Cognitive Behaviour Therapy for Bulimia Nervosa and Eating Disorders Not Otherwise Specified: Translation from Randomized Controlled Trial to a Clinical Setting

Effectiveness of web-based guided self-help cognitive behavioral therapy-enhanced for binge-eating disorder: An implementation study

INTRODUCTION

Web-based guided self-help cognitive behavioral therapy-enhanced (CBT-E) is a 12-weeks, 12-sessions, digitalized version of part II of the self-help book Overcoming Binge Eating. This intervention is effective when offered under controlled circumstances in a randomized-controlled-trial. It is unknown how patients with binge-eating disorder (BED) respond to this intervention when offered in real-world clinical-settings. The aim of this study is to examine post-intervention effectiveness of guided self-help CBT-E for BED in real-world settings.

METHOD

The present study used a cohort-design examining the effectiveness of web-based guided self-help CBT-E according to an intention-to-treat (ITT) analysis. BED patients (n = 278) were assessed pre- and post-intervention. The primary outcome was reduction in binge-eating episodes. Other outcomes were full-recovery (EDE-Q score <2.77 and abstinence from binge-eating episodes), impaired psychosocial functioning, defined as secondary impairment, and general psychopathology post-intervention.

RESULTS

The number of binge-eating episodes reduced by an average of 16 binge-eating episodes per 4 weeks pre-intervention to five binge-eating episodes during the last 4 weeks of treatment. Abstinence from binge eating was reported by 30%, and 28% reported full recovery. Effect sizes (Cohen's d) were large (d ≥ 1.0) for all outcome measures. There were no differences in outcomes between the ITT and the completers sample.

DISCUSSION

Guided self-help CBT-E is associated with significant improvements. The effects of guided self-help CBT-E offered in a real-world-setting are comparable to self-help CBT-E offered in a randomized-controlled-trial. However, it should be noted that comparisons with randomized-controlled-trials requires caution. Longer-term follow-up data are necessary to measure persistence of treatment benefits.

PUBLIC SIGNIFICANCE

Offering CBT-E as a web-based guided self-help intervention has several benefits for patients with BED. Guided self-help CBT-E is associated with significant improvements on the short term when offered in real-world clinical settings.

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.

Psychotherapies for eating disorders: findings from a rapid review

BACKGROUND

Psychotherapy is considered central to the effective treatment of eating disorders-focusing on behavioural, psychological, and social factors that contribute to the illness. Research indicates psychotherapeutic interventions out-perform placebo, waitlist, and/or other treatments; but, outcomes vary with room for major improvement. Thus, this review aims to (1) establish and consolidate knowledge on efficacious eating disorder psychotherapies; (2) highlight select emerging psychotherapeutic interventions; and (3) identify knowledge gaps to better inform future treatment research and development.

METHODS

The current review forms part of a series of Rapid Reviews published in a special issue in the Journal of Eating Disorders to inform the development of the Australian-government-funded National Eating Disorder Research and Translation Strategy 2021-2031. Three databases were searched for studies published between 2009 and 2023, published in English, and comprising high-level evidence studies (meta-analyses, systematic reviews, moderately sized randomised controlled studies, moderately sized controlled-cohort studies, and population studies). Data pertaining to psychotherapies for eating disorders were synthesised and outlined in the current paper.

RESULTS

281 studies met inclusion criteria. Behavioural therapies were most commonly studied, with cognitive-behavioural and family-based therapies being the most researched; and thus, having the largest evidence-base for treating anorexia nervosa, bulimia nervosa, and binge eating disorder. Other therapies, such as interpersonal and dialectical behaviour therapies also demonstrated positive treatment outcomes. Emerging evidence supports specific use of Acceptance and Commitment; Integrative Cognitive Affective; Exposure; Mindfulness; and Emotionally-Focused therapies; however further research is needed to determine their efficacy. Similarly, growing support for self-help, group, and computer/internet-based therapeutic modalities was noted. Psychotherapies for avoidant/restrictive food intake disorder; other, and unspecified feeding and eating disorders were lacking evidence.

