The impact of different outcome measures on estimates of remission in a 3-year follow-up of eating disorders

Lived experience perspectives on a definition of eating disorder recovery in a sample of predominantly white women: a mixed method study

BACKGROUND

There has recently been a push for recovery-focused research in the eating disorder (ED) field, starting with a consensus definition of recovery. One definition, in particular, proposed by Bardone-Cone et al. [21] has received considerable attention given its transdiagnostic nature and validation studies. However, no studies to date have elicited lived experience views of this definition. The goal of the current study was to examine perspectives on this definition of recovery from individuals with a past or present ED and to determine whether participant agreement with the model differed based on diagnostic history or current symptom severity.

METHODS

Sixty-two individuals (95.2% women; 91.9% White/European) participated in a 1-2 h interview aimed at capturing their perspectives on ED recovery. Transcripts were analyzed using qualitative content analysis and codebook thematic analysis to examine agreement with and thoughts on Bardone-Cone's definition of recovery, respectively. Chi-squared tests of independence and binary logistic regression were computed to determine whether agreement with the definition differed across diagnostic history and self-reported symptoms.

RESULTS

Although some participants indicated acceptance of the definition, the majority expressed concerns related to its categorical nature, proposed criteria, feasibility, language, and applications. There were no differences in acceptance based on diagnostic history or current symptom severity.

CONCLUSION

A single definition of recovery does not seem to fit individuals' lived ED experience. Future research may benefit from distinguishing between recovery as an individually-defined phenomenon and related constructs such as remission (i.e., loss of diagnosis or absence of clinical symptoms). A more comprehensive multi-faceted, and person-centered model of recovery may have merit in clinical settings.

Initial self-blame predicts eating disorder remission after 9 years

BACKGROUND

Research into predictors of outcome in eating disorders (ED) has shown conflicting results, with few studies of long-term predictors and the possible importance of psychological variables that may act as risk- and maintenance factors.

AIM

To identify baseline predictors of ED remission nine years after initial clinical assessment using self-report measures of ED psychopathology, psychiatric symptoms, and self-image in a sample of adult ED patients (N = 104) treated at specialist units in Stockholm, Sweden. Sixty patients participated in the follow-up, of whom 41 patients (68%) had achieved remission.

RESULTS

Results suggested that the only significant predictor of diagnostic remission after nine years was initial levels of self-blame.

CONCLUSION

In order to ensure long-term recovery in ED it may be important for clinicians to widen their therapeutic repertoire and utilise techniques that reduce self-blame and increase self-compassion. It is difficult to predict how an eating disorder will develop, and research has found varying factors that affect the outcome of the condition. Recovery rates vary from nearly nil to over 90%. This variation could be explained by different research factors, but are more likely due to varying definitions of 'recovery', with less stringent definitions yielding high recovery rates and more stringent definitions yielding lower rates. The present study investigated whether the severity of eating disorder symptoms and other psychiatric symptoms could predict recovery nine years from first admission to specialised eating disorder care. Sixty patients at three eating disorder treatment units participated, and their scores on self-report measures of symptoms were used as predictor variables. Forty-one participants had no eating disorder diagnosis at nine-year follow-up. Most participants with binge-eating disorder had recovered, while the poorest outcome was found for anorexia nervosa with slightly over half of patients recovered after nine years. The only predictor for the nine-year outcome was a higher initial rating of self-blame, measured with the Structural Analysis of the Social Behavior. It was concluded that it may be important for clinicians to detect and address self-blame early in the treatment of eating disorders in order to enhance the possibility of recovery. Treatment should focus on reducing self-blame and increasing self-acceptance.

Is personality the key in cognitive-behavioural therapy for eating disorders? A review

The efficacy of individual cognitive-behavioural therapy (CBT) for eating disorders can be assessed by investigating the potential predictors, mediators and moderators of treatment. The present review focused on personality since its crucial role has been emphasized both by research and practice. Sixteen studies were collected, and data were extracted through a highly operationalized coding system. Overall, personality disorders were the most investigated construct; however, their influence was somewhat contradictory. A more cogent result occurred for borderline personality disorder (BPD) when considered as a moderator (not a predictor nor a mediator). Patients with a more disturbed borderline personality benefited to a greater extent from treatments including booster modules on affects, interpersonal relationships and mood intolerance, rather than symptoms exclusively. Nine additional personality dimensions, beyond BPD, were investigated sparsely, and results regarding them were barely indicative in this review. However, some of these dimensions (e.g., affective lability and stimulus-seeking behaviours) could be traced back to BPD, thereby strengthening evidence of the role of borderline disorder as a moderator. Although research on the relationship between personality and eating disorders needs to be increased and methodologically improved, personality, taken as a whole, emerged as a promising variable for enhancing the efficacy of CBT.

