Psychotherapy for eating disorders: A meta-analysis of direct comparisons

Exploring mental health dynamics during eating disorder treatment: A psychometric network study with panel data

To explore mental health associations during eating disorder (ED) treatment. Based on the dual-continua model of mental health, general and ED-specific psychopathology, as well as emotional, psychological, and social well-being were considered as mental health domains.

Network analyses with panel data were applied to explore within- (temporal and contemporaneous networks) and between-person effects in a sample of 1250 female ED patients during 12 months of outpatient treatment. The associations between the domains and their centrality were examined. Autoregressive and cross-lagged effects were also estimated.

ED psychopathology was the most central domain in the temporal network. ED psychopathology changes predicted further ED psychopathology changes and small changes in the other domains. Weak bi-directional associations were found between changes in the well-being domains and general psychopathology. In contrast to the temporal network, ED psychopathology was the least central and psychological well-being the most central domain in the contemporaneous and between-subjects networks. This suggests a central role of psychological well-being for experiencing mental health within time points.

ED psychopathology may change relatively independent from other mental health domains. Well-being domains may be considered as more stable aspects of mental health.

Eye movement desensitisation and reprocessing as add-on treatment to enhanced cognitive behaviour therapy for patients with anorexia nervosa reporting childhood maltreatment: A quasi-experimental multicenter study

OBJECTIVE

This quasi-experimental study aimed to compare the outcome of patients with Anorexia Nervosa (AN) reporting moderate/severe childhood maltreatment (CM) treated exclusively with Enhanced Cognitive Behaviour Therapy (CBT-E) or with CBT-E plus Eye Movement Desensitisation and Reprocessing (EMDR).

METHOD

A total of 75 patients with AN reporting moderate/severe CM were initially assessed regarding body mass index (BMI), general and eating disorder (ED)-specific psychopathology, and dissociative symptoms, and re-evaluated after 40 CBT-E sessions (T1). Then, 18 patients received EMDR, whereas the others were placed on a waiting list and continued CBT-E. T2 assessment was performed after 20-25 sessions of EMDR or CBT-E. A control group of 67 patients without CM was also enroled and treated with CBT-E.

RESULTS

Contrary to patients without CM, neither of the traumatised groups improved in BMI, general and ED psychopathology, or dissociation at T1. However, at T2, both traumatised groups improved in BMI and ED-specific psychopathology, with the CBT + EMDR group demonstrating greater improvements. Moreover, only the CBT + EMDR group improved in general psychopathology and dissociative symptoms. The reduction of ED symptoms in traumatised patients was mediated by the amelioration of dissociation.

DISCUSSION

The addition of EMDR to CBT-E may benefit patients with AN reporting moderate/severe CM.

Moving toward targeted eating disorder care for transgender, non-binary, and gender expansive patients in the United States

OBJECTIVE

Literature suggests that transgender, non-binary, and/or gender expansive (TNG) people are more likely than cisgender peers to experience eating disorders (EDs) and engage in dangerous weight control behaviors. TNG individuals with EDs are dramatically higher risk for self-harm behaviors, suicidal ideation, and suicidal behaviors than cisgender peers with EDs or TNG peers without EDs, and often engage in ED symptoms/behaviors to alleviate gender dysphoria. Yet, no treatment paradigms have yet been adapted for TNG-specific ED care. This qualitative study aims to identify stakeholder needs from such care to inform future clinical interventions.

METHODS

We elicited patient (n = 12) and mental health clinician (n = 9) stakeholder needs and preferences regarding TNG-specific ED care. Semi-structured interview guides informed by the Consolidated Framework for Implementation Research (CFIR) and a behavioral insights framework, EAST, were developed to ensure uniform inclusion and sequencing of topics and allow for valid comparison across interviews. Using a rapid analysis procedure, we produced a descriptive analysis for each group identifying challenges of and opportunities in providing ED care for TNG adults.

RESULTS

Stakeholders expressed needs and preferences for TNG-specific treatment including that it be: (1) TNG-affirming, weight-inclusive, trauma-informed, and anti-racist; (2) delivered by an interdisciplinary team, including gender-affirming care clinicians; (3) focused on parsing gender dysphoria from other body image concerns, building distress tolerance, and working toward gender euphoria (rather than body acceptance).