CONCLUSIONS

Currently, clinical practice is largely supported by research indicating that behavioural and cognitive-behavioural psychotherapies are most effective for the treatment of eating disorders. However, the efficacy of psychotherapeutic interventions varies across studies, highlighting the need for investment and expansion of research into enhanced variants and novel psychotherapies to improve illness outcomes. There is also a pressing need for investigation into the whole range of eating disorder presentations and populations, to determine the most effective interventions.

Efficacy of Web-Based, Guided Self-help Cognitive Behavioral Therapy-Enhanced for Binge Eating Disorder: Randomized Controlled Trial

BACKGROUND

Owing to the gap between treatment supply and demand, there are long waiting periods for patients with binge eating disorder, and there is an urgent need to increase their access to specialized treatment. Guided self-help cognitive behavioral therapy-enhanced (CBT-E) may have great advantages for patients if its efficacy can be established.

OBJECTIVE

The aim of this study was to examine the efficacy of guided self-help CBT-E compared with that of a delayed-treatment control condition.

METHODS

A single-blind 2-arm randomized controlled trial was designed to evaluate guided self-help CBT-E according to an intention-to-treat analysis. A total of 180 patients were randomly assigned to guided self-help CBT-E (n=90, 50%) or the delayed-treatment control condition (n=90, 50%) for which guided self-help CBT-E was provided after the initial 12-week delay. The primary outcome was reduction in binges. The secondary outcome was full recovery at the end of treatment, as measured using the Eating Disorder Examination during the last 4 weeks of treatment. A linear mixed model analysis was performed to compare treatment outcomes at the end of treatment. A second linear mixed model analysis was performed to measure between- and within-group effects for up to 24 weeks of follow-up. The Eating Disorder Examination-Questionnaire and clinical impairment assessment were conducted before and after treatment and during follow-up. In addition, dropout rates were assessed in both conditions.

RESULTS

During the last 4 weeks of treatment, objective binges reduced from an average of 19 (SD 16) to 3 (SD 5) binges, and 40% (36/90) showed full recovery in the guided self-help CBT-E group. Between-group effect size (Cohen d) was 1.0 for objective binges. At follow-up, after both groups received treatment, there was no longer a difference between the groups. Of the 180 participants, 142 (78.9%) completed treatment. The overall treatment dropout appeared to be associated with gender, level of education, and number of objective binges at baseline but not with treatment condition.

CONCLUSIONS

This is the first study to investigate the efficacy of guided self-help CBT-E. Guided self-help CBT-E appeared to be an efficacious treatment. This study's findings underscore the international guidelines recommending this type of treatment for binge eating disorder.

TRIAL REGISTRATION

Netherlands Trial Registry (NTR) NL7994; https://trialsearch.who.int/Trial2.aspx?TrialID=NL7994.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12888-020-02604-1.

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)

From research to practice: a model for clinical implementation of evidence-based outpatient interventions for eating disorders

BACKGROUND

A question frequently raised in the field is whether evidence-based interventions have adequate translational capacity for delivery in real-world settings where patients are presumed to be more complex, clinicians less specialized, and multidisciplinary teams less coordinated. The dual purpose of this article is to (a) outline a model for implementing evidence-driven, outpatient treatments for eating disorders in a non-academic clinical setting, and (b) report indicators of feasibility and quality of care.

MAIN BODY

Since our inception (2015), we have completed nearly 1000 phone intakes, with first-quarter 2021 data suggesting an increase in the context of COVID-19. Our caseload for the practice currently consists of approximately 200 active patients ranging from 6 to 66 years of age. While the center serves a transdiagnostic and trans-developmental eating disorder population, modal concerns for which we receive inquiries are Anorexia Nervosa and Avoidant Restrictive Food Intake Disorder, with the most common age range for prospective patients spanning childhood through late adolescence/emerging adulthood; correspondingly, the modal intervention employed is Family-based treatment. Our team for each case consists, at a minimum, of a primary internal therapist and a physician external to the center.

SHORT CONCLUSION

We will describe our processes of recruiting, training and coordinating team members, of ensuring ongoing fidelity to evidence-based interventions, and of training the next generation of clinicians. Future research will focus on a formal assessment of patient outcomes, with comparison to benchmark outcomes from randomized controlled trials.

