A 10-session cognitive-behavioral therapy (CBT-T) for eating disorders: Outcomes from a case series of nonunderweight adult patients

Recent Advances in Cognitive-Behavioural Therapy for Eating Disorders (CBT-ED)

PURPOSE OF REVIEW

Eating disorders require more effective therapies than are currently available. While cognitive behavioural therapy for eating disorders (CBT-ED) has the most evidence to support its effectiveness, it requires substantial improvement in order to enhance its reach and outcomes, and to reduce relapse rates. Recent years have seen a number of noteworthy developments in CBT-ED, which are summarised in this paper.

RECENT FINDINGS

The key advances identified here include: improvements in the efficiency and availability of CBT-ED; expansion of applicability to younger cases across durations of eating disorder; and new methodologies. There have been important recent advances in the field of CBT-ED. However, it is important to stress that there remain gaps in our evidence base and clinical skills, and suggestions are made for future research and clinical directions.

Clinical Experiences Using Cognitive-Behavioral Therapy for Eating Disorders

Data suggests that despite the availability of evidence-based psychological treatments for eating disorders (EDs), techniques from these therapies may be less frequently used within real-life clinical practice. The aim of this study was to provide the opportunity for clinicians to give feedback on their experiences treating EDs using cognitive-behavioral therapy (CBT) through reporting on use of CBT techniques and barriers to treatment implementation in naturalistic settings. Clinicians (N = 126) who self-identified as using CBT for EDs reported demographic information, frequency/usefulness of empirically supported treatment techniques, problems/limitations of CBT, and barriers faced while implementing CBT. The most frequently used technique reported by clinicians was psychoeducation, and the least frequently used technique was use of surveys to address mind reading. Patients' unwillingness to follow a meal plan/nutritional guide was rated as the most impactful barrier, alongside ED severity. Of the problems/limitations of CBT, too little guidance on treating co-occurring symptoms was rated as the most impactful. This study provided a mechanism for clinicians to share their experiences using CBT for EDs in real-world settings. Overall, results regarding frequency of use and usefulness of techniques indicate a high level of endorsement. Moreover, the most frequently endorsed barriers to/limitations of CBT related to lack of guidance on treating complex ED presentations. Future research should explore ways to treat cases that go beyond the prototypical ED case and explore ways to adapt CBT to meet the needs of naturalistic treatment settings.

Testing the role of associative learning in evidence-based treatments for anorexia nervosa

Treatments for anorexia nervosa (AN) remain ineffective for many patients. Processes that can account for differential treatment outcomes remain mostly unknown. We propose that the field test the role of associative learning in current psychological treatments. We hold that this line of research could yield actionable information for understanding non-response and improving long-term outcomes. To make this argument, we define associative learning and outline its proposed role in understanding psychiatric disorders and their treatment. We then briefly review data exploring associative learning in AN. We argue that associative learning processes are implicitly implicated in existing treatments; by this rationale, baseline differences in learning may interfere with treatment response. Finally, we outline future research to test our hypotheses. Altogether, future research aimed at better understanding how associative learning may contribute to AN symptom persistence has the potential to inform novel directions in intervention research. PUBLIC SIGNIFICANCE: There is a pressing need to improve outcomes in treatments for anorexia nervosa (AN). We propose that individual differences in associative learning-the ability to form and update associations between cues, contexts, behaviors, and outcomes-may account for differential response to existing treatments. Undertaking this research could provide an understanding of how current treatments work and inform new approaches for those who may be at risk of poor outcomes.

Clinician perspectives of the implementation of an early intervention service for eating disorders in England: a mixed method study

BACKGROUND

The First Episode Rapid Early Intervention for Eating Disorders (FREED) service has been shown to reduce the wait for care and improve clinical outcomes in initial evaluations. These findings led to the national scaling of FREED in England. To support this scaling, we conducted a mixed method evaluation of the perceptions and experiences of clinicians in the early phases of scaling. The Normalisation Process Theory (NPT) was used as a conceptual lens to understand if and how FREED becomes embedded in routine practice.

METHODS

The convergent mixed method evaluation included 21 semi-structured interviews with clinicians from early adopter sites and 211 surveys administered to clinicians before, immediately after and 3 months after the FREED training. The interview guide and survey included questions evaluating attitudes towards early intervention for eating disorders (EDs) and NPT mechanisms. Interview data were analysed using an inductive thematic analysis. The NPT was applied to the inductively derived themes to evaluate if and how NPT domains impacted the implementation. Survey data were analysed using multilevel growth models.

RESULTS

Six themes and 15 subthemes captured barriers and facilitators to implementation at the patient, clinician, service, intervention, implementation and wider system levels. These interacted with the NPT mechanisms to facilitate or hinder the embedding of FREED. Overall, clinicians were enthusiastic and positive towards early intervention for EDs and FREED, largely because of the expectation of improved patient outcomes. This was a considerable driver in the uptake and implementation of FREED. Clinicians also had reservations about capacity and the potential impact on other patients, which, at times, was a barrier for its use. The FREED training led to significant improvements in positive attitudes and NPT mechanisms that were largely maintained at the 3-month follow-up. However, negative attitudes did not significantly improve following training.

