Clinical moderators and predictors of cognitive-behavioral therapy by guided-self-help versus therapist-led for binge-eating disorder: Analysis of aggregated clinical trials

The predictive value of emotion regulation difficulties and negative mood on short and long-term treatment outcomes in an online guided self-help programme for adults with binge-eating disorder

OBJECTIVE

Cognitive behaviour therapy (CBT) online guided self-help programs represent efficacious and accessible treatment options for adults with binge-eating disorder (BED), but research on predictors of treatment outcome is scarce. This study aimed to investigate the predictive value of emotion regulation difficulties relative to that of negative mood on short- and longer-term treatment outcomes in an online guided self-help programme for BED above and beyond other predictors (age, sex, baseline BED severity).

METHODS

Participants were 63 adults (87% female, mean age 37.2 years) with BED. Data was analysed using a hierarchical model approach.

RESULTS

Emotion regulation difficulties better predicted both weekly binge-eating frequency and eating disorder (ED) pathology at posttreatment than negative mood, after controlling for the effect of age, sex and baseline BED severity. At 6-month follow-up, neither emotion regulation difficulties nor negative mood further added to the prediction of weekly binge-eating frequency, whereas negative mood, but not emotion regulation difficulties, did so for ED pathology.

CONCLUSION

These findings indicate that emotion regulation difficulties at treatment begin might be a relevant predictor of immediate treatment outcome in online guided self-help for adults with BED but might have lower impact on longer-term treatment outcome than negative mood.

CLINICAL TRIAL REGISTER NUMBER

The clinical trial register number is not given in this version of the manuscript due to anonymisation.

The Dutch Body Shape Questionnaire among patients with binge-eating disorder: psychometrics and norms of the full version (BSQ34) and the short version (BSQ8C)

PURPOSE

This study examined the psychometric properties and provided normative data of the Dutch Body Shape Questionnaire (BSQ34) and its shortened BSQ8C among patients with binge-eating disorder.

METHODS

The two versions of the BSQ were administered to patients with binge-eating disorder (N = 155) enrolled for treatment, and to a community sample (N = 333). The translation and back-translation of the BSQ were performed by translators with and without eating-disorder expertise. Internal consistency, concurrent validity, test-retest reliability, incremental validity, and sensitivity to change were determined. A receiver-operating-characteristic curve-analysis was used to establish criterion-related validity, for which the Eating Disorder Examination-Shape concern subscale, was used. Uni-dimensionality of the instrument was investigated with confirmatory factor analysis. Norms (population-based T-scores and clinical percentile-scores) were determined.

RESULTS

The psychometric properties of the BSQs were satisfactory. The BSQ34 discriminated well in body-shape dissatisfaction between patients with binge-eating disorder and the community sample (area-under-the-curve value = 0.91-0.98) and had a unidimensional factor structure. Comparing structural invariance between both samples revealed that scaler invariance was not supported, indicating that items may be interpreted differently by patients with binge-eating disorder and subjects from the community. Analyses were repeated for the BSQ8C, which yielded similar results.

CONCLUSION

The results indicated that both versions of the BSQ appeared suitable to screen for body-shape dissatisfaction among patients with binge-eating disorder. The BSQ34 supplies valuable information on the various types of concerns respondents have, which are critical to consider in clinical settings; the BSQ8C is recommended as a short screening tool.

LEVEL OF EVIDENCE

Level III: Evidence obtained from well-designed cohort or case-control analytic studies.

Treatment of Eating Disorders: Current Status, Challenges, and Future Directions

Specific psychological treatments have demonstrated efficacy and represent the first-line approaches recommended for anorexia nervosa, bulimia nervosa, and binge-eating disorder. Unfortunately, many patients, particularly those with anorexia nervosa, do not derive sufficient benefit from existing treatments, and better or alternative treatments for eating disorders are needed. Less progress has been made in developing pharmacologic options for eating disorders. No medications approved for anorexia nervosa exist, and only one each exists for bulimia nervosa and for binge-eating disorder; available data indicate that most patients fail to benefit from available medications. Longer and combined treatments have generally not enhanced outcomes. This review presents emerging findings from more complex and clinically relevant adaptive treatment designs, as they offer some clinical guidance and may serve as models for future enhanced treatment research.