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.

Evaluating evidence-based interventions in low socio-economic-status populations

OBJECTIVE

Socio-economic-status (SES) has rarely been reported or investigated in eating disorders (EDs) research. This Research Forum considers, from various perspectives, how SES may impact on evaluating evidence-based treatments for EDs.

METHOD

We first reviewed previous literature that informs how SES impacts prevalence of EDs, help-seeking, and treatment outcome. We then present findings from a case series effectiveness study of an early intervention program in low SES areas for EDs and discuss implications about the impact of SES on the effectiveness of evidence-based interventions. Finally, we examine barriers to conducting rigorous evaluations in this population and discuss directions for future treatment outcome research.

RESULTS

Evidence suggests a higher level of disordered eating but less help seeking in lower SES groups. In our case series, 96 participants started treatment and completed a mean of 13.85 sessions, 84 (87.5%) completed a mean of 6.40 sessional measures on ED cognitions and behaviors, but only 31% completed more extensive pre-treatment and post-treatment measures. The completer effect size decrease for the global Eating Disorder Examination-Questionnaire score was 2.05 (95% CI: 1.43, 2.68) commensurate with other effectiveness studies in mixed SES groups. The high rates of missing data related to more extensive assessment present a barrier to evaluating evidence-based treatments in this population.

DISCUSSION

Evidence from the present study revealed individuals from low SES can achieve similar treatment outcomes to other populations when receiving evidence-based ED treatment. Future studies should investigate a range of approaches to maximizing data collection, including use of shorter sessional measures.

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.

Implementing evidence-based individual psychotherapies for adults with eating disorders in a real world clinical setting

OBJECTIVE

This study aimed to evaluate the effectiveness of evidenced-based psychological treatments (specifically, Cognitive-Behaviour Therapy for Eating Disorders [CBT-ED] and Maudsley Anorexia Nervosa Treatment for Adults [MANTRA]) for a transdiagnostic eating disorder population in a routine clinical setting. In particular, it aimed to determine the extent to which treatment was provided in line with current clinical guidelines (NICE, 2017) and how effective treatment was in improving eating disorder and general psychopathology.

METHOD

Three hundred and seventy-nine participants meeting criteria for DSM-5 anorexia nervosa, bulimia nervosa, binge-eating disorder or other specified feeding or eating disorder completed pre- and posttreatment measures of eating disorder pathology and general distress. Clinicians recorded weight and episodes of bingeing and purging.

RESULTS

Ninety seven percent of participants received treatment in line with evidence-based psychotherapies. Treatment was completed by 59.9% of the whole sample. Using stringent criteria and ITT analysis 21.4% met criteria for remission at end of treatment. In the underweight sample, there was a significant increase in BMI, averaging 1.38 kg/m² over treatment, with similar outcomes for MANTRA and CBT-ED.

DISCUSSION

These findings, in a large transdiagnostic population, add to emerging literature on the translation of evidence-based psychotherapies to real-world clinical settings. Our results converge well with prior similar studies. Findings highlight the need for routine data collection in services and for the ongoing improvement of treatments for the eating disorders.

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)

Bringing Virtual Reality From Clinical Trials to Clinical Practice for the Treatment of Eating Disorders: An Example Using Virtual Reality Cue Exposure Therapy

Novel treatment options for eating disorders (EDs) are critically needed to enhance treatment outcomes and reduce the rates of treatment dropouts. On average, only 50% of individuals receiving evidence-based care remit, whereas 24% drop out before treatment completion. One particularly promising direction involves integrating virtual reality (VR) with existing evidence-based treatments (EBTs) such as cue exposure therapy (CET). Across psychiatric disorders, VR-based interventions are demonstrating at least preliminary efficacy and noninferiority to traditional treatments. Furthermore, VR technology has become increasingly portable, resulting in improved acceptance, increased access, and reductions in cost. However, more efficient research processes may be needed to uncover the potential benefits of these rapid technological advances. This viewpoint paper reviews existing empirical support for integrating VR with EBTs (with a focus on its use with EDs) and proposes key next steps to more rapidly bring this innovative technology-based intervention into real-world clinic settings, as warranted. VR-CET for EDs is used to illustrate a suggested process for developing such treatment enhancements. We recommend following a deployment-focused model of intervention development and testing to enable rapid implementation of robust, practice-ready treatments. In addition, our review highlights the need for a comprehensive clinical protocol that supports clinicians and researchers in the implementation and testing of VR-CET and identifies key missing protocol components with rationale for their inclusion. Ultimately, this work may lead to a more complete understanding of the full potential of the applications and integrations of VR into mental health care globally.