CONCLUSIONS

Positive attitudes towards early intervention for EDs increased enthusiasm and engagement with the model. Features of the model and its implementation were effective at developing adopter commitment and capabilities. However, there were aspects of the model and its implementation which require attention in the future (e.g., capacity and the potential impact on the wider service).

Feasibility and preliminary effectiveness of a cognitive-behavioral, family-centered partial hospitalization program for adolescents with anorexia nervosa and atypical anorexia nervosa at six- and twelve-month follow-up

This study examined the feasibility and preliminary effectiveness of a cognitive-behavioral, family-centered partial hospitalization program (PHP) for adolescents with anorexia nervosa (AN) and atypical AN (AAN), and described the outpatient services received following discharge. Participants (N = 31) completed anthropometric and self-report assessments at admission, discharge, and six and twelve months after discharge from the PHP. Descriptive statistics explored markers of feasibility. Paired samples t-tests evaluated changes in weight and eating disorder (ED) symptomatology from admission to discharge, admission to six-month follow-up, and admission to twelve-month follow-up. Descriptive statistics and effect sizes compared symptoms at each timepoint between participants with AN and AAN. Results indicated that we were successful at recruiting greater than 50% of adolescents approached for this study. We collected follow-up data from more than 70% of participants at discharge, but did not meet this retention benchmark at six-month and twelve-month follow-ups. The entire sample demonstrated significant improvements in weight and ED symptomatology from admission to discharge, and generally maintained these improvements at six- and twelve-month follow-up. While descriptive statistics suggested that participants with AN and AAN received similar outpatient services following discharge from the PHP, those with AN experienced greater improvement in self-reported ED symptomatology than those with AAN at six- and twelve-month follow-up. These findings provide preliminary support for the efficacy of PHPs in treating adolescents with AN and AAN. Further research with larger sample sizes should investigate whether adolescents with AAN experience poorer outcomes than those with AN following discharge from a PHP.

New understandings meet old treatments: putting a contemporary face on established protocols

In the twenty years since the publication of the most widely used treatment manuals describing evidence-based therapies for eating disorders, there have been some substantial advances in the field. New methods of delivering treatments have been trialled and our perception of mental health has advanced; significant cultural changes have led to shifts in our societal landscape; and new technologies have allowed for more in-depth research to be conducted. As a result, our understanding of eating disorders and their treatment has broadened considerably. However, these new insights have not necessarily been translated into improved clinical practice. This paper highlights the changes we consider to have had the greatest impact on our work as experienced clinical psychologists in the field and suggests a list of new learnings that might be incorporated into clinical practice and research design.

Therapeutic alliance with psychotherapist versus dietician: a pilot study of eating disorder treatment in a multidisciplinary team during the COVID-19 pandemic

Little is known about the therapeutic alliance (TA) formed with different professionals in multidisciplinary eating disorder (ED) treatment, particularly in the context of online treatment during the COVID-19 pandemic. We aimed to conduct a pilot study during the COVID-19 pandemic examining characteristics of patients' TA with their dieticians and psychotherapists, associations between patients' and therapists' views of the TA, and relationships between psychological characteristics and TAs. Sixty-three patients with EDs and their treating psychotherapists and dieticians were surveyed during the COVID-19 pandemic using the Working Alliance Inventory (WAI-S). Spearman correlation tests were used to examine associations between variables. Positive associations were found between the TAs examined. Concordance was stronger in patient-dietician dyads than in patient-psychotherapist dyads. Severe ED psychopathology was associated with weaker TA (bond subscale). General psychopathology was associated with weaker TA with the dietician (task subscale). Given that several differences were found between the TAs of treatment dyads, further longitudinal studies are needed to validate our pilot findings and to investigate multidisciplinary TAs and their impact on treatment outcomes in online ED treatment settings during the COVID-19 pandemic, as well as in other treatment settings (e.g., in-person settings). This study will contribute to a deeper understanding of the dynamics of TAs in multidisciplinary ED treatment and inform the development of more effective interventions.

Assessing clinician competence in the delivery of cognitive-behavioural therapy for eating disorders: development of the Cognitive-Behavioural Therapy Scale for Eating Disorders (CBTS-ED)

Evidence-based cognitive-behaviour therapy for eating disorders (CBT-ED) differs from other forms of CBT for psychological disorders, making existing generic CBT measures of therapist competence inadequate for evaluating CBT-ED. This study developed and piloted the reliability of a novel measure of therapist competence in this domain-the Cognitive Behaviour Therapy Scale for Eating Disorders (CBTS-ED). Initially, a team of CBT-ED experts developed a 26-item measure, with general (i.e. present in every session) and specific (context- or case-dependent) items. To determine statistical properties of the measure, nine CBT-ED experts and eight non-experts independently observed six role-played mock CBT-ED therapy sessions, rating the therapists' performance using the CBTS-ED. The inter-item consistency (Cronbach's alpha and McDonald's omega) and inter-rater reliability (ICC) were assessed, as appropriate to the clustering of the items. The CBTS-ED demonstrated good internal consistency and moderate/good inter-rater reliability for the general items, at least comparable to existing generic CBT scales in other domains. An updated version is proposed, where five of the 16 "specific" items are reallocated to the general group. These preliminary results suggest that the CBTS-ED can be used effectively across both expert and non-expert raters, though less experienced raters might benefit from additional training in its use.