DISCUSSION

Future work is needed exploring ED care delivery models that integrate gender-affirming care services with mental health care. Such models may improve TNG access to ED treatment and recovery.

PUBLIC SIGNIFICANCE

Transgender, non-binary, and/or gender expansive (TNG) experience disproportionately high rates of eating disorders and have unique barriers to accessing care. In individual interviews, TNG adults with eating disorders and mental health clinicians who provide psychotherapy for eating disorders voiced desire for greater availability of TNG-affirming, weight-inclusive eating disorder care, integrated with other gender-affirming care services. This informs future research developing eating disorder care for TNG individuals.

Yoga as an adjunct treatment for the eating disorders: A qualitive enquiry of clinician perspectives

BACKGROUND

Yoga has been recognised as a beneficial adjunct for eating disorder (ED) treatment due to demonstrating positive effects on ED symptomology. Despite this, research exploring the perspectives of clinicians regarding the use of yoga for the spectrum of the EDs is limited. Consequently, this study utilised qualitative enquiry to explore the experiences and perspectives of clinicians regarding the implementation of yoga as an adjunct for ED treatment. This research examines how yoga may be safely applied for the EDs, to enhance ED treatment approaches and recovery.

METHODS

This study employed semi-structured interviews with 12-clincians with up to 20-years of experience working therapeutically with people with EDs. Participants were asked their perspectives on the benefits, risks, and adaptations for delivering safe and suitable yoga programs for the spectrum of EDs. Template thematic analysis was used.

RESULTS

Four distinct themes were identified. They included the (1) benefits of yoga, (2) risks associated with the practice, (3) recommendations for adapting yoga for this cohort, and (4) implementing yoga alongside current psychological treatment.

CONCLUSIONS

Clinicians viewed yoga as a safe and suitable transdiagnostic treatment, with the potential to support individuals with a more holistic and sustained recovery model. Clinicians raised concerns that might arise with the use of yoga for this cohort, however, they also emphasised the ability for these to be mitigated with a series of key adaptations. Importantly, clinicians recommended that yoga is implemented and monitored alongside ED treatment to ensure its suitability and safety. Key barriers for implementing yoga as an adjunct treatment and future research directions are discussed. Recent research has explored the benefits of yoga for individuals with eating disorders (EDs). However, researchers have not yet interviewed clinicians who work with those with EDs regarding their views on using yoga for their clients. This study therefore interviewed 12 clinicians working with individuals with EDs, to obtain their views for using yoga as a therapeutic treatment for this group. Overall, clinicians viewed yoga as a safe and beneficial treatment for EDs. While some concerns were raised regarding the safety of yoga for this group, clinicians emphasised that these could be relieved by a series of key adaptations. This study offers unique insights into how yoga may be safely applied into the care for ED clients, to enhance their treatment approaches and recovery.

Metacognitive interpersonal therapy-eating disorders versus cognitive behavioral therapy for eating disorders for non-underweight adults with eating disorders: study protocol for a pilot pre-registered randomized controlled trial

Eating disorders (ED) are serious disorders characterized by an alteration of eating habits and excessive concern about weight and body shapes (Fairburn, 2002), accompanied by significant impairment inequality of life, high mortality rates and serious organic consequences (Jenkins et al., 2011; Treasure et al., 2015; 2020). Although evidence-based psychological therapies for nonunderweight ED presentations such as cognitive behavioral therapy for eating disorders (CBT-ED) are widely available, there is substantial scope for improvements, particularly in terms of efficacy and adherence. One option is to develop interventions to address elements of pathology not fully addressed by existing empirical supported treatments, such as incorporating techniques aimed at addressing interpersonal problems and personality disorder features into existing treatment delivery. We adapted Metacognitive Interpersonal Therapy, a psychological intervention supported by evidence for treating personality disorders and integrated it with existing CBT techniques for eating disorders (MIT-ED). MIT-ED targets aspects of ED that are not included in the transdiagnostic CBT-E model such as poor metacognition, or maladaptive interpersonal schemas. This is a pre-registered (Protocol number: 0000781) pilot randomized clinical trial aimed at assessing acceptability and feasibility of MIT-ED and establishing preliminary evidence of effectiveness for future larger studies. Twenty patients (10 in each arm) will be randomized to 20 sessions of individual psychotherapy, either MIT-ED or CBTE. Repeated follow-ups will be collected up to 24 months. Participants are recruited at a private outpatient clinic for ED treatment. Acceptability will be assessed via session attendance, completion rates and preliminary outcomes. The primary outcome is ED pathology assessed with the Eating Disorder Examination Questionnaire-6. Other ED outcomes assessed will be eating disorder attitudes, clinical impairment and binge eating pathology. Secondary treatment outcomes are anxiety, depression, and global symptomatology. We will also assess emotional awareness, emotion regulation and therapeutic alliance. Based on previous studies of MIT for personality disorders we hypothesize that MIT-ED will be acceptable to patients, evidenced by high treatment adherence and retention. We hypothesize that MIT-ED will be associated with reductions in eating disorder pathology, at least equivalent to CBT-E. Results will be used to inform the study design, sampling, likely effect sizes and choice of outcome measures for future larger trials of MIT-ED in ED samples.

