Particular emphasis is placed on examining recent efforts to expand the availability and reach of treatments by making treatment delivery and training more scalable. We highlight promising developments and areas where further research is needed.

Attitudes to and practice of bibliotherapy among senior trainees in psychiatry

OBJECTIVES

This study was to assess the attitudes and practice of, senior psychiatric trainees with regard to bibliotherapy.

METHODS

A brief online survey was used to assess the attitudes to and practice of bibliotherapy among senior psychiatric trainees in Ireland. There were 34 responses out of 82 (response rate 41.5%). Respondents were asked to indicate their agreement with three statements.

RESULTS

The majority 27 (79.4%) strongly agreed or agreed that they were comfortable recommending books, with none strongly disagreeing and 4 (11.8%) disagreeing. Over half 20 (58.8%) of respondents strongly disagreed or disagreed that self help books could only be a poor substitute for psychotherapy or counselling, with none strongly agreeing and 2 (5.9%) agreeing. Many 19 (55.9%) disagreed or strongly disagreed that self help books could do more harm than good, with 8 (23.5%) agreeing or strongly agreeing. Finally respondents were asked to state their awareness of prescribe-a-book schemes. 4 (11.8%) respondents reported awareness, with 30 (88.2%) unaware of any such schemes.

CONCLUSIONS

Although majority of senior psychiatric trainees were comfortable recommending self help books and did not consider them harmful, most were unaware of such schemes in Ireland.

Treatment of binge eating disorder in racially and ethnically diverse obese patients in primary care: randomized placebo-controlled clinical trial of self-help and medication

The objective was to determine whether treatments with demonstrated efficacy for binge eating disorder (BED) in specialist treatment centers can be delivered effectively in primary care settings to racially/ethnically diverse obese patients with BED. This study compared the effectiveness of self-help cognitive-behavioral therapy (shCBT) and an anti-obesity medication (sibutramine), alone and in combination, and it is only the second placebo-controlled trial of any medication for BED to evaluate longer-term effects after treatment discontinuation. 104 obese patients with BED (73% female, 55% non-white) were randomly assigned to one of four 16-week treatments (balanced 2-by-2 factorial design): sibutramine (N = 26), placebo (N = 27), shCBT + sibutramine (N = 26), or shCBT + placebo (N = 25). Medications were administered in double-blind fashion. Independent assessments were performed monthly throughout treatment, post-treatment, and at 6- and 12-month follow-ups (16 months after randomization). Mixed-models analyses revealed significant time and medication-by-time interaction effects for percent weight loss, with sibutramine but not placebo associated with significant change over time. Percent weight loss differed significantly between sibutramine and placebo by the third month of treatment and at post-treatment. After the medication was discontinued at post-treatment, weight re-gain occurred in sibutramine groups and percent weight loss no longer differed among the four treatments at 6- and 12-month follow-ups. For binge-eating, mixed-models revealed significant time and shCBT-by-time interaction effects: shCBT had significantly lower binge-eating frequency at 6-month follow-up but the treatments did not differ significantly at any other time point. Demographic factors did not significantly predict or moderate clinical outcomes. Our findings suggest that pure self-help CBT and sibutramine did not show long-term effectiveness relative to placebo for treating BED in racially/ethnically diverse obese patients in primary care. Overall, the treatments differed little with respect to binge-eating and associated outcomes. Sibutramine was associated with significantly greater acute weight loss than placebo and the observed weight-regain following discontinuation of medication suggests that anti-obesity medications need to be continued for weight loss maintenance. Demographic factors did not predict/moderate clinical outcomes in this diverse patient group.

Binge eating frequency and regular eating adherence: the role of eating pattern in cognitive behavioral guided self-help

Cognitive behavioral guided self-help (CBTgsh) is an evidence-based, brief, and cost-effective treatment for eating disorders characterized by recurrent binge eating. However, more research is needed to improve patient outcomes and clarify treatment components most associated with symptom change. A main component of CBTgsh is establishing a regular pattern of eating to disrupt dietary restriction, which prior research has implicated in the maintenance of binge eating. The present study used session-by-session assessments of regular eating adherence and weekly binge totals to examine the association between binge frequency and regular eating in a sample of participants (n = 38) receiving 10 sessions of CBTgsh for recurrent binge eating. Analyses were conducted using Hierarchical Linear Modeling (HLM) to allow for data nesting, and a likelihood ratio test determined which out of three regression models best fit the data. Results demonstrated that higher regular eating adherence (3 meals and 2-3 planned snacks daily) was associated with lower weekly binge frequency in this sample, and both the magnitude and direction of the association were maintained after accounting for individual participant differences in binge and adherent day totals. Findings provide additional empirical support for the cognitive behavioral model informing CBTgsh. Possible clinical implications for treatment emphasis and sequencing in CBTgsh are discussed.