The outcome at follow-up after inpatient eating disorder treatment: a naturalistic study

BACKGROUND

Patients with eating disorders may experience a severe and enduring course of illness. Treatment outcome for patients provided with inpatient treatment is reported as poor. Research to date has not provided consistent results for predictors of treatment outcome. The aims of the study were to investigate rates of remission at follow-up after inpatient treatment, symptom change from admission to follow-up, and predictors of treatment outcome.

METHODS

The follow-up sample consisted of 150 female adult former patients (69.4% of all eligible female patients) with eating disorders. Mean age at admission was 21.7 (SD = 4.9) years. Diagnostic distribution: 66% (n = 99) anorexia nervosa, 21.3% (n = 32) bulimia nervosa and 12.7% (n = 19) other specified feeding or eating disorder, including binge eating. Data were collected at admission, discharge and follow-up (mean 2.7 (SD = 1.9) years). Definition of remission was based on the EDE-Q Global score, body mass index and binge/purge behavior. Paired T-tests were performed to investigate change over time. Univariate and multivariate logistic regressions were estimated to investigate predictors of remission.

RESULTS

At follow-up, 35.2% of the participants were classified as in remission. Significant symptom reduction (in all patients) (p <  0.001) and significant increase in body mass index (BMI) (in underweight participants at admission) (p <  0.001) was found. Increased BMI (p <  0.05), the level of core eating disorder symptoms at admission (p <  0.01) and reduced core eating disorder symptoms (p <  0.01) during inpatient treatment were found significant predictors of outcome in the multivariate model.

CONCLUSIONS

All participants had an eating disorder requiring inpatient treatment. Approximately one-third of all participants could be classified as in remission at follow-up. However, most participants experienced significant symptom improvement during inpatient treatment and the improvements were sustained at follow-up. Increased probability of remission at follow-up was indicated by lower core ED symptoms at admission for all patients, raised BMI during admission for patients with AN, and reduced core ED symptoms during inpatient treatment for all patients. This finding contributes important information and highlights the importance of targeting these core symptoms in transdiagnostic treatment programs.

Depressive symptoms rather than executive functioning predict group cognitive behavioural therapy outcome in binge eating disorder

Executive functions play an important role in mediating self-control and self-regulation. It has been suggested that the inability to control eating in Binge Eating Disorder (BED) may indicate inefficiencies in executive functioning. This study investigated whether executive functioning predicted cognitive behavioural therapy outcome in BED while accounting for other possible predictors: depressive symptoms, interpersonal factors, eating disorder psychopathology, and self-esteem. Executive functioning and other predictors were assessed in 91 patients with BED by means of neuropsychological tests and questionnaires at baseline. Eating disorder (ED) symptoms were assessed during treatment at variable time points. Potential predictor variables were investigated using multivariate Cox regression models. Recovery was defined by means of two different indicators based on the Eating Disorder Examination-Questionnaire: (a) showing a 50% reduction in baseline symptom ED severity and/or reaching the clinical significance cut-off; and (b) achieving abstinence of objective binge eating. Severity of depressive symptoms was a significant predictor for outcome on both indicators. Patients with no or mild depressive symptoms recovered faster (i.e., 50% reduction in ED symptoms and abstinence of objective binge eating) than those with severe depressive symptoms, which is in line with previous studies. Executive functioning was not related to treatment outcome in this study.

Self-assessment of eating disorder recovery: Absence of eating disorder psychopathology is not essential

OBJECTIVE

The definition of recovery in eating disorders (EDs) according to researchers is not necessarily similar to the patient definition. This study aimed to explore the concept of recovery as assessed by those affected by an ED themselves.

METHOD

Participants from the Netherlands Eating disorder Registry (NER) who reported an (former) ED diagnosis (n = 814) assessed their own recovery level: current ED, partial or full recovery. Furthermore, research-based criteria (Bardone-Cone et al., Behaviour Research and Therapy, 2010, 48, 194-202) were applied to define recovery. Within the self-assessed full recovery group (n = 179), participants who also fulfilled the research-based criteria were compared to those who were only recovered based on self-assessment in the following domains: ED psychopathology, psychiatric comorbidity, quality of life, and social and societal participation.

RESULTS

Ninety-six of the participants (54%) who considered themselves recovered did not fulfill the research-based definition. The two recovery groups did not significantly differ in psychiatric comorbidity, quality of life, and social and societal participation.