Effectiveness of a Web-Based Cognitive Behavioral Self-Help Intervention for Binge Eating Disorder: A Randomized Clinical Trial

Importance

Binge eating disorder (BED) is one of the most frequent eating pathologies and imposes substantial emotional and physical distress, yet insufficient health care resources limit access to specialized treatment. Web-based self-help interventions emerge as a promising solution, offering more accessible care.

Objective

To examine the effectiveness of a web-based cognitive behavioral self-help intervention for individuals with BED.

Design, Setting, and Participants

This 2-arm, parallel-group randomized clinical trial conducted from January 15, 2021, to August 3, 2022, in Germany and other German-speaking countries enrolled patients aged 18 to 65 years who met the diagnostic criteria for BED (according to the Diagnostic and Statistical Manual of Mental Disorders [Fifth Edition]). Data analysis occurred between January 27 and September 4, 2023, following our statistical analysis plan.

Interventions

Participants were randomized to a web-based self-help intervention or a waiting-list control condition.

Main Outcomes and Measures

The primary outcome was a change in objective binge eating episodes from baseline to after treatment. Secondary outcomes included global eating pathology, clinical impairment, work capacity, well-being, comorbid psychopathology, self-esteem, and emotion regulation.

Results

A total of 1602 patients were screened, of whom 154 (mean [SD] age, 35.93 [10.59] years; 148 female [96.10%]) fulfilled the criteria for BED and were randomized (77 each to the intervention and control groups). The web-based intervention led to significant improvements in binge eating episodes (Cohen d, -0.79 [95% CI, -1.17 to -0.42]; P < .001), global eating psychopathology (Cohen d, -0.71 [95% CI, -1.07 to -0.35]; P < .001), weekly binge eating (Cohen d, -0.49 [95% CI, -0.74 to -0.24]; P < .001), clinical impairment (Cohen d, -0.75 [95% CI, -1.13 to -0.37]; P < .001), well-being (Cohen d, 0.38 [95% CI, 0.01 to 0.75]; P = .047), depression (Cohen d, -0.49 [95% CI, -0.86 to -0.12]; P = .01), anxiety (Cohen d, -0.37 [95% CI, -0.67 to -0.07]; P = .02), self-esteem (Cohen d, 0.36 [95% CI, 0.13 to 0.59]; P = .003), and emotion regulation (difficulties: Cohen d, -0.36 [95% CI, -0.65 to -0.07]; P = .01 and repertoire: Cohen d, 0.52 [95% CI, 0.19 to 0.84]; P = .003).

Conclusion and Relevance

In this randomized clinical trial of a web-based self-help intervention for patients with BED, the findings confirmed its effectiveness in reducing binge eating episodes and improving various mental health outcomes, highlighting a scalable solution to bridge the treatment gap for this condition.

Trial Registration

ClinicalTrials.gov Identifier: NCT04876183.

Web-based guided self-help cognitive behavioral therapy-enhanced versus treatment as usual for binge-eating disorder: a randomized controlled trial protocol