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.

Self-help for binge eating disorder in primary care: a randomized controlled trial with ethnically and racially diverse obese patients

OBJECTIVE

The objective was to examine the effectiveness of a self-help treatment as a first line primary care intervention for binge eating disorder (BED) in obese patients. This study compared the effectiveness of a usual care plus self-help version of cognitive behavioral therapy (shCBT) to usual care (UC) only in ethnically/racially diverse obese patients with BED in primary care settings in an urban center.

METHOD

48 obese patients with BED were randomly assigned to either shCBT (N = 24) or UC (N = 24) for four months. Independent assessments were performed monthly throughout treatment and at post-treatment.

RESULTS

Binge-eating remission rates did not differ significantly between shCBT (25%) and UC (8.3%) at post-treatment. Mixed models of binge eating frequency determined using the Eating Disorder Examination (EDE) revealed significant decreases for both conditions but that shCBT and UC did not differ. Mixed models of binge eating frequency from repeated monthly EDE-questionnaire assessments revealed a significant treatment-by-time interaction indicating that shCBT had significant reductions whereas UC did not during the four-month treatments. Mixed models revealed no differences between groups on associated eating disorder psychopathology or depression. No weight loss was observed in either condition.

CONCLUSIONS

Our findings suggest that pure self-help CBT did not show effectiveness relative to usual care for treating BED in obese patients in primary care. Thus, self-help CBT may not have utility as a front-line intervention for BED for obese patients in primary care and future studies should test guided-self-help methods for delivering CBT in primary care generalist settings.

Enhancing motivation to change in eating disorders with an online self-help program

Ambivalence to change is a major obstacle to treating people with eating disorders. Enhancing motivation to change can contribute to recovery from the disorders. This study used an Internet-based self-help program developed in the Asia-Pacific region to identify the motivational stages of change in people with eating disorders. It explored their perceptions of the benefits and costs of taking action against their eating disorders, and assessed their involvement in motivational enhancement exercises and their improvement in eating disorder psychopathology. A total of 185 participants, aged 16-50 years (mean age, 26.5) were involved in the open-trial program with a motivational enhancement component and completed the Motivational Stages of Change Questionnaire (MSCARED), the Eating Disorder Examination Questionnaire version 5 (EDE-Q5) and the Eating Disorder Inventory version 3 (EDI-3). The results show that more participants perceived the benefits of taking action against their eating disorders than the costs. Completer analysis shows that they experienced significant improvement in motivational stages of change and eating disorder psychopathology, from a baseline assessment to 1-month and 3-month follow ups. The self-help program has potential benefit for people with eating disorders and its use could be encouraged by health-care professionals to enhance the motivation to change and facilitate recovery.

Enhancing quality of life in people with disordered eating using an online self-help programme

BACKGROUND

Eating disorders are serious mental illnesses that have a significant effect on afflicted individuals' quality of life. Evidence has shown that they can be improved with treatment. Internet-based interventions are useful in engaging individuals with eating disorders in self-management and treatment. This study aimed primarily to identify the change in quality of life of individuals with disordered eating after participating in an open trial of an Internet-based self-help programme, and compared their quality of life at assessment with that of healthy controls. Factors affecting their quality of life were examined. Secondary outcomes related to symptom improvement were also reported.

METHODS

This study included 194 individuals with disordered eating and 50 healthy controls. The former group was recruited from eating disorder outpatient clinics and treatment units, as well as via information disseminated through various Internet websites, while the healthy controls were recruited from university student newspapers and university campuses. The Medical Outcomes Study Short Form Survey (SF-36v2) was used to assess participants' quality of life. Other measures were used to assess their symptoms and motivational stages of change to recover from an eating disorder. The Wilcoxon signed ranks test and one-way repeated measures ANOVA were used to identify the change in quality of life of individuals with disordered eating from baseline to 1-, 3- and 6-month follow-ups. The Mann-Whitney U test was employed to compare the difference in quality of life between participants with disordered eating and the healthy controls. Spearman rank order correlations were performed to examine the factors associated with quality of life.