Brief group cognitive-behavioral therapy for bulimia nervosa and binge-eating disorder: A pilot study of feasibility and acceptability

OBJECTIVE

Brief cognitive-behavioral therapy for non-underweight eating disorders (CBT-T) has been shown to be clinically useful in non-underweight samples, when delivered one-to-one. This pilot study assessed the acceptance, compliance and feasibility levels of a group version of CBT-T, which has the potential to enhance patient access.

METHOD

A group CBT-T protocol was developed and piloted in two therapy groups (N = 8). Eating disorder attitudes and behaviors, depression and anxiety were assessed at the beginning and end of treatment.

RESULTS

A third of all patients approached accepted the offer of group CBT-T, and entered treatment. Among that group of treatment starters, none were lost to treatment. The therapy was feasible in practical terms, including online delivery. Finally, mean scores on measures suggested improvement in clinical profiles.

DISCUSSION

This pilot study demonstrated that a group CBT-T is a feasible intervention for non-underweight eating disorders in adults, with low acceptance but high compliance. Group CBT-T has the potential to reduce demand on services and in turn increase availability of treatment to those with eating disorders.

PUBLIC SIGNIFICANCE

The present research contributes to the treatment of non-underweight adults with eating disorders. Group CBT-T was shown to be feasible in this pilot study. It was associated with low acceptance but strong compliance. If supported by further research, group CBT-T has the potential to reduce waitlists, ensure throughput in services, and ultimately improve the lives of many who are affected by eating disorders.

Editorial Perspective: A perfect storm - how and why eating disorders in young people have thrived in lockdown and what is happening to address it

The number of children and young people referred to community eating disorders services escalated dramatically shortly after onset of the Covid-19 pandemic. Many presented with medical instability following restrictive eating and needed acute hospitalisation to correct malnutrition. In addition to the many risk factors for mental health problems that young people have been subjected to since onset of the pandemic, the question for eating disorders researchers, practitioners and policy makers is how, for so many, did it become about eating. In this editorial, some of the factors that may explain how eating, weight, shape and body image may have taken centre stage in young people's lives are explored. Finally, some clinical service adaptations and gaps, policy considerations, and research priorities are outlined.

Alliance matters: but how much? A systematic review on therapeutic alliance and outcome in patients with anorexia nervosa and bulimia nervosa

PURPOSE

Patients with eating disorders (ED) pose a high-risk group regarding relapse. The understanding of factors contributing to a better outcome is much-needed. Therapeutic alliance (TA) is one important, pantheoretical variable in the treatment process, which has shown to be connected with outcome. This review looks into a possible predictive effect of TA on outcome as well as related variables.

METHODS

A systematic review with pre-determined inclusion criteria following the PRISMA guidelines was conducted for studies published since 2014. Three previous reviews including studies up until 2014 were analyzed for studies matching our inclusion criteria. A total of 26 studies were included.

RESULTS

The results were heterogeneous between different patient groups. Regarding the predictive effect of TA, in adolescent samples, the TA of either the patients or their parents seems to impact outcome as well as completion. For adults, results are mixed, with a tendency to a greater impact of TA for anorexia nervosa (AN) patients, while some samples of adult bulimia nervosa (BN) patients did not find any relation between TA and outcome.

CONCLUSION

The effect of TA on clinical outcome depends on the patient group. TA has a greater impact on adolescents, irrespective of diagnosis, and on adults with AN. The examined studies have different limitations which include small sample sizes and questionable study design. The examination of motivation as a potential influencing factor is recommended.

LEVEL OF EVIDENCE

Level I, systematic review.

Comparing the effectiveness and predictors of cognitive behavioural therapy-enhanced between patients with various eating disorder diagnoses: a naturalistic study

Cognitive behaviour therapy-enhanced (CBT-E) is an effective treatment for non-underweight patients with eating disorders. Its efficacy and effectiveness is investigated mostly among transdiagnostic samples and remains unknown for binge eating disorder. The aim of the present study was to assess several treatment outcome predictors and to compare effectiveness of CBT-E among adult out-patients with bulimia nervosa (n=370), binge eating disorder (n=113), and those with a restrictive food pattern diagnosed with other specified feeding and eating disorders (n=139). Effectiveness of CBT-E was assessed in routine clinical practice in a specialised eating disorders centre. Eating disorder pathology was measured with the EDEQ pre- and post-treatment, and at 20 weeks follow-up. Linear mixed model analyses with fixed effect were performed to compare treatment outcome among the eating disorder groups. Several predictors of treatment completion and outcome were examined with a regression analysis. No predictors for drop-out were found, except the diagnosis of bulimia nervosa. Eating disorder pathology decreased among all groups with effect sizes between 1.43 and 1.70 on the EDE-Q total score. There were no differences in remission rates between the three groups at end of treatment or at follow-up. Eating disorder severity at baseline affected treatment response. The results can be generalised to other specialised treatment centres. No subgroup of patients differentially benefited from CBT-E supporting the transdiagnostic perspective for the treatment of eating disorders. Longer-term follow-up data are necessary to measure persistence of treatment benefits.

