Prediction of failure of inpatient treatment of anorexia nervosa from early weight gain

Acute Activity Urges Predict Lower Early Weight Gain During Inpatient Treatment for Anorexia Nervosa

Early weight gain is a primary goal in the treatment of anorexia nervosa (AN) and associated with more favorable discharge weights and clinical outcomes. Activity urges, that is, a motivational state to engage in activity, have been suspected to delay early weight gain, but their prognostic role remains barely explored. Here, we investigated whether acute (state-like) activity urges at treatment onset would predict within-person weight gain in patients with AN during the initial 2 weeks of inpatient treatment. Adults with AN from an inpatient unit (N = 53) completed an activity urges measure at treatment onset, and weight changes were monitored for the duration of their treatment. Regression analyses, controlling for admission body mass index and other patient variables (i.e., patient age and AN subtype), found that higher state activity urges were associated with lower initial weight gain. Mediation analyses showed that differences in early weight changes further linked higher activity urges at admission to lower discharge weights. An activity urge cutoff value of 2.76 for distinguishing between cases with optimal and suboptimal initial weight gain is proposed. We discuss potential mechanisms of the link between activity urges and early weight gain and the implications of activity urges as a prognostic factor for improving weight restoration during AN treatment.

Exploring Gender Differences in Early Weight Change and Variability in Adolescents with Anorexia Nervosa during Inpatient Treatment

Background: Adolescents' early responses and overall outcomes during anorexia nervosa (AN) treatment may differ by patient gender, raising the question of whether evaluating clinical data during AN treatment may require different criteria. Methods: We investigated, using patient records, whether young men and young women with AN differed in terms of early treatment response (defined as weight change and variability within the first 14 days) and whether early treatment responses predicted treatment outcomes similarly across genders. Results: Weight changes predicted patient discharge weight across all gender groups. Weight variability predicted higher disordered eating psychopathology and higher body image insecurities at discharge. Gender differences emerged only for weight gain, which was more pronounced for young men, and gender modulated the effects of weight gain and variability on general psychopathology outcomes. Conclusions: The present findings suggest that early weight changes and weight variability are similarly important predictors of AN treatment outcomes in adolescents but also hint at possible gender differences in terms of the link between weight change and, respectively, variability on general psychopathology.

Premature termination of inpatient eating disorder treatment: Does timing matter?

BACKGROUND

Premature termination of treatment is a serious problem in the treatment of eating disorders. Prior research attempting to differentiate patients who are able to complete treatment from those who terminate early has yielded mixed results. One proposed explanation for this is a failure to examine the time course of treatment termination. This study was designed to explore associations between baseline patient characteristics and timing of treatment termination.

METHODS

Participants were 124 eating disorder patients admitted voluntarily to the inpatient program at Toronto General Hospital between 2009 and 2015. At admission, all patients completed measures of eating disorder symptoms, eating disorder cognitions, depressive symptoms and emotional dysregulation. Body weight was measured weekly. Data analyses were completed using one-way ANOVAs and Chi Square tests.

RESULTS

Results showed significant associations between timing of treatment termination and eating disorder diagnosis, severity of eating disorder cognitions and severity of depressive symptoms. Post-hoc analyses revealed that patients who left treatment early had more severe depressive symptoms, eating disorder cognitions related to eating and difficulties engaging in goal directed behaviors when emotionally dysregulated.

CONCLUSIONS

Patients who terminated inpatient treatment early in their admissions differ from patients who terminated later and those who completed treatment. These differences have potential clinical implications for the clinical management of patients with severe eating disorders requiring inpatient admission. Trial registration This paper is not associated with a clinical trial.

Early within-person weight gain and variability during inpatient treatment for anorexia nervosa: Age-dependent effects on treatment outcome

OBJECTIVE

Early weight gain during inpatient treatment for anorexia nervosa (AN) is a dynamic process characterised by within-person variability that may be age-dependent. We examined whether age moderates the effect of within-person weight gain and variability on treatment outcome.