Cognitive behavioral therapy for eating disorders: A map of the systematic review evidence base

OBJECTIVE

To map and examine the systematic review evidence base regarding the effects of cognitive-behavioral therapy (CBT) for eating disorders (EDs), especially against active interventions.

METHOD

This systematic review is an extension of an overview of CBT for all health conditions (CBT-O). We identified ED-related systematic reviews from the CBT-O database and performed updated searches of EMBASE, MEDLINE, and PsychInfo in April 2021 and September 2022.

RESULTS

The 44 systematic reviews included (21 meta-analyses) were of varying quality. They focused on "high intensity" CBT, delivered face-to-face by qualified clinicians, in BN, BED and mixed, not specifically low-weight samples. ED-specific outcomes were studied most, with little consensus on their operationalization. The, often insufficient, reporting of sample characteristics did not allow assessment of the generalizability of findings. The meta-analytic syntheses show that high intensity one-to-one CBT produces better short-term effects than a mix of active controls especially on ED-specific measures for BED, BN, and transdiagnostic samples. There is little evidence favoring group CBT or low intensity CBT against other active interventions.

DISCUSSION

While this study found evidence consistent with current ED treatment recommendations, it highlighted notable gaps that need to be addressed. There were insufficient data to allow generalizations regarding sex and gender, age, culture and comorbidity and to support CBT in AN samples. The evidence for group CBT and low intensity CBT against active controls is limited, as it is for the longer-term effects of CBT. Our findings identify areas for future innovation and research within CBT.

PUBLIC SIGNIFICANCE

This study provides a comprehensive mapping and quality assessment of the current large systematic review research base regarding the effects of cognitive behavioral therapy (CBT) for eating disorders (EDs), with a focus on comparisons to other active interventions. By transcending the more limited scope of individual systematic reviews, this overview highlights the gaps in the current evidence base, and thus provides guidance for future research and clinical innovation.

Case report: Changes in defense mechanisms, personality functioning, and body mass index during psychotherapy with patients with anorexia nervosa

Eating disorders (EDs) are difficult to treat in psychotherapy due to their pervasive symptomatology and frequent and rapid relapses. Restrictive anorexia nervosa (AN) is the most challenging ED, often associated with severe physical and mental conditions. Perceived as an ego-syntonic syndrome that somehow protects the patient from a number of developmental tasks, treating AN requires extensive multidisciplinary long-term intervention. As with other emotion regulation strategies, defense mechanisms mediate an individual's reaction to internal or external stressors, including those related to ED conditions. Improving defensive functioning adaptiveness predicts psychotherapy outcomes and is an essential component of the therapeutic process. In this study, we qualitatively described changes in the use of defense mechanisms, personality functioning (PF), and body mass index (BMI) in two patients with severe AN in treatment with intense dynamic psychotherapy. Changes in personality functioning and defense mechanisms were periodically assessed every 6 months using clinician report measures such as the Shedler-Westen Assessment Procedure-200 (SWAP-200) and the Defense Mechanisms Rating Scales Q-sort (DMRS-Q), respectively. BMI was also monitored throughout the treatment. A qualitative description of the patient's defensive profile and the quantitative score on all ranges of defense mechanisms were used for studying changes in patients' use of defenses during the treatment and relationships between defenses and outcome indexes. Personality and defensive functioning improved after 1 year of intense dynamic psychotherapy, independently from BMI improvement. All outcome indexes dramatically decreased before a scheduled interruption of the treatment, underling that an integrated therapeutic approach is essential for improving and eventually orienting toward complete ED symptoms remission. Long-term dynamic psychotherapy fosters self-awareness of psychological distress and enhances more mature ways of coping. Monitoring changes in personality and defense mechanisms helps in understanding patients' reactions to stressful life events and in developing specific therapeutic interventions.