Key learning aims

(1)

New developments in cognitive-behavioural therapy for eating disorders (CBT-ED)

PURPOSE OF REVIEW

This review summarizes recent developments in cognitive-behavioural therapy for eating disorders (CBT-ED). More specifically, the past five years were covered, with the latest UK and Dutch guidelines for eating disorders as a starting benchmark, and with special consideration of the past 18 months.

RECENT FINDINGS

The new research can be divided into findings that have: (1) reinforced our existing understanding of CBT-ED's models and impact; (2) advanced our understanding and the utility of CBT-ED, including its application for the 'new' disorder Avoidant/Restrictive Food Intake Disorder (ARFID); (3) suggested new directions, which require further exploration in clinical and research terms. These include learning from the circumstances of the COVID-19 pandemic.

SUMMARY

CBT-ED has developed substantially in the past 5 years, with consolidation of its existing evidence base, further support for real-life implementation, extension of methods used, and the development of new approaches for working with younger people - particularly in the form of treatments for ARFID. Over the past 18 months, even more promising changes in delivery occurred in response to the COVID19 pandemic, showing that we can adapt our methods in order to work effectively via remote means. Challenges remain regarding poor outcomes for anorexia nervosa.

Brief psychological interventions for anxiety and depression in a secondary care adult mental health service: an evaluation

Due to continuing pressures on the UK National Health Service’s mental health services, there has been increased interest in the development of brief psychological interventions (BPIs). These interventions are usually defined as including selected components of established psychological interventions, delivered over fewer sessions, and by staff with less specialised training (paraprofessionals). Cognitive behavioural therapy (CBT)-based BPIs for anxiety and depression have been found to be helpful for clients with mild to moderate mental health problems. This project evaluates the introduction of BPIs for anxiety and depression in a secondary care adult mental health service, with clients experiencing moderate to severe mental health difficulties. The service developed CBT-based manuals for anxiety (anxiety management) and depression (behavioural activation) BPIs. The BPIs were delivered by mental health workers without core therapeutic training, who were offered training and group supervision by psychologists in the team. Measures of anxiety (GAD-7), depression (PHQ-9), wellbeing (SWEMWBS) and functioning (WSAS) were completed at the start and end of treatment. The data reported from a 2-year period suggest that BPIs are associated with reductions in symptoms of anxiety and low mood, and improvements in wellbeing and functioning. Whilst this is a small-scale initial evaluation, the results are promising for the potential benefit of BPIs for clients in secondary care settings. Given that this new way of working has possible additional benefits such as improving access to psychological treatment and cost-effectiveness, further research in the area is warranted and encouraged.

Key learning aims

(1)

A randomized controlled trial of two 10-session cognitive behaviour therapies for eating disorders: An exploratory investigation of which approach works best for whom

Cognitive behaviour therapy for eating disorders (CBT-ED) outperforms other treatments for non-underweight eating disorders in adults, but we have limited ability to match CBT-ED to individual profiles. We examined if we could identify who benefits most from two forms of 10-session CBT-ED; one emphasizing early behaviour change with substantial content on improving body image (CBT-T), and the other including motivational work and no content on body image using chapters from self-help books (CBTm). Participants were 98 consecutive referrals to the Flinders University Services for Eating Disorders. Fourteen clinical psychology postgraduates delivered the treatment under expert supervision. Outcome measures were completed on five occasions: baseline, 4-, 10-, 14- and 22-weeks post-randomisation. Our primary outcome was global eating psychopathology. Moderators included motivation (readiness and confidence to change) and body avoidance and body checking. Intent-to-treat analyses showed no difference between the groups with a significant main effect of time associated with large effect size improvements, commensurate with longer forms of CBT-ED. Participants with lower readiness to change in CBTm had significantly greater decreases in disordered eating over follow-up compared to those with low motivation in CBT-T. People with lower readiness to change might benefit from the incorporation of motivational work in CBT-ED.

The effect of group cognitive behavior therapy on Chinese patients with anorexia nervosa: an open label trial

BACKGROUND

The high cost of treatment for anorexia nervosa (AN) and lack of trained specialists have resulted in limited accessibility of effective treatment to patients with AN, which is particularly problematic in China. To increase the accessibility of evidence-based treatment and reduce the cost of treatment, this study aimed to explore the feasibility and efficacy of group cognitive behavior therapy (G-CBT) adapted from enhanced cognitive behavior therapy for eating disorders (CBT-E) in Chinese AN patients.

METHOD

A total of 78 patients with AN were assigned to G-CBT or individual outpatient treatment (IOT) and received three months of treatment for AN in each condition. Measures of eating pathology, depression and anxiety were administrated to both intervention groups at three time points: baseline, one month of treatment, and end of treatment; results were compared between groups and over time.