Implementing cognitive behavioral therapy-enhanced in a routine inpatient and outpatient setting: Comparing effectiveness and treatment costs in two consecutive cohorts

BACKGROUND

Even though evidence-based interventions can enhance clinical outcomes and cost effectiveness, in the field of eating disorders, implementation of empirically supported treatments (ESTs) in routine inpatient and outpatient settings is slow.

OBJECTIVE

This study examined differential (cost-) effectiveness, after implementing evidence-based cognitive behavioral therapy-enhanced (CBT-E) throughout a Dutch treatment center.

METHOD

Two consecutive cohorts of adult patients, BMI between 17.5 and 40, were compared, with one cohort (N = 239) receiving treatment-as-usual (TAU) between 2012 and 2014 and the other (N = 320) receiving CBT-E between 2015 and 2017.

RESULTS

Eating disorder pathology, measured with self-reports, decreased significantly in both cohorts; overall, no differences in clinical outcomes between both cohorts were found. Treatment costs and treatment duration were considerably lower in 2015-2017. When limiting the cost analysis to direct costs, there is a 71% likelihood that CBT-E is more cost-effective and a 29% likelihood that CBT-E leads to fewer remissions at lower costs, based on the distribution of the cost-effectiveness plane. The likelihood that TAU leads to lower costs is 0%.

DISCUSSION

Findings show that implementing an EST throughout inpatient and outpatient settings leads to lower costs with similar treatment effect and has the advantage of shorter treatment duration and a shorter inpatient stay.

A systematic review of enhanced cognitive behavioral therapy (CBT-E) for eating disorders

OBJECTIVE

To review the literature examining the efficacy and effectiveness of enhanced cognitive behavioral therapy (CBT-E) for adults and older adolescents with eating disorders.

METHOD

A systematic search of the literature (using PsycINFO and PubMed) was conducted in order to identify relevant publications (randomized controlled trials [RCTs] and uncontrolled trials) up to June 2019. Effect sizes were reported for outcomes including treatment attrition and remission rates, eating disorder behaviors, body mass index (BMI), and core eating disorder psychopathology. The Downs and Black checklist was used to assess the quality of included studies.

RESULTS

Twenty studies (10 RCTs and 10 uncontrolled trials) met criteria for inclusion. Support was found for the efficacy and effectiveness of CBT-E for the full spectrum of eating disorders, with respect to reducing eating disorder behaviors and core psychopathology. BMI also increased, with large effects, for individuals with AN. However, the majority of the randomized trials included in this review did not demonstrate superiority of CBT-E over comparison treatments, particularly in the longer-term. Furthermore, rates of attrition and remission for CBT-E among individuals without AN did not appear to differ from rates for CBT-BN.

DISCUSSION

There is evidence to support CBT-E as an efficacious and effective treatment for adults and older adolescents with a range of eating disorder diagnoses. Future research would benefit from directly comparing CBT-E to CBT-BN, expanding measured outcomes to include driven exercise and subjective binge eating, increasing consistency in the definition and measurement of outcomes, and exploring factors associated with treatment retention.