METHOD

Within-person level estimates of N = 2881 underweight adolescents and adults with AN for daily average weight gain (linear slope) and variability (root mean squared errors) were obtained using random-effects modelling. Between-person level regression analyses were calculated to assess effects on weight, eating disorder psychopathology and attaining normal body weight (body mass index [BMI]: 18.5-25 kg/m² ).

RESULTS

Higher weight gain during first 2 weeks of inpatient treatment predicted higher weight, lower drive for thinness and lower body dissatisfaction at discharge, but not lower bulimic symptoms. Moreover, it predicted a higher probability of discharge weight within normal range. Younger age was associated with stronger effects of early weight gain on weight, drive for thinness and body dissatisfaction at discharge. Weight variability was not associated with any outcome.

CONCLUSIONS

Age moderated effects of early weight gain on treatment outcomes, with larger effects for younger patients. Weight variability alone did not influence treatment across age and should be of lesser clinical concern during early inpatient treatment.

Rapid response is predictive of treatment outcomes in a transdiagnostic intensive outpatient eating disorder sample: a replication of prior research in a real-world setting

OBJECTIVE

There is a growing call to identify specific outcome predictors in real-world eating disorder (ED) treatment settings. Studies have implicated several ED treatment outcome predictors [rapid response (RR), weight suppression, illness duration, ED diagnosis, and psychiatric comorbidity] in inpatient settings or randomized controlled trials of individual outpatient therapy. However, research has not yet examined outcome predictors in intensive outpatient programs (IOP). The current study aimed to replicate findings from randomized controlled research trials and inpatient samples, identifying treatment outcome predictors in a transdiagnostic ED IOP sample.

METHOD

The current sample comprised 210 consecutive unique IOP patient admissions who received evidence-based ED treatment, M(SD)_Duration = 15.82 (13.38) weeks. Weekly patient measures of ED symptoms and global functioning were obtained from patients' medical charts.

RESULTS

In relative weight analysis, RR was the only significant predictor of ED symptoms post treatment, uniquely accounting for 45.6% of the predicted variance in ED symptoms. In contrast, baseline ED pathology was the strongest unique predictor of end-of-treatment global functioning, accounting for 15.89% of predicted variance. Baseline factors did not differentiate patients who made RR from those who did not.

CONCLUSIONS

Consistent with findings in more controlled treatment settings, RR remains a robust predictor of outcome for patients receiving IOP-level treatment for EDs. Future work should evaluate factors that mediate and moderate RR, incorporating these findings into ED treatment design and implementation.

LEVEL OF EVIDENCE

Level IV, uncontrolled intervention.

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

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

Risk factors for a low weight gain in the early stage of adolescent anorexia nervosa inpatient treatment: findings from a pilot study

PURPOSE

Body weight restoration is a major treatment aim in juvenile inpatients with anorexia nervosa (AN) (i.e., 500-1000 g/week according to the German guidelines). Several studies suggest the early weight gain to be crucial for remission. The identification of patients at risk of a low early weight gain could enable an adequate adaptation of treatment. Thus, we aimed at detecting risk factors of a low weight gain during inpatient treatment.

METHODS

The presented work analyzes data from a pilot study in 30 female adolescent inpatients with AN (restricting subtype; age range at admission: 12.6-17.6 years). Premorbid characteristics, history of symptomatology, anthropometric data, and eating-disorder psychopathology were compared between those who gained at least an average of 500 g/week during the first 7 weeks of treatment (high weight gainers, HWG) and those who did not (low weight gainers, LWG).

RESULTS

At admission, LWG (n = 15) had a significantly higher BMI(-SDS) and scored significantly higher in the eating-disorder examination questionnaire (EDE-Q) than HWG (n = 15). A logistic regression analysis indicated both parameters to be independently associated with a low weight gain.