RESULTS

The participants with disordered eating had significantly poorer quality of life than the healthy controls in both physical and psychological domains. The factors associated with their poor quality of life included dieting behaviour, use of laxatives, severe eating disorder psychopathology, depression and anxiety. Over a six-month follow-up period, a significant number of participants engaged in self-help behaviours using the Internet-based programme. They experienced improvements in their quality of life, eating disorder psychopathology, depression severity, anxiety level and motivational stages of change.

CONCLUSIONS

Internet-based self-help programmes have the potential to enhance quality of life in individuals with disordered eating and could be useful adjuncts to professional treatment.

How effective is bibliotherapy-based self-help cognitive behavioral therapy with Internet support in clinical settings? Results from a pilot study

Cognitive behavioral therapy-based guided self-help (CBT-GSH) via the Internet has been shown to be effective in the treatment of bulimia nervosa (BN) and similar eating disorders (EDs), but it is rarely offered, and little is known about the effects, in clinical settings. The present study investigated the effects of a bibliotherapy-based CBT-GSH with Internet support in a clinical setting. Participants were 48 adult outpatients who were recruited without randomization from a specialized ED clinic, diagnosed with BN or similar eating disorder. Forty-eight patients in an intensive day patient program (DPP) were used as comparison group. The Eating Disorder Examination Questionnaire (EDE-Q) and the Eating Disorder Inventory 2 measured pre- and post treatment symptoms. Results showed that both groups attained significant improvements in core- as well as related ED symptoms in both instruments. As expected, treatment effects were larger in the more intensive DPP. Nonetheless, bibliotherapy CBT-GSH appears to be a cost-effective treatment that represents a new way to provide more CBT in clinical settings.

Integrative Response Therapy for Binge Eating Disorder

Binge Eating Disorder (BED), a chronic condition characterized by eating disorder psychopathology and physical and social disability, represents a significant public health problem. Guided Self Help (GSH) treatments for BED appear promising and may be more readily disseminable to mental health care providers, accessible to patients, and cost-effective than existing, efficacious BED specialty treatments which are limited in public health utility and impact given their time and expense demands. No existing BED GSH treatment has incorporated affect regulation models of binge eating, which appears warranted given research linking negative affect and binge eating. Integrative Response Therapy (IRT), a new group-based guided self-help treatment, based on the affect regulation model of binge eating, that has shown initial promise in a pilot sample of adults meeting DSM IV criteria for BED, is described. Fifty-four% and 67% of participants were abstinent at post-treatment and three month follow-up respectively. There was a significant reduction in the number of binge days over the previous 28 days from baseline to post-treatment [14.44 (±7.16) to 3.15 (±5.70); t=7.71, p<.001; d=2.2] and from baseline to follow-up [14.44 (±7.16) to 1.50 (±2.88); t=5.64, p<.001; d=1.7]. All subscales from both the Eating Disorder Examination - Questionnaire and Emotional Eating Scale were significantly lower at post-treatment compared to baseline. 100% of IRT participants would recommend the program to a friend or family member in need. IRT's longer-term efficacy and acceptability are presently being tested in a National Institute of Mental Health funded randomized controlled trial.

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.

INTERBED: internet-based guided self-help for overweight and obese patients with full or subsyndromal binge eating disorder. A multicenter randomized controlled trial

Background

Binge eating disorder (BED) is a prevalent clinical eating disorder associated with increased psychopathology, psychiatric comorbidity, overweight and obesity, and increased health care costs. Since its inclusion in the DSM-IV, a few randomized controlled trials (RCTs) have suggested efficacy of book-based self-help interventions in the treatment of this disorder. However, evidence from larger RCTs is needed. Delivery of self-help through new technologies such as the internet should be investigated in particular, as these approaches have the potential to be more interactive and thus more attractive to patients than book-based approaches. This study will evaluate the efficacy of an internet-based guided self-help program (GSH-I) and cognitive-behavioral therapy (CBT), which has been proven in several studies to be the gold standard treatment for BED, in a prospective multicenter randomized trial.

Methods

The study assumes the noninferiority of GSH-I compared to CBT. Both treatments lasted 4 months, and maintenance of outcome will be assessed 6 and 18 months after the end of treatment. A total of 175 patients with BED and a body mass index between 27 and 40 kg/m² were randomized at 7 centers in Germany and Switzerland. A 20% attrition rate was assumed. As in most BED treatment trials, the difference in the number of binge eating days over the past 28 days is the primary outcome variable. Secondary outcome measures include the specific eating disorder psychopathology, general psychopathology, body weight, quality of life, and self-esteem. Predictors and moderators of treatment outcome will be determined, and the cost-effectiveness of both treatment conditions will be evaluated.