Comparing randomized controlled trials of outpatient family-based or inpatient multimodal treatment followed by outpatient care in youth with anorexia nervosa: Differences in populations, metrics, and outcomes

OBJECTIVE

Various approaches exist to treat youth with anorexia nervosa (AN). Family-based treatment (FBT) has never been compared to long inpatient, multimodal treatment (IMT) in a randomized controlled trial (RCT). The aim of this study was to compare data on body weight trajectories, change in eating disorder psychopathology, hospital days and treatment costs in RCTs delivering FBT or IMT.

METHOD

Review of RCTs published between 2010 and 2020 in youth with AN, delivering FBT or IMT.

RESULTS

Four RCTs delivering FBT (United States, n = 2; Australia, n = 2), one RCT delivering Family Therapy for AN (United Kingdom) and two RCTs delivering IMT (France, n = 1; Germany, n = 1) were identified from previous meta-analyses. The comparison of studies was limited by (1) significant differences in patient baseline characteristics including pretreated versus non-pretreated patients, (2) use of different psychometric and weight measures and (3) different initial velocity of weight recovery. Minimal baseline and outcome reporting standards for body weight metrics and nature/dose of interventions allowing international comparison are needed and suggestions to developing these standards are presented.

DISCUSSION

An RCT should investigate, whether FBT is a viable alternative to IMT, leading to comparable weight and psychopathology improvement with less inpatient time and costs.

Integration of hatha yoga and evidence-based psychological treatments for common mental disorders: An evidence map

BACKGROUND

Interest in the use of yoga to enhance engagement with and augment the benefits of psychological treatment has grown. However, a systematic approach to reviewing existing research examining the use of yoga with psychological treatment is lacking.

MATERIALS AND METHODS

This mapping review identified and synthesised research trialling yoga as an integrated or adjunct therapy with evidence-based psychological interventions for the treatment of anxiety, depression, PTSD, and eating disorders.

RESULTS

Overall, the review identified ten published and three unpublished studies, representing either single group or small quasi-experimental research designs.

DISCUSSION

Limited but promising findings were shown for yoga with CBT for anxiety and depression, and the integration of yoga within intensive treatment models for PTSD.

CONCLUSIONS

Future research is encouraged to focus on controlled trials that enable examination of the component effect of yoga when applied with evidence-based psychological treatment and acceptability and feasibility data to further knowledge regarding a role for yoga in clinical practice.

Risk and resilience factors for specific and general psychopathology worsening in people with Eating Disorders during COVID-19 pandemic: a retrospective Italian multicentre study

PURPOSE

The COVID-19 pandemic restrictions had negative impact on the psychopathology of people with Eating Disorders (EDs). Factors involved in the vulnerability to stressful events have been under-investigated in this population. We aimed to assess which factors contributed to COVID-19-induced worsening in both general and specific psychopathology.

METHODS

Three-hundred and twelve people with a clinically defined diagnosis of an ED and undergoing a specialist ED treatment in different Italian ED services before the spreading of COVID-19 pandemic filled in an online survey. ED specific and general psychopathology changes after COVID-19 quarantine were retrospectively evaluated. Factors related to COVID-19 concerns (financial condition, fear of contagion, perceived social isolation/support, satisfaction in peer, family or sentimental relationships), illness duration and treatment-related variables (type of treatment provided, type of access to care, satisfaction with therapeutic relationships) were included as predicting factors in a structural equational model, which included latent variables consisting of general and ED psychopathology items as outcomes.

RESULTS

A perceived low quality of therapeutic relationships, fear of contagion and increased isolation were positively associated with psychopathology worsening. Reduced satisfaction with family and with friends' relationships and reduced perceived social support were associated with ED and general symptoms deterioration, respectively. No significant effect emerged for intimate relationships, illness duration, economic condition and type of treatment.

CONCLUSIONS

This study provides a comprehensive evaluation of clinical variables associated with psychopathological changes during the COVID-19 lockdown period highlighting potential risk and resilience factors and, possibly, informing treatment as well as prevention strategies for EDs.