CONCLUSION

Higher EDE-Q scores seem to be a major risk factor for a low weight gain at the beginning of treatment. Moreover, a higher BMI(-SDS) at admission does not necessarily indicate a less severe AN symptomatic, as it was associated with a lower weight gain in our sample during the first 7 weeks of treatment. Reassessment of our results in larger studies is required to draw firm conclusions for clinical practice.

LEVEL OF EVIDENCE

Level V.

Pre-treatment patient characteristics as predictors of drop-out and treatment outcome in individual and family therapy for adolescents and adults with anorexia nervosa: A systematic review and meta-analysis

Understanding variables predicting drop-out or unfavourable outcome following treatment for anorexia nervosa (AN) may help to improve upon intervention efforts. However, the current literature has demonstrated sparse and inconsistent significant findings. The current systematic review and meta-analysis summarised the evidence base examining baseline predictors of drop-out and outcome in AN treatment. A literature search was conducted to identify research investigating predictors of drop-out and outcome in individuals treated for AN. Four online databases were searched, and predictors were organised by category and dependent variable (outcome versus drop-out). 27 studies were included. Lower motivation, lower BMI, and having the binge-purge subtype of AN predicted drop-out. Greater ED pathology and poorer motivation predicted poorer outcome. Clinical recommendations include taking particular care during assessment stages to identify patients at risk of drop-out and/or poor outcome based on their clinical profile and level of motivation for recovery. At-risk patients should be receiving tailored treatment to enhance engagement and reduce risk of drop-out. In conclusion, there's some evidence that motivation, BMI, subtype, and ED pathology predicts drop-out and/or outcome in individual and family-based therapy for AN amongst adolescents and adults; however, research incorporating carefully designed multi-site studies is required to further examine these findings.

Heterogeneous weight restoration trajectories during partial hospitalization treatment for anorexia nervosa

Early response to treatment has been shown to predict good outcome in family-based treatment, but little is known about who responds quickly.

OBJECTIVE

The purpose of the current study was to examine the short-term weight gain trajectories among youth receiving partial hospitalization program services for anorexia nervosa (AN), and to identify predictors of these trajectories.

METHOD

Adolescent and young adults (n = 102) with AN or subthreshold AN completed semi-structured interviews and self-report measures on admission to a family-based partial hospitalization program. Patients participated in programming 5 days a week.

RESULTS

Three weight gain trajectories were found to indicate slow, moderate, and rapid weight gain trajectories. All rapid responders gained at least four lbs. in the first 4 weeks of treatment, compared to 86.1% of moderate responders and 51.2% of slow responders. Patients were less likely to have a moderate or rapid response trajectory if they had a mood disorder diagnosis and higher parental expressed emotion. Additionally, the presence of compensatory behavior increased the likelihood of having a rapid response.

DISCUSSION

Despite the sometimes chronic nature of AN, most patients fell into one of the two favorable response trajectories. The identification of these trajectories underscores the importance of considering the core disordered eating behaviors (i.e., restricting, binge eating, and purging), comorbid psychopathology, and parental expressed emotion.

Trajectories of Change in Body Weight During Inpatient Treatment for Anorexia Nervosa

BACKGROUND

Identifying distinct trajectories of change in body weight during inpatient treatment for anorexia nervosa (AN) may provide knowledge about the process of weight restoration and may help detect optimal body weight response patterns among individuals who are at risk for not achieving weight restoration or leaving treatment prematurely.

OBJECTIVE

This study explored the extent to which distinct trajectories of change in body weight existed among individuals during inpatient treatment for AN.

DESIGN

Group-based trajectory modeling was used to identify distinct trajectories of change in body weight among 500 individuals receiving inpatient treatment for AN.

RESULTS

Four distinct trajectories were identified: weight gain ( n = 197), treatment resistant ( n = 177), weight plateau ( n = 82), and weight fluctuate ( n = 44).

CONCLUSION

Clinically, it is important to consider the heterogeneity of changes in body weight during inpatient treatment to help guide interventions and outcomes.

Early Response to treatment in Eating Disorders: A Systematic Review and a Diagnostic Test Accuracy Meta-Analysis

OBJECTIVE

Early response to eating disorders treatment is thought to predict a later favourable outcome. A systematic review of the literature and meta-analyses examined the robustness of this concept.