Results

The methodology for the INTERBED study has been detailed.

Conclusions

Although there is evidence that CBT is the first-line treatment for BED, it is not widely available. As BED is still a recent diagnostic category, many cases likely remain undiagnosed, and a large number of patients either receive delayed treatment or never get adequate treatment. A multicenter efficacy trial will give insight into the efficacy of a new internet-based guided self-help program and will allow a direct comparison to the evidence-based gold standard treatment of CBT in Germany.

Trial Registration

Current Controlled Trials ISRCTN40484777

German Clinical Trial Register DRKS00000409

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.

Psychological treatments for binge eating disorder

Binge eating disorder (BED) is the most prevalent eating disorder in adults, and individuals with BED report greater general and specific psychopathology than non-eating disordered individuals. The current paper reviews research on psychological treatments for BED, including the rationale and empirical support for cognitive behavioral therapy (CBT), interpersonal psychotherapy (IPT), dialectical behavior therapy (DBT), behavioral weight loss (BWL), and other treatments warranting further study. Research supports the effectiveness of CBT and IPT for the treatment of BED, particularly for those with higher eating disorder and general psychopathology. Guided self-help CBT has shown efficacy for BED without additional pathology. DBT has shown some promise as a treatment for BED, but requires further study to determine its long-term efficacy. Predictors and moderators of treatment response, such as weight and shape concerns, are highlighted and a stepped-care model proposed. Future directions include expanding the adoption of efficacious treatments in clinical practice, testing adapted treatments in diverse samples (e.g., minorities and youth), improving treatment outcomes for nonresponders, and developing efficient and cost-effective stepped-care models.

Cultural Adaptation of a Cognitive Behavior Therapy Guided Self-Help Program for Mexican American Women With Binge Eating Disorders

Data on the compatibility of evidence-based treatment in ethnic minority groups are limited. This study utilized focus group interviews to elicit Mexican American women's (N = 12) feedback on a cognitive behavior therapy guided self-help program for binge eating disorders. Findings revealed 6 themes to be considered during the cultural adaptation process and highlighted the importance of balancing the fidelity and cultural relevance of evidence-based treatment when disseminating it across diverse racial/ethnic groups.

Who benefits most from guided self-help for binge eating? An investigation into the clinical features of completers and non-completers

Guided self-help (GSH) is a recommended first step in treatment for bulimia nervosa (BN) and binge eating disorder (BED) (NICE, 2004). It remains unclear what makes some individuals more likely to respond to this form of treatment than others. Forty-eight patients participated in this study using a GSH programme for binge eating. Profiles of treatment completers and non-completers are compared, and reasons for non-completion explored. Completion of treatment was associated with significant improvements in mood, general functioning and on measures of dietary restraint, frequency of objective binge eating (OBE), laxative misuse, self-induced vomiting (SIV) and driven exercise. Improvements were maintained at follow-up. Treatment non-completers reported significantly higher pre-treatment levels of depression and weight concern, and lower levels of general health and vitality. Reasons for discontinuing treatment were related to perceptions of the GSH programme; practicalities of the programme; and readiness to change. Whilst GSH can be effective for a sub-group of patients, factors such as pre-morbid level of depression, degree of weight concern, perceptions of the programme, and readiness to change may increase the likelihood of non-completion.

An open trial of self-help behaviours of clients with eating disorders in an online programme

AIM

The aim of this study was to evaluate the self-help behaviour of individuals with eating disorders in an Internet-based self-help programme developed in the Asia-Pacific region and to determine their compliance with the programme.

BACKGROUND

Eating disorders represent a growing health problem affecting both Western and Asian countries. Without timely and adequate treatment, individuals with eating disorders are at risk of premature death. Self-help approaches for treating eating disorders offer therapeutic promise.

DESIGN

An open trial design was used.

METHOD

This study, conducted from August 2006-July 2011, included 280 participants recruited from outpatient eating disorder clinics and treatment units and through a university student newspaper and Internet websites. This open trial evaluated an Internet-based self-help programme, which included components on healthy eating, family education, health assessment, motivation enhancement, self-help strategies, and psychological health promotion. The progress of participants was followed up via monthly e-mails. A tracking system was implemented to determine their compliance with the programme.