Binge-eating disorder (BED) is a psychiatric disorder characterized by recurrent episodes of eating a large amount of food in a discrete period of time while experiencing a loss of control. Cognitive behavioral therapy-enhanced (CBT-E) is a recommended treatment for binge-eating disorder and is typically offered through 20 sessions. Although binge-eating disorder is highly responsive to CBT-E, the cost of treating these patients is high. Therefore, it is crucial to evaluate the efficacy of low-intensity and low-cost treatments for binge-eating disorder that can be offered as a first line of treatment and be widely disseminated. The proposed noninferiority randomized controlled trial aims to determine the efficacy of web-based guided self-help CBT-E compared to treatment-as-usual CBT-E. Guided self-help will be based on a self-help program to stop binge eating, will be shorter in duration and lower intensity, and will require fewer therapist hours. Patients with binge-eating disorder (N = 180) will be randomly assigned to receive guided self-help or treatment-as-usual. Assessments will take place at baseline, mid-treatment, at the end of treatment, and at 20- and 40-weeks post-treatment. Treatment efficacy will be measured by examining the reduction in binge-eating days in the previous 28 days between baseline and the end of treatment between groups, with a noninferiority margin (Δ) of 1 binge-eating day. Secondary outcomes will include full remission, body shape dissatisfaction, therapeutic alliance, clinical impairment, health-related quality of life, attrition, and an economic evaluation to assess cost-effectiveness and cost-utility. The moderators examined will be baseline scores, demographic variables, and body mass index. It is expected that guided self-help is noninferior in efficacy compared to treatment-as-usual. The proposed study will be the first to directly compare the efficacy and economically evaluate a low-intensity and low-cost binge-eating disorder treatment compared to treatment-as-usual. If guided self-help is noninferior to treatment-as-usual in efficacy, it can be widely disseminated and used as a first line of treatment for patients with binge-eating disorder. The Dutch trial register number is R21.016. The study has been approved by the Medical Research Ethics Committees United on May 25th, 2021, case number NL76368.100.21.

Predictors of neurofeedback treatment outcome in binge-eating disorder: An exploratory study

OBJECTIVE

Knowledge on predictors for treatment response to psychotherapy in binge-eating disorder (BED) is mixed and not yet available for increasingly popular neurofeedback (NF) treatment targeting self-regulation of aberrant brain activity. This study examined eating disorder- and psychopathology-related predictors for NF treatment success in BED.

METHOD

Patients with BED (N = 78) were randomized to 12 sessions of real-time functional near-infrared spectroscopy (rtfNIRS)-NF, targeting individual prefrontal cortex signal up-regulation, electroencephalography (EEG)-NF, targeting down-regulation of fronto-central beta activity, or waitlist (WL). The few studies assessing predictors for clinical outcomes after NF and evidenced predictors for psychotherapy guided the selection of baseline eating disorder-related predictors, including objective binge-eating (OBE) frequency, eating disorder psychopathology (EDP), food cravings, and body mass index (BMI), and general psychopathology-related predictors, including depressive and anxiety symptoms, impulsivity, emotion dysregulation, and self-efficacy. These questionnaire-based or objectively assessed (BMI) predictors were regressed on outcomes OBE frequency and EDP as key features of BED at post-treatment (t1) and 6-month follow-up (t2) in preregistered generalized mixed models (https://osf.io/4aktp).

RESULTS

Higher EDP, food cravings, and BMI predicted worse outcomes across all groups at t1 and t2. General psychopathology-related predictors did not predict outcomes at t1 and t2. Explorative analyses indicated that lower OBE frequency and higher self-efficacy predicted lower OBE frequency, and lower EDP predicted lower EDP after the waiting period in WL.

DISCUSSION

Consistent with findings for psychotherapy, higher eating disorder-related predictors were associated with higher EDP and OBE frequency. The specificity of psychopathological predictors for NF treatment success warrants further examination.

PUBLIC SIGNIFICANCE

This exploratory study firstly assessed eating disorder- and psychopathology-related predictors for neurofeedback treatment outcome in binge-eating disorder and overweight. Findings showed an association between higher eating disorder symptoms and worse neurofeedback outcomes, indicating special needs to be considered in neurofeedback treatment for patients with a higher binge-eating disorder symptom burden. In general, outcomes and assignment to neurofeedback treatment may be improved upon consideration of baseline psychological variables.