Eating Behavior and the Evolutionary Perspective on Anorexia Nervosa

On the standard perspective, anorexia nervosa and other eating disorders are caused by genetically determined, neurochemically mediated mental illnesses. Standard treatment, cognitive behavioral therapy (CBT), targets cognitive processes thought to maintain the disorders. Effective neurochemically based treatments are not available and the rate of remission is ≤25% 1 year after CBT, with unknown outcomes in the long-term. With starvation as the major threat in biological history, the evolutionary perspective focuses on foraging for food and eating behavior. A neural network, including hypothalamic arcuate peptide-neurons, brainstem serotonin- and dopamine-neurons and their prefrontal cortical projections, mediates (rather than controls) the behavioral adaptations to variations in food availability; activation of the network is associated with opposing behavioral outcomes depending upon external variations. In the clinic, the control of eating behavior is therefore outsourced to a machine that provides feedback on how to eat. Hundreds of eating disorders patients have recovered by practicing eating; the rate of remission is 75% in on average 1 year of treatment, the rate of relapse is 10% over 5 years of follow-up and no patient has died. A two-parameter asymptotic exponential growth curve modeled the eating behavior of 17 healthy women but not that of 17 women with anorexia nervosa. When in remission, the eating behavior of the anorexic women approached that of the healthy women. It is suggested that the treatment of eating disorders should focus on eating behavior.

Treatment outcomes for eating disorders in Sweden: data from the national quality registry

OBJECTIVE

To report the outcomes of eating disorders treatment in Sweden in 2012-2016.

DESIGN

The number of patients treated and the number of patients not fulfilling an eating disorders diagnosis (remission) at 1 year of follow-up at the clinics listed in the National Quality Registry for Eating Disorders Treatment were analysed. The published outcomes at three clinics, which used survival analysis to estimate outcomes, were compared with their outcomes in the registry. Outcomes at the three biggest clinics were compared.

SETTING

All eating disorders clinics.

PARTICIPANTS

All patients treated at eating disorders clinics.

INTERVENTION

Cognitive-behavioural therapy at most clinics and normalisation of eating behaviour at the three clinics with published outcomes.

OUTCOME MEASURE

Proportion of patients in remission.

RESULTS

About 2600 patients were treated annually, fewer than half were followed up and remission rates decreased from 21% in 2014 to 14% in 2016. Outcomes, which differed among clinics and within clinics over time, have been publicly overestimated by excluding patients lost to follow-up. The published estimated rate of remission at three clinics that treated 1200 patients in 1993-2011 was 27%, 28% and 40% at 1 year of follow-up. The average rate of remission over the three last years at the biggest of these clinics was 36% but decreased from 29% and 30% to 16 and 14% at the two other of the biggest clinics.

CONCLUSIONS

With more than half the patients lost to follow-up and no data on relapse in the National Quality Registry, it is difficult to estimate the effects of eating disorders treatment in Sweden. Analysis of time to clinically significant events, including an extended period of follow-up, has improved the quality of the estimates at three clinics. Overestimation of remission rates has misled healthcare policies. The effect of eating disorders treatment has also been overestimated internationally.

Manualised Cognitive Behaviour Therapy for Anorexia Nervosa: Use of Treatment Modules in the ANTOP Study

Standardised treatment manuals facilitate therapy planning and enhance comparability for research purposes. Within the Anorexia Nervosa Treatment of Out Patients (ANTOP) study, the largest multisite outpatient intervention trial in anorexia nervosa (AN) to date, manualised enhanced cognitive-behavioural therapy (CBT-E) was offered as one treatment modality. The manual consisted of 9 modules, of which Motivation, Nutrition, Formulation and Relapse Prevention were compulsory. Homework worksheets were provided, to ensure the transfer of therapeutic improvements to daily life. This study investigated the use of modules and worksheets in order to explore practice styles of trained therapists in the treatment of AN. This secondary analysis was based on log-sheets (n = 2604) CBT-E therapists completed after each session. Frequencies of modules and worksheets used across all sessions were calculated. Relationships, such as that between use of module and duration of illness, were examined. The most commonly used module was Motivation. In patients with longer illness duration, the module Self Esteem seemed to be particularly important. The worksheet Scales, balancing the pros and cons of AN, was prioritised by therapists. The results underline the importance of motivational work in the treatment of AN, including validating the ambivalence experienced by most AN patients. With increasing duration of illness, resource-oriented elements, such as self esteem stabilisation, should be of focus.