FINDINGS

A small majority of the participants (56·9%) were already undergoing treatment for their eating disorders. About 63% (n = 176) demonstrated self-help behaviour, as manifested by their completion of health assessment questionnaires, involvement in motivation enhancement exercises, or the use of self-help strategies such as monitoring, normalizing eating behaviour, and stress management. Improvements were observed in their eating disorder psychopathology, motivational stage of change and psychological health from baseline to the 1-month follow up.

CONCLUSION

Internet-based self-help programmes for eating disorders are helpful adjuncts to professional treatment.

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.

Guided self-help as the first step for bulimic symptoms: implementation of a stepped-care model within specialized psychiatry

OBJECTIVE

This study describes the implementation and effectiveness of the first step, guided self-help (GSH), in a clinical setting, of a stepped-care model of cognitive behavior therapy for patients with bulimic symptoms.

METHOD

Eighty-nine patients participated.

RESULTS

In the intent to-treat analyses, the effect sizes were small to moderate (0.25-0.66). However, the effect sizes were substantially larger (0.44-1.66) for the patients who completed all the GSH sessions (45%). The majority of noncompleters stayed within psychiatric services. Supplementary treatments were mostly directed towards comorbid conditions, especially depression. Those discontinuing treatment in advance where characterized by more lifetime diagnoses and higher ratings on the restraint subscale of the EDE-Q.

DISCUSSION

GSH within specialized psychiatry might be effective for about 30% of the patients. There is no indication of patients losing their confidence in psychiatric services by being offered GSH as the first treatment.

Self-efficacy as a robust predictor of outcome in guided self-help treatment for broadly defined bulimia nervosa

OBJECTIVE

To examine predictors of guided self-help (GSH) treatment outcome in bulimia nervosa (BN).

METHOD

Data were included from 87 individuals who participated in one of two randomized controlled trials evaluating GSH interventions for BN. Participants received eight sessions of GSH over a 6- to 8-week period and were assessed at baseline, pretreatment, posttreatment, and 6-month follow-up.

RESULTS

Motivation (confidence in ability to change) proved to be the most robust predictor of outcome, across three of the four outcome measures. Baseline measures of concern over mistakes perfectionism also uniquely predicted outcome at posttreatment. Posttreatment measures of stress, eating disorder-related automatic thoughts, and frequency of binge episodes predicted outcome at 6-month follow-up.

DISCUSSION

This study suggests that tackling motivation early in therapy, with a particular focus on confidence in succeeding in change, could be of benefit to outcome in BN treatment.

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

BACKGROUND

This study compared the best available treatment for bulimia nervosa, cognitive-behavioural therapy (CBT) augmented by fluoxetine if indicated, with a stepped-care treatment approach in order to enhance treatment effectiveness.

AIMS

To establish the relative effectiveness of these two approaches.

METHOD

This was a randomised trial conducted at four clinical centres (Clinicaltrials.gov registration number: NCT00733525). A total of 293 participants with bulimia nervosa were randomised to one of two treatment conditions: manual-based CBT delivered in an individual therapy format involving 20 sessions over 18 weeks and participants who were predicted to be non-responders after 6 sessions of CBT had fluoxetine added to treatment; or a stepped-care approach that began with supervised self-help, with the addition of fluoxetine in participants who were predicted to be non-responders after six sessions, followed by CBT for those who failed to achieve abstinence with self-help and medication management.

RESULTS

Both in the intent-to-treat and completer samples, there were no differences between the two treatment conditions in inducing recovery (no binge eating or purging behaviours for 28 days) or remission (no longer meeting DSM-IV criteria). At the end of 1-year follow-up, the stepped-care condition was significantly superior to CBT.

CONCLUSIONS

Therapist-assisted self-help was an effective first-level treatment in the stepped-care sequence, and the full sequence was more effective than CBT suggesting that treatment is enhanced with a more individualised approach.

Treatment of eating disorders in primary care: a systematic review

This review evaluated psychological treatments for Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder conducted in primary care. Five studies met inclusion criteria. Guided self-help cognitive-behavioral therapy via a self-help book may be a beneficial, first-line treatment for reducing binging and purging symptoms. Outcomes combining self-help with antidepressants remain unclear, although antidepressants alone may provide reduction of symptoms. High attrition and non-compliance rates among studies reviewed indicate the importance of a strong therapeutic alliance between provider and patient. Further research in primary care is needed to develop a standard of care for patients with eating disorders.