METHOD

The criteria used across studies to define early response were summarised following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Diagnostic Test Accuracy methodology was used to estimate the size of the effect.

RESULTS

Findings from 24 studies were synthesized and data from 14 studies were included in the meta-analysis. In Anorexia Nervosa, the odds ratio of early response predicting remission was 4.85(95%CI: 2.94-8.01) and the summary Area Under the Curve (AUC) = .77. In Bulimia Nervosa, the odds ratio was 2.75(95%CI:1.24-6.09) and AUC = .67. For Binge Eating Disorder, the odds ratio was 5.01(95%CI: 3.38-7.42) and AUC = .71.

CONCLUSION

Early behaviour change accurately predicts later symptom remission for Anorexia Nervosa and Binge Eating Disorder but there is less predictive accuracy for Bulimia Nervosa. Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.

Effects of perceptual body image distortion and early weight gain on long-term outcome of adolescent anorexia nervosa

Anorexia nervosa (AN), a severe mental disorder with an onset during adolescence, has been found to be difficult to treat. Identifying variables that predict long-term outcome may help to develop better treatment strategies. Since body image distortion and weight gain are central elements of diagnosis and treatment of AN, the current study investigated perceptual body image distortion, defined as the accuracy of evaluating one's own perceived body size in relation to the actual body size, as well as total and early weight gain during inpatient treatment as predictors for long-term outcome in a sample of 76 female adolescent AN patients. Long-term outcome was defined by physical, psychological and psychosocial adjustment using the Morgan-Russell outcome assessment schedule as well as by the mere physical outcome consisting of menses and/or BMI approximately 3 years after treatment. Perceptual body image distortion and early weight gain predicted long-term outcome (explained variance 13.3 %), but not the physical outcome alone. This study provides first evidence for an association of perceptual body image distortion with long-term outcome of adolescent anorexia nervosa and underlines the importance of sufficient early weight gain.

Rapid response to eating disorder treatment: A systematic review and meta-analysis

OBJECTIVE

This review aimed to (a) examine the effects of rapid response on behavioral, cognitive, and weight-gain outcomes across the eating disorders, (b) determine whether diagnosis, treatment modality, the type of rapid response (changes in disordered eating cognitions or behaviors), or the type of behavioral outcome moderated this effect, and (c) identify factors that predict a rapid response.

METHOD

Thirty-four articles met inclusion criteria from six databases. End of treatment and follow-up outcomes were divided into three categories: Behavioral (binge eating/purging), cognitive (EDE global scores), and weight gain. Average weighted effect sizes(r) were calculated.

RESULTS

Rapid response strongly predicted better end of treatment and follow-up cognitive and behavioral outcomes. Moderator analyses showed that the effect size for rapid response on behavioral outcomes was larger when studies included both binge eating and purging (as opposed to just binge eating) as a behavioral outcome. Diagnosis, treatment modality, and the type of rapid response experienced did not moderate the relationship between early response and outcome. The evidence for weight gain was mixed. None of the baseline variables analyzed (eating disorder psychopathology, demographics, BMI, and depression scores) predicted a rapid response.

DISCUSSION

As there is a solid evidence base supporting the prognostic importance of rapid response, the focus should shift toward identifying the within-treatment mechanisms that predict a rapid response so that the effectiveness of eating disorder treatment can be improved. There is a need for future research to use theories of eating disorders as a guide to assess within-treatment predictors of rapid response. © 2016 Wiley Periodicals, Inc. Int J Eat Disord 2016; 49:905-919.

Within-persons predictors of change during eating disorders treatment: An examination of self-compassion, self-criticism, shame, and eating disorder symptoms

OBJECTIVE

Attempts to identify the predictors of change during eating disorders treatment have focused almost exclusively on identifying between-persons factors (i.e., differences between patients). Research on within-person predictors of change (i.e., variations within patients over time) may provide novel and clinically useful information. To illustrate, we test the theory that within patients, self-compassion, self-criticism, shame, and eating disorder symptoms reciprocally influence one another over time.