RESULTS

There were 70 participants included in the final analysis. Both G-CBT and IOT groups showed significant improvement in eating pathology and associated psychopathology (ps < .001) over the course of treatment, but no significant difference in symptom improvement was found between the two groups (ps > .05). G-CBT resulted in additional significant improvement in ED psychopathology over the last two months of treatment, and its overall therapeutic effect was influenced by baseline weight and early symptom improvement.

CONCLUSION

Preliminary findings from this open label trial suggest that G-CBT adapted from CBT-E is feasible in an outpatient setting and as effective as IOT in facilitating weight regain and reducing psychopathology in Chinese AN patients with little evidence for the superiority of either intervention.

TRIAL REGISTRATION

The current study was registered at clinical trials.gov on September 23, 2018 (registration number NCT03684239). People with anorexia nervosa (AN) are known to be unmotivated for treatment and prone to relapse. Recovery from AN often needs intensive, long-term treatment from a specialized multidisciplinary team, which is not accessible for most people in China. Given the increasing incidence of AN and lack of eating disorder (ED) specialists in China, it is important to develop short-term cost-effective treatments for AN. In this study, we explored the feasibility and efficacy of group cognitive behavior therapy (G-CBT) adapted from enhanced cognitive behavior therapy (CBT-E) for people with AN from China. We found that G-CBT was as effective as individual outpatient treatment (IOT) typically provided to AN patients at the research site in facilitating weight regain, improving eating behaviors, and reducing ED and other symptoms. We also found that patients receiving G-CBT made more improvements in cognitive symptoms of the ED, which might help maintain treatment gains and prevent relapse in the long run. This potential long-term advantage of G-CBT needs to be verified in long-term follow-up.

A case series of CBT-T in routine clinical practice

OBJECTIVE

CBT-T is a relatively new, brief cognitive behavioral therapy eating disorder treatment for non-underweight patients. This study evaluates CBT-T independently from the team that developed the protocol, and examines the relationship between eating disorder duration and CBT-T effectiveness.

METHOD

A case series design was used, comprising N = 40 adults with bulimia or atypical anorexia type eating disorders. CBT-T was delivered by CBT therapists in a specialist outpatient service. Mixed model analysis examined the interactions between eating disorder duration and change to eating disorder psychopathology and secondary impairment from pre-post treatment. Abstinence, good outcome, and remission rates were also provided.

RESULTS

Intervention effect sizes were large. Treatment completers reported abstinence from binge eating and purging over the final 28-days, and 7-days of treatment at 30.1%, and 73.1%, respectively; 76.9% reported good outcome; and 23.1% reported remission. No relationship between eating disorder duration and treatment effectiveness was found.

DISCUSSION

These findings build on existing evidence supporting provision of CBT-T in routine clinical practice, for patients with eating disorders of any duration. Replication, extension, and RCT will strengthen comparability with other evidence-based approaches.

Effects of cognitive-behavioral and psychodynamic-interpersonal treatments for eating disorders: a meta-analytic inquiry into the role of patient characteristics and change in eating disorder-specific and general psychopathology in remission

BACKGROUND

Cognitive behavior therapy (CBT) and psychodynamic-interpersonal therapies (PIT) are two widely used and conceptually different outpatient treatments for eating disorders (EDs). To better understand how these treatments works, for whom, and under what circumstances, there is a need for knowledge about how outcomes are affected by diagnosis, comorbidity, changes in psychopathology, and study design.

METHOD

Reports on the effects of CBT and PIT for eating disorders were searched. Rates of remission and changes in ED specific- and general psychopathology were computed. Regression models were made to predict event rates by changes in specific- and general psychopathology, as well as ED diagnosis and study design.

RESULTS

The remission rate of CBT for binge eating disorder was 50%, significantly higher than the effect for other diagnostic groups (anorexia = 33%, bulimia: 28%, mixed samples 30%). The number of studies found for PIT was limited. All effect sizes differed from zero (binge eating disorder = 27%, anorexia = 24%, bulimia = 18%, mixed samples = 15%), but the precision of the estimates was low, with some lower-bound confidence intervals close to zero. For CBT, change in ED specific psychopathology predicted remission only when controlling for ED diagnosis, while change in general psychopathology did not predict remission at all. The predictive value of change in psychopathology for PIT, and the potential impact of comorbid personality disorders could not be analyzed due to a lack of studies. There was no difference in effects between randomized controlled trials and observational studies.

CONCLUSIONS

CBT showed consistent remission rates for all EDs but left a substantial number of patients not in remission. Extant evidence suggest that PIT is not consistently effective in achieving remission for patients with EDs, although this finding is uncertain due to a small number of eligible studies. A group of patients with eating disorders may, however, require therapy aimed at strengthening deficits in self functions not easily ameliorable by cognitive behavioral techniques alone. Further research should be aimed at identifying treatment interventions that helps patients change behavior, while strengthening self-functions to substitute eating-disordered behavior in the long-term.