The role of email guidance in internet-based cognitive-behavioural self-care treatment for bulimia nervosa

Email has been progressively used as a means for providing therapeutic guidance and support for cognitive behavioural treatment (CBT) self-care programmes. Many aspects of the use of email in self-care need to be explored such as the content of therapists' emails. Such information would optimise the delivery of self-care treatments. To date no study has looked at the content of the therapists' emails. We analysed the content of emails (n = 712) sent by therapists to participants (n = 71) of a randomised controlled trial (RCT) of internet-based CBT with email support for bulimic disorders. 14.7% of the emails therapists sent contained at least one CBT comment, while 95.4% had at least one supportive comment and 13.6% had at least one technical comment. The mean time spent on providing email support to each participant across the complete programme was 45 minutes. Emails sent by therapists were mainly supportive in content, with only a small amount of time being required by therapists to provide email support.

Cognitive behavioral guided self-help for the treatment of recurrent binge eating

OBJECTIVE

Despite proven efficacy of cognitive behavioral therapy (CBT) for treating eating disorders with binge eating as the core symptom, few patients receive CBT in clinical practice. Our blended efficacy-effectiveness study sought to evaluate whether a manual-based guided self-help form of CBT (CBT-GSH), delivered in 8 sessions in a health maintenance organization setting over a 12-week period by master's-level interventionists, is more effective than treatment as usual (TAU).

METHOD

In all, 123 individuals (mean age = 37.2; 91.9% female, 96.7% non-Hispanic White) were randomized, including 10.6% with bulimia nervosa (BN), 48% with binge eating disorder (BED), and 41.4% with recurrent binge eating in the absence of BN or BED. Baseline, posttreatment, and 6- and 12-month follow-up data were used in intent-to-treat analyses.

RESULTS

At 12-month follow-up, CBT-GSH resulted in greater abstinence from binge eating (64.2%) than TAU (44.6%; number needed to treat = 5), as measured by the Eating Disorder Examination (EDE). Secondary outcomes reflected greater improvements in the CBT-GSH group in dietary restraint (d = 0.30); eating, shape, and weight concern (ds = 0.54, 1.01, 0.49, respectively; measured by the EDE Questionnaire); depression (d = 0.56; Beck Depression Inventory); and social adjustment (d = 0.58; Work and Social Adjustment Scale), but not weight change.

CONCLUSIONS

CBT-GSH is a viable first-line treatment option for the majority of patients with recurrent binge eating who do not meet diagnostic criteria for BN or anorexia nervosa.

Evaluation of a guided internet self-treatment programme for bulimia nervosa in several European countries

OBJECTIVE

The purposes of this study were to evaluate the use of an online guided self-treatment programme for bulimia nervosa (BN) and to determine predictors of outcome. Data were collected in four European countries where the programme was simultaneously used.

METHOD

One hundred and twenty-seven BN or subthreshold BN female patients (mean age of 24.7 years) participated in a 4-month intervention using a CBT based online-guided self-help programme. Contact during the treatment period included weekly e-mails with a coach.

ASSESSMENT

Measures included the Eating Disorders Inventory-2 (EDI-2) and the Symptom Check List-Revised (SCL-90R).

RESULTS

Severity of eating disorders symptoms and general psychopathology improved significantly. Twenty-three per cent of patients were symptom free at the end of treatment. The dropout rate was 25.2%. A better score of general psychological health was a predictor of a better outcome.

CONCLUSIONS

This study encourages further developments and research on innovative therapy approaches, particularly for those disorders such as BN, with difficult therapy and unclear prognosis.

Cognitive behavioral therapy for eating disorders

Cognitive behavioral therapy (CBT) is the leading evidence-based treatment for bulimia nervosa. A new "enhanced" version of the treatment appears to be more potent and has the added advantage of being suitable for all eating disorders, including anorexia nervosa and eating disorder not otherwise specified. This article reviews the evidence supporting CBT in the treatment of eating disorders and provides an account of the "transdiagnostic" theory that underpins the enhanced form of the treatment. It ends with an outline of the treatment's main strategies and procedures.

Screening for binge eating disorders using the Patient Health Questionnaire in a community sample

OBJECTIVE

To examine the operating characteristics of the Patient Health Questionnaire eating disorder module (PHQ-ED) for identifying bulimia nervosa/binge eating disorder (BN/BED) or recurrent binge eating (RBE) in a community sample and to compare true positive (TP) versus false positive (FP) cases on clinical validators.