LEVEL OF EVIDENCE IV

Evidence obtained from multiple time series analysis such as case studies.

Early maladaptive schemas in eating disorders: A systematic review

OBJECTIVE

Research and theory suggest the aetiological nature and symptomatic profile of eating disorders (EDs) can be explained by multiple factors, including the development of early maladaptive schemas (EMS). Yet, there is lack of consensus regarding the evidence supporting the relationship between EMS and EDs. Therefore, this systematic review aimed to examine existing literature concerning the relationship between different ED diagnoses and EMS to provide a synthesis and evaluation of relevant research.

METHOD

A comprehensive literature search of four electronic databases was conducted and studies were included that examined the association between EMS and EDs. Studies were required to use a variant of Young Schema Questionnaire and establish ED diagnosis or symptomology using self-report questionnaires or clinical interview.

RESULTS

A total of 29 studies were included in the review. Compared to healthy controls and varying clinical populations, individuals with EDs generally reported significantly higher scores across all EMS except for Entitlement. Furthermore, Unrelenting Standards consistently appeared as a significant EMS across all ED diagnoses whilst Insufficient Self-Control was significantly lower in ED diagnoses with restrictive behaviour compared to diagnoses with binge eating or purging behaviour.

DISCUSSION

Research supports significant associations between EMS and EDs, which may contribute to our understanding of ED aetiology, including different diagnostic categories. This review underscores the need for studies to explore more gender and age diverse samples and highlights important implications for practitioners.

Patients' Experience of Attending a Binge Eating Group Program - Qualitative Evaluation of a Pilot Study

We developed a group program for patients with binge eating disorders (BED), comprising cognitive therapy, affect consciousness, and therapeutic writing. We wished to investigate how therapeutic writing and affect consciousness were experienced by the patients when integrated in a cognitive behavioral therapy (CBT) program. To our knowledge, such an intervention has not been tried in patients with BED. Aim: To explore patients’ experience of attending a binge eating group program comprising therapeutic writing, affect consciousness, and CBT. Research question: How do patients evaluate their experience of attending an integrative binge eating group program? Method: A qualitative design using an evaluative focus group interview with participants (four women and two men) who had completed the pilot program. Results: Three themes emerged: Enhanced self-awareness about the meaning of feelings; A more generous attitude towards oneself; and On the path to a better grip on the eating difficulties. Discussion: We interpreted the three themes in light of transition processes. The program was described as an essential part of the healing process and seems valuable for enabling new approaches leading to therapeutic changes when suffering from BED.

Personality as a predictor of symptomatic change in a residential treatment setting for anorexia nervosa and bulimia nervosa

PURPOSE

Although personality has been widely researched in patients with anorexia nervosa (AN) and bulimia nervosa (BN), the nature of this relationship has not yet been clearly articulated. The pathoplasty model theorizes that personality might shape symptomatic presentation and thus affect therapeutic outcomes, but more research is needed. The present study aimed at investigating the predictive value of a broad spectrum of personality traits in determining AN and BN treatment outcomes, considering both the statistical and clinical significance of the therapeutic change.

METHODS

Eighty-four female patients with AN and BN treated in a residential program were evaluated at treatment onset using the Shedler-Westen Assessment Procedure-200-a clinician-rated measure of personality disorders and healthy personality functioning. At both intake and discharge, patients completed the Eating Disorder Inventory-3 to assess eating symptoms and the Outcome Questionnaire-45.2 to evaluate overall impairment.

RESULTS

Considering overall ED symptomatic change, multiple regression analyses showed that, even when controlling for baseline symptoms and DSM-5 categories, schizoid (B = 0.41, p ≤ 0.01), avoidant (B = 0.31, p ≤ 0.05), and paranoid (B = 0.25, p ≤ 0.05) personality features predicted worse therapeutic outcomes. Similar results were found when applying the clinical significance approach, with the emotionally dysregulated factor as an additional negative predictor of significant/reliable change (B =  - 0.09; p < 0.01). Healthy personality functioning predicted better therapeutic outcomes (B =  - 0.34, p ≤ 0.001).

CONCLUSIONS

Pathoplastic models and personality-based research in this clinical population have the potential to inform effective treatment strategies by targeting relevant individual factors.

LEVEL OF EVIDENCE

Level III, longitudinal cohort study.