Brief cognitive behavioural therapy for binge-eating disorder: clinical effectiveness in a routine clinical setting

Brief cognitive behavioural therapy (CBT) is effective in working with non-underweight eating disorder patients across transdiagnostic groups. However, it is not clear whether it will be as effective in the treatment of binge-eating disorder, where emotional eating is likely to play a larger role than starvation-driven eating. This case series tested whether brief, 10-session CBT (CBT-T) would be effective in a case series of 53 patients with binge-eating disorder. Attrition rates were comparable to previous research. Eating attitudes, binge frequency, anxiety and depression were measured. Remission was measured comparing different categorical methods: ‘cut-off’; reliable change index (RCI); and clinically significant change (CSC). CBT-T was effective for binge-eating disorder patients, at comparable levels to other non-underweight patients. All measures of pathology were significantly reduced, with large to moderate effect sizes. When categorical changes were used to indicate remission, RCI and CSC levels were more appropriate than existing cut-off methods, potentially because of the lower levels of initial restrained eating in this clinical group. CBT-T’s effectiveness in transdiagnostic groups is replicated in binge-eating disorder patients, despite their greater level of emotionally driven eating. More stringent definitions of remission (CSC and RCI) should be used more widely, to ensure realistic estimates.

Key learning aims

(1)

Early response to psychological treatment for eating disorders: A systematic review and meta-analysis

Early response is a well-established predictor of positive outcomes at the end of psychological treatments for common mental disorders. There is some prior evidence that this conclusion also applies to eating disorders, including three meta-analyses, but no moderators of that relationship have been identified. However, a number of further papers have been published since, which might influence the size of the effect of early response or the potential role of moderating factors. This pre-registered systematic review presents a comprehensive examination of this literature. Three databases were searched (Scopus, PsycInfo, PubMed). In total, 33 eligible studies were included in a narrative synthesis, and 25 studies were included in random-effects meta-analysis. The majority (91%) of studies were rated as having low or moderate risk of bias. Approximately half of patients across clinical samples showed early response to psychological therapy, which was most often defined as reliable symptomatic improvement during the first four sessions. A significant and moderate association was found between early response and post-treatment outcomes (r = 0.41 [95% CI: 0.32-0.481], p < .0001). Significant evidence of heterogeneity (Q[28] = 136.42, p < .0001; I² = 80.2%) was evident. The review was limited by the exclusion of grey literature and only 76% of studies provided sufficient statistical information for meta-analytic synthesis, although we found no significant evidence of publication bias, χ²(1) = 0.001, p = .97. Overall, evidence accumulated over twenty years establishes early response as the most robust predictor of treatment outcomes in the field of eating disorders. However, only half of patients show early change in this way. Further research is needed to determine whether there are patient or clinician characteristics that predict early response to psychological treatment for eating disorders.

Effectiveness of a brief form of group dialectical behavior therapy for binge-eating disorder: Case series in a routine clinical setting

OBJECTIVE

While there is evidence to support the use of group dialectical behavior therapy (DBT) in the treatment of binge-eating disorder (BED), treatment is relatively long compared with other evidence-based treatments. This study explored the effectiveness of brief DBT groups for BED, delivered in a routine community setting.

METHOD

Eighty-four adults with BED entered 10-week DBT group treatment in a community eating disorders service. In total, 12 groups were conducted. Patients completed measures of eating disorder pathology, anxiety, depression, and emotional eating at the start and end of treatment, and at 1-month follow-up. Frequency of weekly binges was recorded.

RESULTS

Outcomes were similar to those of longer versions of DBT, with an attrition rate of 26%, and significant reductions in eating disorder psychopathology and emotional eating by the end of treatment and at follow-up. Over 50% of patients were abstinent from binge eating by Session 4.

DISCUSSION

Group DBT delivered in a 10-session format is clinically equivalent to longer versions of the same treatment. Future research is required to explore patterns of change and to demonstrate replicability under controlled conditions, but these findings are promising for the efficient delivery of effective treatment and reducing waiting times.

The abrupt transition from face-to-face to online treatment for eating disorders: a pilot examination of patients' perspectives during the COVID-19 lockdown

BACKGROUND

Studies investigating patients' perspectives towards an abrupt transition from face-to-face to online treatment in eating disorders (EDs) are scarce. The current study aimed to (1) conduct a preliminary assessment of patients' perspectives regarding this transition, and (2) explore potential demographic, clinical, and treatment-related factors associated with these perspectives.

METHODS

Sixty-three patients with EDs whose treatment was moved to an online format, were surveyed during the COVID-19 lockdown (April-May 2020). A 6-item measure was developed to examine their perspectives toward this transition. Exploratory factor analyses (EFAs) were conducted to confirm the rational-theoretical structure of the measure (Eigenvalue = 3.745, explaining 62.4% of variance). The Cronbach's alpha value was excellent (α = 0.878). Validated questionnaires were used to measure ED symptoms, general psychopathology, therapeutic alliance, and pandemic anxiety, and their associations with our transition-focused scale and telemedicine satisfaction were examined.

RESULTS

Mixed views were found regarding the transition, with the majority (68%) stating that they would not choose to continue online therapy given the option. Longer duration of treatment (r = 0.291, p = 0.022), stronger therapeutic alliance (r = 0.293, p = 0.028), and higher COVID-19 anxiety (r = 0.276, p = 0.029) were linked with more positive views towards the transition.