METHOD

Two hundred and fifty-nine screen-positive individuals and a random sample of 89 screen negative cases completed a diagnostic interview. Sensitivity, specificity, and positive predictive value (PPV) were calculated. TP and FP cases were compared using t-tests and Chi-square tests.

RESULTS

The PHQ-ED had high sensitivity (100%) and specificity (92%) for detecting BN/BED or RBE, but PPV was low (10 or 19%). TP and FP cases did not differ significantly on frequency of subjective bulimic episodes, objective overeating, restraint, on BMI, and on self-rated health.

DISCUSSION

The PHQ-ED is recommended for use in large populations only in conjunction with follow-up questions to rule out cases without objective bulimic episodes.

Eating disorders

This Seminar adds to the previous Lancet Seminar about eating disorders, published in 2003, with an emphasis on the biological contributions to illness onset and maintenance. The diagnostic criteria are in the process of review, and the probable four new categories are: anorexia nervosa, bulimia nervosa, binge eating disorder, and eating disorder not otherwise specified. These categories will also be broader than they were previously, which will affect the population prevalence; the present lifetime prevalence of all eating disorders is about 5%. Eating disorders can be associated with profound and protracted physical and psychosocial morbidity. The causal factors underpinning eating disorders have been clarified by understanding about the central control of appetite. Cultural, social, and interpersonal elements can trigger onset, and changes in neural networks can sustain the illness. Overall, apart from studies reporting pharmacological treatments for binge eating disorder, advances in treatment for adults have been scarce, other than interest in new forms of treatment delivery.

Psychological treatments of binge eating disorder

CONTEXT

Interpersonal psychotherapy (IPT) is an effective specialty treatment for binge eating disorder (BED). Behavioral weight loss treatment (BWL) and guided self-help based on cognitive behavior therapy (CBTgsh) have both resulted in short-term reductions in binge eating in obese patients with BED.

OBJECTIVE

To test whether patients with BED require specialty therapy beyond BWL and whether IPT is more effective than either BWL or CBTgsh in patients with a high negative affect during a 2-year follow-up.

DESIGN

Randomized, active control efficacy trial.

SETTING

University outpatient clinics.

PARTICIPANTS

Two hundred five women and men with a body mass index between 27 and 45 who met DSM-IV criteria for BED. Intervention Twenty sessions of IPT or BWL or 10 sessions of CBTgsh during 6 months.

MAIN OUTCOME MEASURES

Binge eating assessed by the Eating Disorder Examination.

RESULTS

At 2-year follow-up, both IPT and CBTgsh resulted in greater remission from binge eating than BWL (P < .05; odds ratios: BWL vs CBTgsh, 2.3; BWL vs IPT, 2.6; and CBTgsh vs IPT, 1.2). Self-esteem (P < .05) and global Eating Disorder Examination (P < .05) scores were moderators of treatment outcome. The odds ratios for low and high global Eating Disorder Examination scores were 2.8 for BWL, 2.9 for CBTgsh, and 0.73 for IPT; for self-esteem, they were 2.4 for BWL, 1.9 for CBTgsh, and 0.9 for IPT.

CONCLUSIONS

Interpersonal psychotherapy and CBTgsh are significantly more effective than BWL in eliminating binge eating after 2 years. Guided self-help based on cognitive behavior therapy is a first-line treatment option for most patients with BED, with IPT (or full cognitive behavior therapy) used for patients with low self-esteem and high eating disorder psychopathology.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00060762.

The efficacy of self-help group treatment and therapist-led group treatment for binge eating disorder

OBJECTIVE

The purpose of this investigation was to compare three types of treatment for binge eating disorder to determine the relative efficacy of self-help group treatment compared to therapist-led and therapist-assisted group cognitive-behavioral therapy.

METHOD

A total of 259 adults diagnosed with binge eating disorder were randomly assigned to 20 weeks of therapist-led, therapist-assisted, or self-help group treatment or a waiting list condition. Binge eating as measured by the Eating Disorder Examination was assessed at baseline, at end of treatment, and at 6 and 12 months, and outcome was assessed using logistic regression and analysis of covariance (intent-to-treat).