Cognitive-behavioural therapy for a variety of conditions: an overview of systematic reviews and panoramic meta-analysis

BACKGROUND

Cognitive-behavioural therapy aims to increase quality of life by changing cognitive and behavioural factors that maintain problematic symptoms. A previous overview of cognitive-behavioural therapy systematic reviews suggested that cognitive-behavioural therapy was effective for many conditions. However, few of the included reviews synthesised randomised controlled trials.

OBJECTIVES

This project was undertaken to map the quality and gaps in the cognitive-behavioural therapy systematic review of randomised controlled trial evidence base. Panoramic meta-analyses were also conducted to identify any across-condition general effects of cognitive-behavioural therapy.

DATA SOURCES

The overview was designed with cognitive-behavioural therapy patients, clinicians and researchers. The Cochrane Library, MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Child Development & Adolescent Studies, Database of Abstracts of Reviews of Effects and OpenGrey databases were searched from 1992 to January 2019.

REVIEW METHODS

Study inclusion criteria were as follows: (1) fulfil the Centre for Reviews and Dissemination criteria; (2) intervention reported as cognitive-behavioural therapy or including one cognitive and one behavioural element; (3) include a synthesis of cognitive-behavioural therapy trials; (4) include either health-related quality of life, depression, anxiety or pain outcome; and (5) available in English. Review quality was assessed with A MeaSurement Tool to Assess systematic Reviews (AMSTAR)-2. Reviews were quality assessed and data were extracted in duplicate by two independent researchers, and then mapped according to condition, population, context and quality. The effects from high-quality reviews were pooled within condition groups, using a random-effect panoramic meta-analysis. If the across-condition heterogeneity was I2 < 75%, we pooled across conditions. Subgroup analyses were conducted for age, delivery format, comparator type and length of follow-up, and a sensitivity analysis was performed for quality.

RESULTS

A total of 494 reviews were mapped, representing 68% (27/40) of the categories of the International Classification of Diseases, Eleventh Revision, Mortality and Morbidity Statistics. Most reviews (71%, 351/494) were of lower quality. Research on older adults, using cognitive-behavioural therapy preventatively, ethnic minorities and people living outside Europe, North America or Australasia was limited. Out of 494 reviews, 71 were included in the primary panoramic meta-analyses. A modest effect was found in favour of cognitive-behavioural therapy for health-related quality of life (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.05 to 0.50, I2 = 32%), anxiety (standardised mean difference 0.30, 95% confidence interval 0.18 to 0.43, prediction interval -0.28 to 0.88, I2 = 62%) and pain (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.28 to 0.74, I2 = 64%) outcomes. All condition, subgroup and sensitivity effect estimates remained consistent with the general effect. A statistically significant interaction effect was evident between the active and non-active comparator groups for the health-related quality-of-life outcome. A general effect for depression outcomes was not produced as a result of considerable heterogeneity across reviews and conditions.

LIMITATIONS

Data extraction and analysis were conducted at the review level, rather than returning to the individual trial data. This meant that the risk of bias of the individual trials could not be accounted for, but only the quality of the systematic reviews that synthesised them.

CONCLUSION

Owing to the consistency and homogeneity of the highest-quality evidence, it is proposed that cognitive-behavioural therapy can produce a modest general, across-condition benefit in health-related quality-of-life, anxiety and pain outcomes.

FUTURE WORK

Future research should focus on how the modest effect sizes seen with cognitive-behavioural therapy can be increased, for example identifying alternative delivery formats to increase adherence and reduce dropout, and pursuing novel methods to assess intervention fidelity and quality.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017078690.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 9. See the NIHR Journals Library website for further project information.

Yoga and eating disorder prevention and treatment: A comprehensive review and meta-analysis

Yoga is frequently used in conjunction with standard treatment approaches for eating disorders. However, yoga's efficacy and effectiveness in preventing and treating eating disorders has remained unclear. The aim of this comprehensive review and meta-analysis is to review the extant literature and assess the effects of yoga in the prevention and intervention of eating disorder symptoms and correlates in both clinical and non-clinical populations. Studies assessing yoga and its effect on eating disorder symptoms and/or body image as related to disordered eating, were eligible for inclusion. The comprehensive review details correlational, non-controlled, non-randomized controlled, and yoga comparison studies. For the meta-analysis, only randomized controlled trials comparing a yoga-based intervention to a non-yoga control group were included. In total, 43 studies are included in this review, with 11 trials involving 754 participants included in the meta-analysis. Results of the comprehensive review and meta-analyses results indicated yoga interventions demonstrated a small, significant effect on global eating disorder psychopathology, a moderate-to-large effect on binge eating and bulimia, and a small effect on body image concerns, as compared to the control conditions. There was no statistically significant effect on dietary restraint in either direction. Additionally, results indicated a small-to-moderate effect on a composite measure of eating disorder-related constructs. These findings suggest that yoga-based interventions may be an effective approach supporting the prevention and treatment of eating disorders.