METHOD

Seventy-eight patients with an eating disorder completed the Self-Compassion Scale, Experience of Shame Scale, and Eating Disorder Examination Questionnaire every three weeks across 12 weeks of treatment.

RESULTS

Multilevel modeling revealed that following periods of increased shame, a patient's eating pathology was more severe than usual. Following periods of increased self-compassion or decreased eating pathology, a patient's level of shame was lower than usual. Between-person differences in the relationships among study variables also emerged.

DISCUSSION

Results support the theory that shame and eating pathology influence one another cyclically within patients over time, and suggest that time-dependent increases in self-compassion may interrupt this cycle. If replicated, these results might suggest that assessing and intervening with increases in a patient's level of shame may help to reduce her eating pathology, and improving a patient's level of self-compassion or eating disorder symptomology may lower her subsequent experiences of shame. Findings highlight the value of administering and examining repeatedly measured within-person predictors of change during eating disorders treatment, and suggest that it may be clinically important to attend to the changes that occur within a given patient over time. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:716-722).

Predictors of Positive Treatment Outcome in People With Anorexia Nervosa Treated in a Specialized Inpatient Unit: The Role of Early Response to Treatment

OBJECTIVE

To investigate factors which predict positive treatment outcome in inpatients with anorexia nervosa (AN), particularly the role of early treatment response.

METHOD

102 patients entering specialist inpatient treatment were assessed for eating disorder history, psychopathology, and motivation to change. Predictive factors assessed were: early treatment response defined as weight increase of at least 0.5-1 kg/week during the first 6 weeks of treatment (n=87), admission body mass index (BMI), onset age, chronicity, motivation to change, diagnosis, and previous hospitalization for AN. Positive treatment outcome was defined as achieving a BMI of 17.5 kg/m(2) within an individual time frame.

RESULTS

Logistic regression indicated that patients were 18 times more likely to reach positive treatment outcome if they met the National Institute for Health and Care Excellence weight guidelines within the first 6 weeks of hospitalization. Higher admission BMI was also found to predict positive treatment outcome.

DISCUSSION

Higher entry BMI and early weight gain predict positive treatment outcome in individuals receiving specialist AN inpatient treatment. Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.

Favorable effects of clearly defined interventions by parents at the start of treatment of adolescents with restrictive eating disorders

OBJECTIVE

To study the effect of clearly defined and decisive parental interventions at the start of treatment of restrictive eating disorders (ED) in adolescents.

METHOD

Forty-seven adolescents with ED (anorexia nervosa = 6, bulimia nervosa = 1, EDNOS = 40) and their families participated. Parents were advised to (1) keep the adolescent home from school, (2) eat all meals together with the adolescent, (3) prevent any form of exercise, and (4) prevent vomiting during the first week of treatment. Weight change was followed up to three months and EDE-Q administered at start of treatment and at three months.

RESULTS

Thirty (64%) of the families accomplished all four interventions during the first week of treatment. Their adolescents gained ∼ 1 kg of weight at one week, 2 kg at one month, and 4 kg at three months while adolescents in families who did not accomplish all four interventions gained only 1.4 kg up to three months. Scores on the EDE-Q decreased during treatment and in adolescents of families who accomplished all four interventions they were in the range of a reference population.

DISCUSSION

Decisive parental management of eating disturbed behaviors at the start of treatment of adolescents with ED promotes later clinical outcome. The finding supports the view that family based therapies are effective in adolescent ED. Results has to be followed up for evaluation of the long term effects of this type of intervention.

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.

Pretreatment and process predictors of nonresponse at different stages of inpatient psychotherapy

OBJECTIVE

Up to 50% of psychotherapeutic treatments end without significant improvements. While there is first evidence about predictors of nonresponse in outpatient psychotherapy, there are currently no studies investigating predictors of nonresponse in inpatient settings. Based upon a previous systematic literature review, we analyzed the predictive value of initial patient characteristics on nonresponse in symptom distress.