Avoidant/Restrictive Food Intake Disorder: An Adult Case Responding to Cognitive Behavioral Therapy

Avoidant/restrictive food intake disorder (ARFID) is a new diagnostic category in the Diagnostic and Statistical Manual of Mental Disorders-5 ( DSM-5) which replaces and extends the DSM-4 diagnosis of feeding disorder of infancy or early childhood. There is limited information as to the characteristics of the patients with ARFID, its course and prognosis and treatment. We aim to contribute to available literature on ARFID by presenting this case. We discussed a young lady with ARFID who responded well to cognitive behavioral therapy (CBT) with successful application of in vivo exposure, systematic desensitization, and cognitive restructuring techniques. After the 12 sessions of CBT as inpatient and eight sessions as outpatient, she gained 4 kg (8.81 lbs); her body mass index (BMI) rising from 16 to 17.5 kg/m2, Hamilton anxiety rating score dropped from 27 to 5. She continued to improve reaching the BMI of 18.3 kg/m2 6-month post-discharge. This case suggests that CBT can be a useful treatment modality in adults with ARFID.

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.

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

OBJECTIVE

Existing forms of evidence-based cognitive behavior therapy for eating disorders (CBT-ED) are relatively effective for nonunderweight cases. However, they are also expensive compared to CBT for other disorders. This study reports the first outcomes for a shorter, 10-session form of CBT-ED (CBT-T) for such cases, designed to be less demanding of resources.

METHOD

A case series of 106 nonunderweight eating disordered cases were considered for this effectiveness study. A protocolized 10-session version of CBT-ED was delivered by clinical assistants, under supervision. Measures assessed eating attitudes and behaviors, anxiety, depression, personality pathology, and the working alliance. Intention-to-treat analyses were used.

RESULTS

Suitability, acceptability, working alliance ratings, and retention were all positive. Outcomes by the end of therapy and at three-month follow-up were positive for all symptoms, with levels of change, abstinence and remission that were comparable to those from effectiveness studies of longer forms of CBT. Higher levels of pretreatment anxiety predicted retention in treatment, but no factors predicted poorer response. Early change in eating attitudes and the working alliance were the strongest predictors of a positive response.

DISCUSSION

This 10-session form of CBT-ED for nonunderweight eating disorders performed at a level that is comparable to versions of CBT-ED that are twice as long, despite being delivered by nonspecialist therapists. Replication and longer-term follow-ups are needed to ensure retained effects. However, CBT-T has promise as a therapy for use in a range of healthcare settings, to enhance access to treatment for such eating disorders.

Cognitive-behavioral therapy for eating disorders in primary care settings: Does it work, and does a greater dose make it more effective?

OBJECTIVE

This study aimed to determine whether cognitive-behavioral therapy (CBT) for eating disorders can be effective in a routine, primary care clinical setting, and to assess dose response.

METHOD

The participants were 47 patients who commenced treatment with a publicly-funded primary care eating disorder service. They attended 7-33 sessions of individual CBT (mean = 17), using an evidence-based approach. Routine measures were collected pre- and post-therapy.

RESULTS

Three-quarters of the patients completed treatment. Using intention to treat analysis (multiple imputation), the patients showed substantial improvements in eating attitudes, bulimic behaviors, and depression. However, there was no association between the level of improvement and the length of therapy past the 8th to 12th session.

DISCUSSION

The level of effectiveness shown here is comparable to that previously demonstrated by more specialist services in secondary and tertiary care. The nonlinear association between number of sessions and recovery highlights the importance of early change, across the eating disorders.

Can temporary cessation of CBT really be therapeutic? A case study

Anorexia nervosa (AN) is a notoriously costly and challenging psychiatric illness to treat. Despite an accumulating evidence base, psychological treatment fails to achieve symptom abstinence in many patients with eating disorders, a shortcoming that is likely to be further pronounced in AN. The case study reported here describes how a mutually agreed break in a course of psychotherapy following an initial lack of progress might have influenced outcome for a client with a severe eating disorder. The patient received 26 sessions of CBT and results, consistent with those of larger studies, showed significant improvement on primary symptom measures. These results are discussed in the context of relevant psychological theories and an exploration of the client's motivation. Consideration is also given to other factors that may have influenced outcome.