DISCUSSION

Absence of ED characteristics was not essential for individuals to consider themselves recovered. Although the self-assessed recovery status may be subjective, it does advocate the use of additional health indicators besides ED psychopathology when defining recovery.

Classifying empirically valid and clinically meaningful change in eating disorders using the Eating Disorders Inventory, version 2 (EDI-2)

The study examined the ability of the EDI-2 to classify empirically valid and clinically meaningful change using clinical significance and the Reliable Change Index (CS/RCI), and compared CS/RCI to classification based on diagnostic change. Eating disorder (ED) patients (N=363) were assessed at intake and after 36months on measures of ED and psychiatric symptoms, self-image, interpersonal relationships, treatment satisfaction and general outcome. Patients were categorized using a four-way classification scheme as "Deteriorated", "Unchanged", "Improved" or "No ED"; and using a two-way classification scheme as either in remission or not in remission. Compared to similar two- and four-way classification based on diagnostic change, CS/RCI using the EDI-2 total score demonstrated greatest overall utility in explaining outcome variance. The EDI-2 can generate empirically valid and clinically meaningful classification of change. Systematic application of CS/RCI using the EDI-2 benefits both clinicians and researchers by providing a simple, clinically relevant, scientifically robust, and cost-effective means of classifying outcome. It may be especially relevant in alerting clinicians to problem cases in need of additional or alternative treatment strategies.

Patient- and clinician- reported outcome in eating disorders

Patient-reported outcome is increasingly applied in health sciences. Patients with eating disorders (EDs) characteristically have a different opinion of their needs to that of the health professionals, which can lead to ambivalence towards treatment and immense compliance difficulties. This cross-sectional study compared data assessed by the clinician to patient-reported measures in patients with a history of EDs. We included data from a cohort of patients with EDs (n=544) referred to a specialized ED unit in Denmark. Patient-reported measures included the Eating Disorder Inventory-2 (EDI-2) and the Short Form 36 (SF-36), and clinical data included remission status and body mass index (BMI). We found a positive association between BMI and EDI-2 scores for anorexia nervosa (AN) and eating disorder not otherwise specified (EDNOS), reflecting increasing ED symptomatology with increasing BMI. This association was not observed in bulimia nervosa (BN). We did not find a correlation between SF-36 scores and BMI in any of the diagnostic groups.

Adolescents with full or subthreshold anorexia nervosa in a naturalistic sample - characteristics and treatment outcome

BACKGROUND

Anorexia Nervosa (AN) destroys developmentally important early years of many young people and knowledge is insufficient regarding course, treatment outcome and prognosis. Only a few naturalistic studies have been conducted within the field of eating disorder (ED) research. In this naturalistic study we included adolescents with AN or subthreshold AN treated in outpatient care, and the overall aim was to examine sample characteristics and treatment outcome. Additional aims were to examine potential factors associated with remission as an outcome variable, and possible differences between three time periods for treatment onset.

METHODS

Participants were identified through the Swedish national quality register for eating disorder treatment (SwEat), in which patients are registered at treatment onset and followed up once a year until end of treatment (EOT). Inclusion criteria were: medical or self-referral to one of the participating treatment units between 1999 and 2014, 13-19 years of age at initial entry into SwEat and diagnosed with AN or subthreshold AN. The total sample consisted of 3997 patient from 83 different treatment units.

RESULTS

The results show that 55% of the participants were in remission and approximately 85% were within a healthy weight range at EOT. Of those who ended treatment according to plan, 70% were in remission and 90% within a healthy weight range. The average treatment duration was approximately 15 months. About one third of the patients terminated treatment prematurely, which was associated with a decreased chance of achieving remission. Remission rates and weight recovery increased over time, while treatment duration decreased. Considering treatment outcome, the results did not show any differences between patients with AN or subthreshold AN.

CONCLUSIONS

The present study shows a relatively good prognosis for adolescent patients with AN or subthreshold AN in routine care and the results indicate that treatment for adolescents with ED in Sweden has become more effective over the past 15 years. The results of the present study contribute to the scope of treatment research and the large-scale naturalistic setting secures the generalizability to a clinical environment. However, more research is needed into different forms of evidence, new research strategies and diversity of treatment approaches.

TRIAL REGISTRATION

Registered in FOU in Sweden (Researchweb.org) 2014-04-14, ID nr 147301.

Predictors of psychological outcome in patients with eating disorders: A routine outcome monitoring study

BACKGROUND

Identifying predictors of psychological outcome for patients with eating disorders may improve the effectiveness of treatment. Patients with different pre-treatment characteristics and symptoms may benefit from different therapies. This study aimed to identify potential predictors of treatment outcome in a large naturalistic cohort of patients with an eating disorder.