METHODS

Treatment episodes from 546 patients, treated for at least 4 weeks, were assessed under naturalistic conditions. Nonresponse status (i.e., lack of a reliable improvement in symptom distress) was investigated at four different time points: at week 4, at discharge, and at a two follow-ups (3 and 12 months after discharge). Hierarchical binary logistic regression models were used to predict nonresponse. Sociodemographic data, clinical variables, and the previous response status were entered subsequently in the model.

RESULTS

A moderate or functional level of initial symptom distress, a comorbid personality disorder, and previous nonresponse were the most consistent predictors of nonresponse.

CONCLUSIONS

The results point to the importance of early outcome assessment and suggest the implementation of more symptom-specific treatments.

[Non-response to therapy in acute and rehabilitative psychosomatic inpatient care - a systematic review]

OBJECTIVES

The study reviews the state-of-the art on failure research in acute and rehabilitative psychosomatic inpatient care. The main focus of interest lies in describing the frequency and possible predictors of unsuccessful therapeutic treatments.

METHODS

We systematically searched the databases MEDLINE, PsycARTICLES, PsycINFO und PSYNDEX and selected studies from the past 20 years focusing on treatment failure in the inpatient psychosomatic treatment of adult patients.

RESULTS

A total of 31 studies were included, 15 of which allowed the extraction of predictors of non-response or deterioration. 20 %to 30%of patients leave psychotherapeutic treatment without any significant change; 5 %to 10%deteriorate during their stay.A high level of symptom distress at intake, a chronic course of the disease as well as somatoform or personality disorders are associated with non-response and deterioration. Early response to treatment and a dysfunctional therapeutic alliance are possible further predictors, whereas sociodemographic and sociomedical variables are unlikely to have a predictive validity.

CONCLUSIONS

Hypotheses about possible predictors can be derived from the results of this review. However, the interpretation of the results is limited by the heterogeneity of the methodology and of the samples of the studies included. Nevertheless the results can be used as a basis for further hypothesis-driven research.

The therapeutic process in psychological treatments for eating disorders: a systematic review

OBJECTIVE

For eating disorders, a vast number of investigations have demonstrated the efficacy of psychological treatments. However, evidence supporting the impact of therapeutic process aspects on outcome (i.e., process-outcome research) has not been disentangled.

METHOD

Using the Generic Model of Psychotherapy (GMP) to organize various process aspects, a systematic literature search was conducted on psychological treatment studies for anorexia nervosa, bulimia nervosa, binge-eating disorder, and eating disorders not otherwise specified.

RESULTS

Improved outcomes resulted for family-based treatment compared to individual treatment, for individual compared to group treatment, booster sessions, and positive patient expectations (GMP contract aspect); for nutritional counseling and exercising but not exposure with response prevention as adjunct interventions (therapeutic operations); for highly motivated patients and, to a lesser extent, for therapeutic alliance (therapeutic bond); as well as for rapid response and longer overall treatment duration (temporal patterns). Regarding other GMP aspects, studies on self-relatedness were completely lacking and in-session impacts were rarely investigated.

DISCUSSION

As most studies assessed only a limited number of process aspects, the ability to draw conclusions about their overall impact regarding outcome is rather limited. Therefore, future process-outcome research is needed beyond investigations of treatment efficacy for eating disorders.

Early weight gain predicts outcome in two treatments for adolescent anorexia nervosa

OBJECTIVE

Determine whether early weight gain predicts full remission at end-of-treatment (EOT) and follow-up in two different treatments for adolescent anorexia nervosa (AN), and to track the rate of weight gain throughout treatment and follow-up.