Enhanced cognitive behavioral therapy for eating disorders adapted for a group setting

OBJECTIVE

This randomized control trial is an evaluation of the effectiveness of enhanced cognitive behavioral treatment (CBT-E) for eating disorders adapted for a group setting. The study aimed to examine the effects of group CBT-E on eating disorder psychopathology and additional maintaining pathology.

METHOD

A transdiagnostic sample of individuals with eating disorders with a BMI ≥ 18 kg/m² (N = 40) were randomized to an immediate-start or delayed-start condition so as to compare therapeutic effects of group CBT-E with a waitlist control. Global Eating Disorder Examination Questionnaire (EDE-Q) scores, BMI, and measures of Clinical Perfectionism, Self-Esteem, Interpersonal Difficulties, and Mood Intolerance were measured across the 8-week control period, throughout the group treatment and at 3-months post-treatment.

RESULTS

Over 70% of those who entered the trial completed treatment. The first eight weeks of group CBT-E were more effective at reducing Global EDE-Q scores than no treatment (waitlist control). By post-treatment, good outcome (a Global EDE-Q within 1 SD of Australian community norms plus BMI ≥ 18.5) was achieved by 67.9% of treatment completers and 66.7% of the total sample. Symptom abstinence within the previous month was reported by 14.3% of treatment completers and 10.3% of the total sample. Significant reductions in Clinical Perfectionism, Self-Esteem, Interpersonal Difficulties, and Mood Intolerance were also observed.

DISCUSSION

This study demonstrated that a group version of CBT-E can be effective at reducing eating disorder psychopathology in a transdiagnostic sample of individuals with eating disorders. Group CBT-E could provide a means of increasing availability of evidence-based treatment for eating disorders.

The Effectiveness of Enhanced Cognitive Behavioural Therapy (CBT-E): A Naturalistic Study within an Out-Patient Eating Disorder Service

Background: The effectiveness of enhanced cognitive behavioural Therapy (CBT-E) for adults with a range of eating disorder presentations within routine clinical settings has been examined in only two known published studies, neither of which included a follow-up assessment period. Aim: The current study aimed to evaluate the effectiveness of CBT-E within an out-patient eating disorder service in Brisbane, Queensland, Australia, and incorporated a follow-up assessment period of approximately 20 weeks post-treatment. Method: The study involved 114 adult females with a diagnosed eating disorder, who attended an average of 20–40 individual CBT-E sessions with a psychologist or a psychiatry registrar between 2009 and 2013. Results: Of those who began treatment, 50% did not complete treatment, and the presence of psychosocial and environmental problems predicted drop-out. Amongst treatment completers, statistically and clinically significant improvements in eating disorder and general psychopathology were observed at post-treatment, which were generally maintained at the 20-week follow-up. Statistically significant improvements in eating disorder and general psychopathology were observed amongst the total sample. Conclusions: The findings, which were comparable to the previous Australian effectiveness study of CBT-E, indicate that CBT-E is an effective treatment for adults with all eating disorders within out-patient settings. Given the high attrition rate, however, minimizing drop-out appears to be an important consideration when implementing CBT-E within clinical settings.

Cognitive-behavioural therapy for non-motor symptoms of Parkinson's disease: a clinical review

Neuropsychiatric symptoms are common in Parkinson's disease (PD) and have a disproportionate impact on quality of life and carer burden. Pharmacological treatment is the main approach in dealing with these symptoms, but it is limited by variable efficacy and risk of drug interactions. Non-pharmacological approaches using the cognitive-behavioural therapy (CBT) model are viable alternatives and in this review paper we summarise the evidence of CBT for three of the most common psychiatric manifestations of PD: depression and anxiety, impulse-control disorders and insomnia. Most studies modified the usual CBT format to include modules accounting for problems specific to PD: activity scheduling around motoric function, motor symptoms as triggers of anxiety, fear of falling and preparation for disease progression as well as accommodation of materials for suspected executive dysfunction. We found a growing evidence base that CBT (modified to account for PD-specific problems) is effective in the treatment of PD psychiatric symptoms. Where controlled study design was used, moderate effect sizes are reported for the efficacy of CBT for depression, including with distance administration of CBT. The effects were sustained during follow-up which was between 1 and 6 months. In addition, there are some initial data on the effects of CBT on impulse-control disorders and insomnia. The studies were limited by their small and potentially unrepresentative samples and the quality of sample reporting (eg, concomitant antidepressant and dopaminergic therapy use). Additional well-designed and adequately powered studies are required to determine the utility of CBT in PD.