Cognitive-behavioral therapy for binge-eating disorder for non-responders to initial acute treatments: Randomized controlled trial

OBJECTIVE

Certain treatments have demonstrated acute efficacy for binge-eating disorder (BED) but many patients who receive "evidence-based" interventions do not derive sufficient benefit. Given the dearth of controlled research examining treatments for patients who fail to respond to initial interventions, this study tested the efficacy of cognitive-behavioral therapy (CBT) for patients with BED who do not respond to initial acute treatments.

METHODS

Prospective randomized double-blind placebo-controlled single-site trial, conducted August 2017-December 2021, tested 16-weeks of therapist-led CBT for non-responders to initial treatment (naltrexone/bupropion and/or behavioral therapy) for BED with obesity. Thirty-one patients (mean age 46.3 years, 77.4% women, 80.6% White, mean BMI 38.99 kg/m2 ) who were non-responders to initial acute treatments were randomized to CBT (N = 18) or no-CBT (N = 13), in addition to continuing double-blinded pharmacotherapy. Independent assessments were performed at baseline, throughout treatment, and posttreatment; 83.9% completed posttreatment assessments.

RESULTS

Intention-to-treat remission rates were significantly higher for CBT (61.1%; N = 11/18) than no-CBT (7.7%; N = 1/13). Mixed models of binge-eating frequency (assessed using complementary methods) converged revealing a significant interaction between CBT and time and a significant main effect of CBT. Binge-eating frequency decreased significantly with CBT but did not change significantly with no-CBT. Since only four patients received behavioral treatment during the acute treatments, we performed "sensitivity-type" analyses restricted to the 27 patients who received pharmacotherapy during the acute treatment and found the same pattern of findings for CBT versus no-CBT.

CONCLUSIONS

Adult patients with BED who fail to respond to initial pharmacological treatments should be offered CBT.

PUBLIC SIGNIFICANCE

Even with leading evidence-based treatments for binge-eating disorder, many patients do not derive sufficient benefit. Almost no controlled research has examined treatments for patients who fail to respond to initial interventions. This study found that that cognitive-behavioral therapy was effective for patients with binge-eating disorder who did not respond to initial interventions, with 61% achieving abstinence.

Obtaining long-term recovery: advances in optimizing treatment outcomes in patients with binge-eating disorder

INTRODUCTION

Binge-eating disorder (BED) is a complex and disabling eating disorder (ED) associated with considerable burden and impairments in quality of life and physical/mental health. It has been recognized as a formal ED category since 2013, however BED is still underdetected and undertreated.

AREAS COVERED

This review summarizes the advances in the understanding of the pathophysiology of BED as well as the evidence on the efficacy of the existing treatments. The authors searched Scopus, PubMed, ClinicalTrials.Gov, and ANZCTR with terms including 'assessment' OR 'treatment' OR 'diagnosis' OR 'mechanisms' AND 'binge eating' OR 'binge-eating disorder' for manuscripts published between January 2013 and April 2023.

EXPERT OPINION

Most of the trials on treatments of BED have been in people of high weight with weight loss as an outcome. Nevertheless, less is known about the treatment of this condition in people with body mass index (BMI) within the normal range where weight stabilization may be a more appropriate goal. Moreover, there is a need for an enhanced appreciation of the role of combination treatment to improve overall outcomes. Also, there are important opportunities for future research in understanding the mechanisms of action and effectiveness of BED treatments.

Machine learning v. traditional regression models predicting treatment outcomes for binge-eating disorder from a randomized controlled trial

BACKGROUND

While effective treatments exist for binge-eating disorder (BED), prediction of treatment outcomes has proven difficult, and few reliable predictors have been identified. Machine learning is a promising method for improving the accuracy of difficult-to-predict outcomes. We compared the accuracy of traditional and machine-learning approaches for predicting BED treatment outcomes.

METHODS

Participants were 191 adults with BED in a randomized controlled trial testing 6-month behavioral and stepped-care treatments. Outcomes, determined by independent assessors, were binge-eating (% reduction, abstinence), eating-disorder psychopathology, and weight loss (% loss, ⩾5% loss). Predictors included treatment condition, demographic information, and baseline clinical characteristics. Traditional models were logistic/linear regressions. Machine-learning models were elastic net regressions and random forests. Predictive accuracy was indicated by the area under receiver operator characteristic curve (AUC), root mean square error (RMSE), and R2. Confidence intervals were used to compare accuracy across models.