METHOD

Participants were 121 adolescents with AN (mean age = 14.4 years, SD = 1.6), from a two-site (Chicago and Stanford) randomized controlled trial. Adolescents were randomly assigned to family-based treatment (FBT) (n = 61) or individual adolescent focused therapy (AFT) (n = 60). Treatment response was assessed using percent of expected body weight (EBW) and the global score on the Eating Disorder Examination (EDE). Full remission was defined as having achieved ≥95% EBW and within one standard deviation of the community norms of the EDE. Full remission was assessed at EOT as well as 12-month follow-up.

RESULTS

Receiver operating characteristic analyses showed that the earliest predictor of remission at EOT was a gain of 5.8 pounds (2.65 kg) by session 3 in FBT (area under the curve (AUC) = 0.670; p = .043), and a gain of 7.1 pounds (3.20 kg) by session 4 in AFT (AUC = 0.754, p = .014). Early weight gain did not predict remission at follow-up for either treatment. A survival analysis showed that weight was marginally superior in FBT as opposed to AFT (Wald chi-square = 3.692, df = 1, p = .055).

DISCUSSION

Adolescents with AN who receive either FBT or AFT, and show early weight gain, are likely to remit at EOT. However, FBT is superior to AFT in terms of weight gain throughout treatment and follow-up.

Premature termination of treatment for anorexia nervosa: differences between patient-initiated and staff-initiated discharge

OBJECTIVES

To investigate treatment drop-out by comparing clinical indicators of patients whose discharge was initiated by staff with those who initiated discharge themselves.

METHOD

Ninety participants with anorexia completed questionnaires at admission and four weeks into hospitalized treatment. Weight data was collected over this same period. At discharge, participants were categorized into completer (n = 38) or patient-initiated (n = 36) /staff-initiated (n = 16) premature termination groups.

RESULTS

Significant differences between staff-initiated and patient-initiated discharge groups were found at admission. Staff initiated groups were on average older (p = .035), and more likely to have had prior compelled treatment (p = .039). At 4 weeks those in the patient-initiated group had put on weight at a faster rate (p = .032) and reported a decrease in alliance (p = .017). At discharge, staff initiated discharge demonstrated greater time in treatment (p = .001), greater weight gain (p = .027), and a higher discharge BMI (p = .013). At discharge, staff-initiated drop-outs had comparable end-of-treatment outcomes to those who completed treatment as planned.

DISCUSSION

There are key differences between those who prematurely discharge themselves from treatment, compared to those who are prematurely discharged by clinical staff. Future research into drop-out needs to take into account and recognize these differences.

Rapid and slow responders to eating disorder treatment: a comparison on clinically relevant variables

OBJECTIVE

Speed of response to eating disorder treatment is a reliable predictor of relapse, with rapid response predicting improved outcomes. This study investigated whether rapid, slow, and nonresponders could be differentiated on clinically relevant variables, and possibly identified prior to treatment.

METHOD

Female patients (N = 181) were classified as rapid, slow, or nonresponders based on the speed and magnitude with which they interrupted their bingeing and/or vomiting symptoms, and were compared on eating disorder behaviors and psychopathology and general psychopathology.

RESULTS

The rapid response group was marginally older and had a slightly shorter course of treatment than the slow response group. The rapid response group also had significantly fewer pretreatment binge episodes, and a longer course of treatment than the nonresponse group. However, the three response groups were not significantly different on any other examined variables.

DISCUSSION

The only pretreatment variable that differentiated response groups was symptom frequency, in that rapid responders had fewer binge episodes than nonresponders. No pre-existing variables differentiated rapid and slow response. Given that few individual pre-existing differences that might account for speed of response were identified, the clinical importance of facilitating a rapid response to treatment for all patients is discussed.

Predicting premature termination of hospitalised treatment for anorexia nervosa: the roles of therapeutic alliance, motivation, and behaviour change

OBJECTIVES

This study aims to investigate treatment drop-out, and the associated roles of motivation, alliance, and behaviour change exhibited over the first four weeks of hospitalised treatment for anorexia.

METHODS

90 participants meeting DSM-IV criteria for anorexia nervosa completed questionnaires at admission, and four weeks into treatment. Weight data was collected over this same time period. At the end of treatment, participants were categorised into completer or premature termination groups.