Treatment Protocols for Eating Disorders: Clinicians' Attitudes, Concerns, Adherence and Difficulties Delivering Evidence-Based Psychological Interventions

There are several protocols in existence that guide clinicians in the implementation of effective, evidence-based psychological interventions for eating disorders. These have been made accessible in the form of treatment manuals. However, relatively few clinicians use those protocols, preferring to offer more eclectic or integrative approaches. Following a summary of the research that shows that these evidence-based approaches can be used successfully in routine clinical settings, this review considers why there is such poor uptake of these therapies in such settings. This review focuses on the role of service culture and on clinicians' own attitudes, beliefs and emotions. Possible means of enhancing uptake are considered, but these cannot be considered to be ideal solutions at present.

Transdiagnostic cognitive behaviour therapy for adolescents with an eating disorder who are not underweight

Little is known about the treatment of adolescents with an eating disorder who are not underweight. Enhanced cognitive behaviour therapy (CBT-E) is a potential option as it is a treatment for adult patients with eating disorders of this type and it has been shown to be effective with adolescent patients who are underweight. The aim of the present cohort study was to evaluate the effects of CBT-E on non-underweight adolescents with an eating disorder. Sixty-eight adolescent patients with an eating disorder and a body mass index (BMI) centile corresponding to an adult BMI ≥18.5 were recruited from consecutive referrals to a community-based eating disorder clinic. Each was offered 20 sessions of CBT-E over 20 weeks. Three-quarters completed the full 20 sessions. There was a marked treatment response with two-thirds (67.6%, intent-to-treat) having minimal residual eating disorder psychopathology by the end of treatment. CBT-E therefore appears to be a promising treatment for those adolescents with an eating disorder who are not underweight.

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A cohort of non-underweight adolescents with an eating disorder was treated with enhanced CBT (CBT-E).

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Three-quarters completed the full 20 sessions.

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Two-thirds had minimal eating disorder psychopathology by the end (intent-to-treat).

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CBT-E appears to be a promising treatment for this patient group.

A transdiagnostic comparison of enhanced cognitive behaviour therapy (CBT-E) and interpersonal psychotherapy in the treatment of eating disorders

Eating disorders may be viewed from a transdiagnostic perspective and there is evidence supporting a transdiagnostic form of cognitive behaviour therapy (CBT-E). The aim of the present study was to compare CBT-E with interpersonal psychotherapy (IPT), a leading alternative treatment for adults with an eating disorder. One hundred and thirty patients with any form of eating disorder (body mass index >17.5 to <40.0) were randomized to either CBT-E or IPT. Both treatments involved 20 sessions over 20 weeks followed by a 60-week closed follow-up period. Outcome was measured by independent blinded assessors. Twenty-nine participants (22.3%) did not complete treatment or were withdrawn. At post-treatment 65.5% of the CBT-E participants met criteria for remission compared with 33.3% of the IPT participants (p < 0.001). Over follow-up the proportion of participants meeting criteria for remission increased, particularly in the IPT condition, but the CBT-E remission rate remained higher (CBT-E 69.4%, IPT 49.0%; p = 0.028). The response to CBT-E was very similar to that observed in an earlier study. The findings indicate that CBT-E is potent treatment for the majority of outpatients with an eating disorder. IPT remains an alternative to CBT-E, but the response is less pronounced and slower to be expressed.

Current controlled trials

ISRCTN 15562271.

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CBT-E had a substantial and sustained effect.

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The effect was seen across the entire transdiagnostic sample.

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The response almost exactly replicated that obtained in the original CBT-E trial.

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The response to interpersonal psychotherapy (IPT) was slower and less pronounced.

Disseminating evidence-based psychological treatments for eating disorders

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