CONCLUSIONS

Analyses suggest that patients' perspectives towards the transition can be measured using a Likert-type 6-item scale. Findings highlight the various responses to online treatment and indicate a need to identify patients who may face difficulties in the transition to this newly ubiquitous treatment mode. Clinicians should be cognizant of these potential difficulties and consider appropriate modes of treatment in the ongoing pandemic situation.

Group dialectical behavioral therapy for binge-eating disorder: Outcomes from a community case series

OBJECTIVE

Whilst there is evidence to support the use of group dialectical behavioral therapy (DBT) in the treatment of binge-eating disorder (BED), few studies have reported on its effectiveness when delivered in routine clinical practice. This study addressed this gap by exploring the effectiveness of group DBT for BED when delivered in a community eating disorder service.

METHOD

Participants were 56 adults who presented with BED, and were offered a 20-week DBT group. Eight groups were conducted. Measures of eating disorder pathology, anxiety, depression and emotion regulation were completed at start and end of treatment, and one-month follow-up.

RESULTS

The attrition rate was 16.1%. Abstinence rates (no objective binges in the previous month) were approximately 60% at the end of treatment and 50% at follow-up. There were significant reductions in eating disorder psychopathology (but not in mood) by end of treatment and improvements were maintained at follow-up.

DISCUSSION

Group DBT is an acceptable and effective treatment for adults with BED when delivered in a routine community setting. Findings are broadly comparable with those from research trials. The lack of significant effect on mood suggests that DBT can be effective by teaching new emotion-regulation skills, rather than changing mood per se.

Outcomes of brief and enhanced cognitive-behavioural therapy for adults with non-underweight eating disorders: A non-randomized comparison

OBJECTIVE

Cognitive-behavioural therapy (CBT) is an efficacious and effective treatment for eating disorders, and is particularly valuable in the treatment of non-underweight cases (e.g., bulimia nervosa; binge eating-disorders). However, its recommended length for such cases (up to 20 sessions) makes it a relatively costly therapy. It has been suggested that a 10-session version (CBT-T) can also be effective, but there has been no direct comparison between the two forms (10 vs. 20 sessions).

METHOD

This study reports the outcomes of brief and standard-length CBT for non-underweight eating disorders, comparing two cohorts of patients from the same clinic (N = 55 and 138, respectively).

RESULTS

The two therapies had very similar results in terms of eating pathology, remission rate, and improved quality of life. Each showed substantial change by the mid-point of therapy and up to 6-month follow-up.

CONCLUSION

It appears that brief CBT (CBT-T) is as effective as existing 20-session CBT, and is less demanding of time and resource. The findings need to be replicated in a randomized control trial before this conclusion can be made definitive.

Behavioral Interventions in the Treatment of Eating Disorders

Behavioral methods are inherent in many evidence-based treatments of eating disorders and have also been used separately. This review demonstrates that behavioral methods are necessary in the effective treatment of eating disorders-in particular, the improvement of nutrition and exposure-based methods. It is also possible that these methods are sufficient to treat anorexia nervosa, although other elements are needed on the treatment of bulimia nervosa. The impacts and mechanisms of behavioral and nutritional change merit serious attention in clinical work and research. Clinicians are often reluctant, however, to use these methods, and that needs to be the focus of supervision.

Education, dissemination, and the science of eating disorders: Reflections on the 2019 International Conference on Eating Disorders: Editorial to accompany IJED Virtual Issue in honor of the 2019 International Conference on Eating Disorders

OBJECTIVE

This virtual issue of the International Journal of Eating Disorders highlights recently published research that aligns with the broad themes of the 2019 International Conference on Eating Disorders (ICED), held in New York, NY, USA.

METHODS AND RESULTS

We selected articles that were published between 2017 and 2019 that complement the content of the keynote and plenary sessions. We also curated additional articles from early career scholars, given that an important component of the annual ICED is to foster the development and training of the next generation of eating-disorder clinicians and researchers.

DISCUSSION

We hope that this virtual issue will spark more in-depth discussion and reflection on the topics, questions, and critical advances in the field of eating disorders that were presented at the 2019 ICED.

Treating bulimia nervosa in the context of gender dysphoria using 10-session cognitive behavior therapy

OBJECTIVE

This case report describes the psychological treatment for bulimia nervosa of a 16-year old with co-occurring gender dysphoria. He reported restricting his food intake and purging for approximately 1 year prior to therapy commencing.

METHOD

Ten sessions of cognitive behavioral therapy for eating disorders (CBT-T) were conducted with accommodations for gender-specific body dissatisfaction.

RESULTS

The client eliminated binging and purging from the second treatment session and had maintained this at the 3-month follow-up. The quantity and variety of foods he was eating had increased and he no longer reported subjective binges. Improvements were also evident in his depression, anxiety and stress symptoms.

DISCUSSION

This suggests that bulimia nervosa may be effectively treated with CBT-T in the context of gender dysphoria. Further research that investigates the generalizability of these outcomes would be beneficial.