METHOD

The study sample included patients (N = 1153) with all types of eating disorders who were receiving residential, day, or outpatient treatment. Remission was defined by means of four different indicators based on the Eating Disorder Examination-Questionnaire global score: 1. achieving reliable change; 2. showing a 50% reduction in baseline symptom severity; 3. reaching the clinical significance cut-off point; and 4. a combination of indicators 2 and 3. Potential predictor variables were investigated in univariate and multivariate Cox regression models.

RESULTS

Different predictors were found for the four outcome criteria. Patients with high levels of interpersonal distrust at baseline were less likely to have achieved reliable change in eating disorder psychopathology. Higher self-esteem and less body dissatisfaction at baseline was independently associated with a symptom reduction of more than 50% and/or reaching the clinical significance cut-off point. Contrary to our expectations, no differences in outcome were found between the eating disorder subtypes.

DISCUSSION

Clinically, it is important to reduce the risk of poor outcome and to achieve a rapid response in treatment using an intervention designed for this purpose, such as shared decision making or an intervention directed at self-esteem or body image, which may act as a catalyst for change. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2016; 49:863-873).

Predictors of treatment outcome in individuals with eating disorders: A systematic review and meta-analysis

OBJECTIVE

Understanding the factors that predict a favourable outcome following specialist treatment for an eating disorder may assist in improving treatment efficacy, and in developing novel interventions. This review and meta-analysis examined predictors of treatment outcome and drop-out.

METHOD

A literature search was conducted to identify research investigating predictors of outcome in individuals treated for an eating disorder. We organized predictors first by statistical type (simple, meditational, and moderational), and then by category. Average weighted mean effect sizes (r) were calculated for each category of predictor.

RESULTS

The most robust predictor of outcome at both end of treatment (EoT) and follow-up was the meditational mechanism of greater symptom change early during treatment. Simple baseline predictors associated with better outcomes at both EoT and follow-up included higher BMI, fewer binge/purge behaviors, greater motivation to recover, lower depression, lower shape/weight concern, fewer comorbidities, better interpersonal functioning and fewer familial problems. Drop-out was predicted by more binge/purge behaviors and lower motivation to recover. For most predictors, there was large interstudy variability in effect sizes, and outcomes were operationalized in different ways. There were generally insufficient studies to allow analysis of predictors by eating disorder subtype or treatment type.

DISCUSSION

To ensure that this area continues to develop with robust and clinically relevant findings, future studies should adopt a consistent definition of outcome and continue to examine complex multivariate predictor models. Growth in this area will allow for stronger conclusions to be drawn about the prediction of outcome for specific diagnoses and treatment types.

And then what happened? A 5-year follow-up of eating disorder patients

BACKGROUND

Eating disorders (EDs) show a varying course and outcome. Within 10 years, between half and three-quarters of patients recover from their disorder. There is, however, a lack of consensus in how to define recovery.

AIMS

The aim of the present naturalistic study was to assess clinical and full recovery in ED patients 5 years after initiated treatment at a specialized outpatient unit for EDs.

METHODS

Data was collected at three time points: after the investigation period (T1), at the end of treatment (T2) and 5 years after the beginning of treatment (T3). Data at T1 and T2 were collected from patient records, and at T3 using a questionnaire. The number of participants was 71 and response rate 78%.

RESULTS

At T3, the proportion in clinical recovery was 83.1%, with no significant differences between diagnostic groups. The proportion in full recovery, i.e. in addition to a subjective account of being fully recovered, presenting no physical, behavioural or psychological ED symptoms, was 40.8%.

CONCLUSIONS

For most ED patients, outpatient treatment is sufficient to enable recovery. How to define and measure recovery still warrants discussion.

Evaluating reliable and clinically significant change in eating disorders: comparisons to changes in DSM-IV diagnoses

Assessing clinically meaningful change is valuable for treatment planning, monitoring course of illness and evaluating outcome. Although DSM eating disorder (ED) diagnoses have been criticized for poor clinical utility, instability, and uncertainty, remission/change of diagnosis is often the standard for evaluating outcome. We tested the validity of the clinically significant reliable change index (CS/RCI) compared to change in DSM-IV ED-diagnoses. We investigated if CS/RCI was concordant to diagnostic change and compared explained variance on measures at follow-up. Using a database for specialized ED treatment in Sweden the sample contained 1042 female patients (246 adolescents/796 adults). CS/RCI was calculated for the Clinical Impairment Assessment (CIA) and the Eating Disorder Examination Questionnaire (EDE-Q). CS/RCI explained more variance in gain scores for psychopathology measures than diagnostic change (DSM-IV). Average agreement between diagnostic change and CS/RCI was 62% and 60% for CIA and EDE-Q, respectively. Diagnostic change always resulted in more positive outcome than CS/RCI. Together with clinical judgment, CS/RCI is a valuable method for determining clinically significant changes in clinical practice and research. It is economically sound and results are easily interpreted and communicated to patients.