RESULTS

The overall rate of premature termination was 57.8%. Those who prematurely terminated treatment demonstrated lower discharge BMI (p<.0005), and weight gain (p<.0005) than those who completed. Therapeutic alliance proved significantly different between outcome groups at admission (p=.004).

DISCUSSION

End-of-treatment outcomes for those who do not complete treatment are invariably poor. Therapeutic alliance appears to be a particularly important factor in this area.

A Modification of Enhanced Cognitive Behavioral Therapy for Anorexia Nervosa

This case study illustrates the treatment of an adult woman who was diagnosed with anorexia nervosa (AN). For approximately 10 years, the client had suffered from various forms of eating disorders and had had several unsuccessful encounters with the health care services. In this study, she was treated with a modification of enhanced cognitive behavioral therapy (CBT-E). CBT-E is a relatively new treatment guide with a transdiagnostic perspective on eating disorders. In all, the treatment consisted of 14 sessions where most sessions were held on a weekly basis. Thereafter, a maintenance and follow-up was conducted via email and with the aid of self-help literature. Treatment time lasted for 8 months followed by a follow-up of 4 months. In this study, the content of each session is described, as are the modifications that were made. The modifications were made to increase motivation and self-esteem, as well as perceived control of eating, which, in itself, is a contribution to increased efficiency and a clarification of important treatment components. Apart from a description of treatment interventions, the study shows the weight gain and other clinically significant components regarding eating disorders that concern, among other things, self-esteem and general mental health. The results of this study demonstrate that this treatment, with the proposed modifications, has been highly effective for this client and hence provides a positive anticipation that this might be a more effective treatment in general for people with AN.

Eating in eating disorders

The aim of this paper is to bring eating back into the centre of the eating disorder discourse. The ability to interrogate and understand the central processes of appetite has increased considerably since the discovery of leptin and the ability to observe brain function with scanning methodologies. This has led to substantial progress in understanding the biological causative and maintaining factors in eating disorders, opening up the possibility of translating the latest findings into new forms of treatment. The biological mechanisms underpinning symptoms evolution and course of illness will first be described, follows by a discussion on integrating the research evidence in fear and feeding into patient care.

Early response to family-based treatment for adolescent anorexia nervosa

OBJECTIVE

The purpose of this study was to determine if early weight gain predicted remission at the end of treatment in a clinic sample of adolescents with anorexia nervosa (AN).

METHOD

Sixty five adolescents with AN (mean age = 14.9 years, SD = 2.1), from two sites (Chicago n = 45; Columbia n = 20) received a course of manualized family-based treatment (FBT). Response to treatment was assessed using percent ideal body weight (IBW) with remission defined as having achieved ≥ 95% IBW at end of treatment (Session 20).

RESULTS

Receiver operating characteristic analyses showed that a gain of at least 2.88% in ideal body weight by Session 4 best predicted remission at end of treatment (AUC = 0.674; p = 0.024).

DISCUSSION

Results suggest that adolescents with AN, receiving FBT, who do not show early weight gain are unlikely to remit at end of treatment.

Modeling psychotherapy process by time-series panel analysis (TSPA)

The authors introduce the methodology of aggregated time-series analysis (time-series panel analysis [TSPA]), by which prototypical process patterns are estimated using longitudinal psychotherapy process data. Empirical trajectories of 202 outpatients (15-107 sessions) were available. Presession questionnaires provided measures of patient's well-being and patient's therapy motivation. TSPA was contrasted with growth curve modeling. Fixed effects were estimated in both methods. Unbalanced longitudinal data considering multiple levels can be analyzed. Using Granger causality derived from time-lagged associations, the TSPA pattern revealed feedback relationships between well-being and therapy motivation. Growth curve analysis highlighted logarithmic increases of well-being trajectories. In particular, TSPA can illuminate change mechanisms in psychotherapy field data by its nonexperimental approximation to an analysis of causal dynamic structures.