Patients' experiences of brief cognitive behavioral therapy for eating disorders: A qualitative investigation

OBJECTIVE

Although it is important to analyze the effectiveness of new therapies, it is also necessary to consider how patients experience them. This is particularly important if we are to maximize treatment acceptability and reduce attrition. This study examined patient experiences of a new 10-session cognitive-behavioral therapy (CBT-T), using a qualitative approach.

METHOD

The sample was 17 patients with a diagnosis of bulimia nervosa who had received CBT-T (including treatment completers and non-completers) within the previous 2 years. Sample size was determined by saturation of the emergent themes. Responses were analyzed using a six-step thematic analysis process.

RESULTS

Rated acceptability and effectiveness of CBT-T were high. Five themes emerged, with subthemes. The key elements of patient experience of the therapy were: the therapeutic relationship; the nature of the therapy; its challenging but beneficial aspects; ending therapy; and the overall experience of CBT-T (including comparison with other therapies).

DISCUSSION

The findings build on the effectiveness research for CBT-T, suggesting that it is an acceptable therapy that addresses many of the same themes that matter to patients as other therapies. The findings show that patients were positive about CBT-T relative to other therapies, and offer suggestions as to how CBT-T might be delivered to emphasize the importance of the time-limited nature of the therapy.

Recent Research on Bulimia Nervosa

Estimates of lifetime bulimia nervosa (BN) range from 4% to 6.7% across studies. There has been a decrease in the presentation of BN in primary care but an increase in disordered eating not meeting full diagnostic criteria. Regardless of diagnostic status, disordered eating is associated with long-term significant impairment to both physical and mental quality of life, and BN is associated with a significantly higher likelihood of self-harm, suicide, and death. Assessment should adopt a motivationally enhancing stance given the high level of ambivalence associated with BN. Cognitive behavior therapy specific to eating disorders outperforms other active psychological comparisons.

Predictors of outcome in cognitive behavioural therapy for eating disorders: An exploratory study

OBJECTIVE

Early decrease in symptoms is a consistent predictor of good treatment outcome across all eating disorders. The current study explored the predictive value of novel early change variables in a transdiagnostic, non-underweight sample receiving 10-session cognitive behavioural therapy.

METHOD

Participants who reported bingeing and/or purging in the week preceding baseline assessment (N = 62) were included in analyses. Early change variables were calculated for novel (body image flexibility, body image avoidance, body checking, and fear of compassion) and established predictors (behavioural symptoms and therapeutic alliance). Outcomes were global eating disorder psychopathology and clinical impairment at posttreatment and three-month follow-up. Intent-to-treat analyses were conducted using linear regression, adjusting for baseline values of the relevant outcome and early change in behavioural symptoms.

RESULTS

Early improvement in body image flexibility was the most consistent predictor of good outcome. Early change in body image avoidance and the fear of expressing and receiving compassion to/from others were significant predictors in some analyses.

DISCUSSION

Novel early change variables were significant predictors of eating disorder outcomes in this exploratory study. Model testing is required to understand the exact mechanisms by which these variables impact on outcomes, and whether there is potential benefit of modifying existing protocols.

ANZCTR TRIAL NUMBER

ACTRN12615001098527.

Outpatient CBT for Underweight Patients with Eating Disorders: Effectiveness Within a National Health Service (NHS) Eating Disorders Service

Background: Underweight eating disorders (EDs) are notoriously difficult to treat, although a growing evidence base suggests that outpatient cognitive behaviour therapy for EDs (CBT-ED) can be effective for a large proportion of individuals. Aims: To investigate the effectiveness of CBT-ED for underweight EDs in a ‘real-world’ settings. Method: Sixty-three adults with underweight EDs (anorexia nervosa or atypical anorexia nervosa) began outpatient CBT-ED in a National Health Service setting. Results: Fifty-four per cent completed treatment, for whom significant changes were observed on measures of ED symptoms, psychological distress and psychosocial impairment. There was also a large effect on body weight at end-of-treatment. Conclusions: The results suggest that good outcomes can be achieved by the majority of those who complete treatment, although treatment non-completion remains a significant barrier to recovery. Future studies should focus on improving treatment retention, as evidence suggests that CBT-ED in ‘real-world’ settings is effective.

Randomized controlled psychotherapy trials in eating disorders: Improving their conduct, interpretation and usefulness

BACKGROUND

While randomized controlled trials (RCTs) inform the efficacy and effectiveness of treatments, we need to understand that even RCTs can be associated with sub-optimal execution. This is of special pertinence to eating disorders given the majority of treatment studies involving cognitive behaviour therapy are of poor quality with respect to managing risk of bias adequately.

METHODS

The current paper outlines the components of a good RCT for psychotherapy, and examines ways to improve the conduct, interpretation, and usefulness of RCTs.

RESULTS

This includes managing reporting bias, recognizing the limits of randomization, applicability, and ethical considerations.

CONCLUSIONS

We highlight a number of strategies for future research, including issues related to utilizing a variety of designs to examine treatment outcomes, integrity, openness and reproducibility.