What does remission tell us about women with eating disorders? Investigating applications of various remission definitions and their associations with quality of life

OBJECTIVE

To compare remission rates, determine level of agreement and identify quality of life (QoL) distinctions across a broad spectrum of remission definitions among patients with eating disorders (ED).

METHODS

Women (N=195; 94 AN, 24 BN, and 77 EDNOS) from inpatient and partial hospital ED programs participated in a study of treatment outcomes. Remission rates were evaluated with percentages, kappa coefficients identified level of agreement and Mann-Whitney-Wilcoxon tests with Bonferroni corrections determined differences in quality of life between remitted and not remitted patients by remission definition.

RESULTS

Depending on remission definition used, the percent of remitted patients varied from 13.2% to 40.5% for AN, 15.0% to 47.6% for BN and 24.2% to 53.1% for EDNOS. Several definitions demonstrated "very good" agreement across diagnoses. Remission was associated with higher quality of life in psychological, physical/cognitive, financial and work/school domains on a disease-specific measure, and in mental but not physical functioning on a generic measure.

CONCLUSIONS

Remission rates vary widely depending on the definition used; several definitions show strong agreement. Remission is associated with quality of life, and often approximates scores for women who do not have an eating disorder. The ED field would benefit from adopting uniform criteria, which would allow for more accurate comparison of remission rates across therapeutic interventions, treatment modalities and facilities. We recommend using the Bardone-Cone criteria because it includes assessment of psychological functioning, was found to be applicable across diagnoses, demonstrated good agreement, and was able to distinguish quality of life differences between remitted and not remitted patients.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

DISCUSSION

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

Recovery from disordered eating: sufferers' and clinicians' perspectives

OBJECTIVE

Disagreement exists on how to define recovery from eating disorders. Definitions typically include a combination of physical, cognitive, emotional, psychological and social factors. However, none provides multidimensional recovery models, addressing and comparing sufferers' and clinicians' viewpoints. This study investigates those recovery perspectives.

METHOD

Two-hundred and thirty-eight participants (individuals with eating difficulties and clinicians working in the field) completed a checklist, rating the importance of somatic, psychological, emotional, social, eating-related and body experience-related recovery criteria.

RESULTS

Recovery criteria fell into meaningful factors (psychological-emotional-social, weight-controlling behaviours, non-life-threatening and life-threatening features and evaluation of one's own appearance). Sufferers and clinicians agreed on the ranking of importance of these factors. However, sufferers considered 'psychological-emotional-social' and 'evaluation of one's own appearance' criteria as more important to recovery than clinicians.

DISCUSSION

Findings are discussed in relation to existing research, together with study limitations and future research. Clinical implications are outlined, focusing on the facilitation of recovery.

Family climate and recovery in adolescent onset eating disorders: a prospective study

OBJECTIVE

This prospective study investigated the self-assessed family climate of adolescent patients and their parents during treatment of and recovery from eating disorders.

METHOD

One hundred two girls aged 13-17 years with eating disorders, answered the self-report Family Climate Scale (FCS) and Eating Disorders Inventory for Children at initial assessment and after 18 and 36 months. The FCS was also answered by their parents at the same time points.

RESULTS

Self-assessed family climate and eating disorder symptoms were similar for recovered (R) and nonrecovered (NR) adolescents at initial assessment and at 18 months. At 36 months, FCS Closeness was higher for R, and FCS Distance was lower for R compared with NR. Parents of R adolescents had higher scores on FCS Closeness and lower scores on FCS Chaos compared with parents of NR adolescents at the 36-month follow-up.

CONCLUSION

Self-reported family climate was associated with recovery. Changes in eating disorder symptoms preceded changes in family climate.

When have eating disordered patients recovered and what do the DSM-IV criteria tell about recovery?

Lack of consensus about criteria for recovery from eating disorders results in greatly varying percentages of recovered patients. Outcome studies not only use different criteria for recovery, but also quite different instruments, rendering their results incomparable. The same problem occurs among studies of predictors for recovery from eating disorders. Without consensus on criteria for recovery, it is not clear which goals of treatment are important to realize full recovery. In order to develop larger consensus on criteria for recovery, this study critically analyzes the most important outcome scores and the criteria for recovery deduced from the DSM-IV.