RESULTS

Across outcomes, AUC ranged from very poor to fair (0.49-0.73) for logistic regressions, elastic nets, and random forests, with few significant differences across model types. RMSE was significantly lower for elastic nets and random forests v. linear regressions but R2 values were low (0.01-0.23).

CONCLUSIONS

Different analytic approaches revealed some predictors of key treatment outcomes, but accuracy was limited. Machine-learning models with unbiased resampling methods provided a minimal advantage over traditional models in predictive accuracy for treatment outcomes.

Examining changes in binge-eating disorder network centrality and structure in patients treated with cognitive-behavioral therapy versus interpersonal psychotherapy

OBJECTIVE

A sizeable minority of patients with binge-eating disorder (BED) do not fully respond to evidence-based treatments. Evidence to guide refinements of treatments is needed. Conceptualizing BED as arising from a network of symptom-to-symptom interactions allows for identification of the most strongly connected symptoms, which could inform intervention targets. This study estimated networks of BED features at pretreatment and posttreatment to assess whether cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) differentially impacted the interrelationships of BED symptoms/features.

METHODS

Participants were 392 adults (83% women, 88% white) with BED who received CBT (n = 236) or IPT (n = 156) and assessed at pretreatment and posttreatment. Networks were estimated across timepoints and treatments. Expected influence (EI) was calculated; symptoms with the highest EI have the most strong and frequent associations with other symptoms. We also assessed whether the symptoms with the highest and lowest EI predicted posttreatment remission indicators.

RESULTS

In the CBT and IPT networks, shape concern, weight concern, and eating concern had the highest EI at pretreatment and posttreatment. EI significantly increased from pretreatment to posttreatment for some symptoms in CBT but did not change for any symptoms in IPT. Shape concern significantly and positively predicted BED remission indicators in CBT and IPT.

CONCLUSIONS

CBT and IPT similarly impacted interrelations among BED features. Pretreatment EI predicted posttreatment remission indicators, indicating that pretreatment centrality could signal meaningful intervention targets. Clinical implications and avenues for future research are discussed including how personalized network analysis may advance the understanding of the clinical utility of centrality.

PUBLIC SIGNIFICANCE

Cognitive behavioral therapy and interpersonal therapy for binge-eating disorder, which are two leading evidence-based treatments for binge-eating disorder that are quite different in their models and approaches, similarly impacted interrelations among binge-eating disorder symptoms. In addition, the most strongly interconnected symptom predicted indicators of remission. Studying the interrelations among symptoms may provide new insight on how treatments impact symptom relationships and inform intervention targets.

Binge eating disorder

Binge eating disorder (BED) is characterized by regular binge eating episodes during which individuals ingest comparably large amounts of food and experience loss of control over their eating behaviour. The worldwide prevalence of BED for the years 2018-2020 is estimated to be 0.6-1.8% in adult women and 0.3-0.7% in adult men. BED is commonly associated with obesity and with somatic and mental health comorbidities. People with BED experience considerable burden and impairments in quality of life, and, at the same time, BED often goes undetected and untreated. The aetiology of BED is complex, including genetic and environmental factors as well as neuroendocrinological and neurobiological contributions. Neurobiological findings highlight impairments in reward processing, inhibitory control and emotion regulation in people with BED, and these neurobiological domains are targets for emerging treatment approaches. Psychotherapy is the first-line treatment for BED. Recognition and research on BED has increased since its inclusion into DSM-5; however, continuing efforts are needed to understand underlying mechanisms of BED and to improve prevention and treatment outcomes for this disorder. These efforts should also include screening, identification and implementation of evidence-based interventions in routine clinical practice settings such as primary care and mental health outpatient clinics.