RESULTS

At end of treatment, the therapist-led (51.7%) and the therapist-assisted (33.3%) conditions had higher binge eating abstinence rates than the self-help (17.9%) and waiting list (10.1%) conditions. However, no between-group differences in abstinence rates were observed at either of the follow-up assessments. The therapist-led condition also showed more reductions in binge eating at end of treatment and follow-up assessments compared to the self-help condition, and treatment or waiting period completion rates were higher in the therapist-led (88.3%) and waiting list (81.2%) conditions than in the therapist-assisted (68.3%) and self-help (59.7%) conditions.

CONCLUSIONS

Therapist-led group cognitive-behavioral treatment for binge eating disorder led to higher binge eating abstinence rates, greater reductions in binge eating frequency, and lower attrition compared to group self-help treatment. Although these findings indicate that therapist delivery of group treatment is associated with better short-term outcome and less attrition than self-help treatment, the lack of group differences at follow-up suggests that self-help group treatment may be a viable alternative to therapist-led interventions.

Psychological treatments for bulimia nervosa and binging

BACKGROUND

A specific manual-based form of cognitive behavioural therapy (CBT) has been developed for the treatment of bulimia nervosa (CBT-BN) and other common related syndromes such as binge eating disorder. Other psychotherapies and modifications of CBT are also used.

OBJECTIVES

To evaluate the efficacy of CBT, CBT-BN and other psychotherapies in the treatment of adults with bulimia nervosa or related syndromes of recurrent binge eating.

SEARCH STRATEGY

Handsearch of The International Journal of Eating Disorders since first issue; database searches of MEDLINE, EXTRAMED, EMBASE, PsycInfo, CURRENT CONTENTS, LILACS, SCISEARCH, CENTRAL and the The Cochrane Collaboration Depression, Anxiety & Neurosis Controlled Trials Register; citation list searching and personal approaches to authors were used. Search date June 2007.

SELECTION CRITERIA

Randomised controlled trials of psychotherapy for adults with bulimia nervosa, binge eating disorder and/or eating disorder not otherwise specified (EDNOS) of a bulimic type which applied a standardised outcome methodology and had less than 50% drop-out rate.

DATA COLLECTION AND ANALYSIS

Data were analysed using the Review Manager software program. Relative risks were calculated for binary outcome data. Standardised mean differences were calculated for continuous variable outcome data. A random effects model was applied.

MAIN RESULTS

48 studies (n = 3054 participants) were included. The review supported the efficacy of CBT and particularly CBT-BN in the treatment of people with bulimia nervosa and also (but less strongly due to the small number of trials) related eating disorder syndromes.Other psychotherapies were also efficacious, particularly interpersonal psychotherapy in the longer-term. Self-help approaches that used highly structured CBT treatment manuals were promising. Exposure and Response Prevention did not enhance the efficacy of CBT.Psychotherapy alone is unlikely to reduce or change body weight in people with bulimia nervosa or similar eating disorders.

AUTHORS' CONCLUSIONS

There is a small body of evidence for the efficacy of CBT in bulimia nervosa and similar syndromes, but the quality of trials is very variable and sample sizes are often small. More and larger trials are needed, particularly for binge eating disorder and other EDNOS syndromes. There is a need to develop more efficacious therapies for those with both a weight and an eating disorder.

Recent advances in therapies for the eating disorders

In the first part of this decade, many reviews of the impact of treatments for the eating disorders were conducted, with broadly similar conclusions. This review provides an update on progress (or otherwise) in the field over the past three years.

A randomised trial investigating guided self-help to reduce perfectionism and its impact on bulimia nervosa: a pilot study

AIM

The purpose of the present study was to evaluate reducing perfectionism as a potential treatment target for individuals with Bulimia Nervosa (BN).

METHOD

Forty-eight individuals meeting DSM-IV criteria for BN or eating disorder - not otherwise specified with binge eating [objective or subjective] or purging at least once per week were recruited. Participants were randomly assigned to receive 8 sessions of manual-based guided self-help (GSH) over a 6-week period that was focused on either cognitive behaviour therapy (CBT) for perfectionism, CBT for BN, or a placebo. Individuals were assessed at baseline, pre-treatment, post-treatment and at six-month follow-up on 12 outcome variables, including diagnostic criteria and psychological variables.

RESULTS

There was no significant change in any of the outcome variables over a 6-week no-treatment period but at post-treatment and 6-month follow-up there were significant main effects of time for 10 and 8 outcome variables respectively, suggesting that all groups reported significant reductions in bulimic symptomatology and related psychopathology at post-treatment and follow-up.

CONCLUSIONS

These findings show potential for the use of novel interventions in GSH for BN.