An Integrative Approach to Clinical Decision-Making for Treating Patients With Binge-Eating Disorder

Transtheoretical integrative decision-making models help clinicians to use patient factors that are known to predict outcomes in order to inform individualized treatment. Patient factors with a strong evidence base include: functional impairment, social support and interpersonal functioning, complexity and comorbidity, coping style, level of resistance, and level of subjective distress. Among those with binge-eating disorder (BED), patient factors have not been extensively characterized relative to norms or other clinical samples. We used an integrative decision-making model of these six patient factor domains related to patient outcomes to characterize a sample of 424 adults seeking treatment for BED. Data were from medical charts, a demographics questionnaire, and validated psychometric scales. We then compared these data to published data from normative and other eating disorder (ED) samples. Results showed that the average patient with BED: (1) was significantly more functionally impaired compared to non-clinical norms but somewhat less impaired than other patients with ED, (2) demonstrated clinically significant problems in social support and interpersonal functioning, (3) presented with complex comorbid pathology and high levels of chronicity, (4) used a more internalizing coping style compared to the norm and other ED samples, (5) had low levels of resistance to interventions, and (6) experienced a moderately high level of subjective distress indicating good motivation for treatment. Corresponding recommendations to these findings are that the average patient with BED should be provided higher intensity treatment that is longer in duration, interpersonally focused, directive in nature, and emphasizing self-reflection and insight. Despite the nomothetic nature of the findings, clinicians are encouraged to assess these patient domains when developing an ideographic case conceptualization and to tailor precision treatment to the individual patient with BED.

The Role of Common Factors in Psychotherapy Outcomes

Psychotherapies may work through techniques that are specific to each therapy or through factors that all therapies have in common. Proponents of the common factors model often point to meta-analyses of comparative outcome studies that show all therapies have comparable effects. However, not all meta-analyses support the common factors model; the included studies often have several methodological problems; and there are alternative explanations for finding comparable outcomes. To date, research on the working mechanisms and mediators of therapies has always been correlational, and in order to establish that a mediator is indeed a causal factor in the recovery process of a patient, studies must show a temporal relationship between the mediator and an outcome, a dose–response association, evidence that no third variable causes changes in the mediator and the outcome, supportive experimental research, and have a strong theoretical framework. Currently, no common or specific factor meets these criteria and can be considered an empirically validated working mechanism. Therefore, it is still unknown whether therapies work through common or specific factors, or both.

The quality of randomized controlled trials of psychotherapy for eating disorders

OBJECTIVE

We investigated the quality of randomized controlled trials (RCTs) that included direct comparisons of psychotherapy for adults with an eating disorder (ED).

METHOD

Thirty-five direct comparison RCTs of psychotherapy for adults diagnosed with an ED were rated using the Randomized Controlled Trials Psychotherapy Quality Rating Scale (RCT-PQRS).

RESULTS

The mean total RCT-PQRS score (mean = 28.26; SD = 7.04) was in line with those that were reported for RCTs of psychotherapy for depression and anxiety disorders. Several standards of quality were unfulfilled by over half of the RCTs of treatment for EDs, including therapist supervision while treatment was being provided (62.9% unfulfilled); outcome assessment performed by raters blind to treatment group/condition (54% unfulfilled); and adequate sample size (66% unfulfilled). More recent RCTs were of higher quality, and higher quality was moderately associated with lower effect sizes.

CONCLUSIONS

To improve the quality of RCTs of psychotherapy of EDs, we recommend that researchers address the quality criteria listed in the RCT-PQRS. Psychotherapy trials should be registered, have a published protocol, and be reported following the Consolidated Standards of Reporting Trials guidelines. Authors should take into account the quality of the research when using that research to inform ED treatment guidelines.