Acceptance and commitment therapy versus cognitive therapy for the treatment of comorbid eating pathology

Conceptual, Psychometric, Methodological and Value Problems in Acceptance and Commitment Therapy: Introduction to the Special Section, "A Critical Appraisal of Acceptance and Commitment Therapy"

There is a voluminous and expanding literature regarding ACT, from descriptions of its theory to its stated roots in relational frame theory, the particulars of its therapy techniques and exercises, favored metaphors, randomized controlled trials, to many self-help books for a wide variety of problems. The therapy is widely marketed through workshops and many self-help books. ACT is associated with its own journal and its own professional organization, the Association for Contextual Behavioral Science (ACBS). This literature is interpreted by ACT proponents as demonstrating the causal efficacy of ACT for a wide range of problems and, at times, even being superior to treatment as usual, which are often more traditional forms of cognitive behavior therapy (CBT). This special section contains a series of 6 papers examining these claims. Correctly understanding and evaluating the claims of ACT proponents is warranted because these can have direct implications for treatment decisions by therapists attempting to deliver the most effective treatment for their clients' problems. The papers, individually and as a whole, urge considerable caution, particularly because much of its research has involved serious measurement problems, problematic research designs, and a unique and problematic conceptualization and perhaps the practice of values and ethics. These papers call for methodological improvements and a commitment to more traditional values associated with science so that ACT can be more fairly evaluated to accurately understand its assets and limitations.

Comparison of the effectiveness of acceptance and commitment therapy (ACT) with metacognitive therapy (MCT) in objective cognitive information processing style of obsessive-compulsive patients (OCD)

BACKGROUND

In recent studies, the deficit in the cognitive process has been investigated as one of the etiological hypotheses in a wide range of obsessive-compulsive disorders (OCD). This study aimed to compare the effectiveness of acceptance and commitment therapy (ACT) and metacognitive therapy (MCT) on objective cognitive information processing style in obsessive-compulsive patients.

MATERIALS AND METHODS

This quasi-experimental study with a pre-test and post-test plan and a control group was conducted on 45 patients with OCD, matched with gender, age, and educational and marital status. The samples in three groups were selected using the convenience sampling method. Finally, the study participants were randomly divided into two experimental groups and one control group and assessed using Pacini and Epstein's rational experimental Inventory (REI) in two stages, pre-test, and post-test. The experimental groups received ACT and MCT weekly during eight and seven sessions and in a group.

RESULTS

The results showed that ACT and MCT are effective at a significant level in the objective cognitive information processing style of obsessive-compulsive patients (P < 0.05). The post-test results showed that the effect of ACT in changing rational processing style is more effective than MCT treatment. Also, the effect of ACT on intuitive processing style changes was greater than on MCT treatment.

CONCLUSION

The findings of this study indicate that ACT and MCT cause a significant change in intuitive style to rationalism in the thematic processing of cognitive information of obsessive-compulsive patients. According to the results, both methods of treatment improve the research variables in these patients.

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.

Examining an integrated sociocultural and objectification model of thinness- and muscularity-oriented disordered eating in Chinese older men and women

OBJECTIVE

We tested an integrated model of three prominent theories of disordered eating (tripartite influence theory, objectification theory, and social comparison theory) in a sample of older Chinese men and women.

METHOD

Chinese older men (n = 270) and women (n = 160) completed questionnaires assessing the tripartite influence, objectification, and social comparison theories and thinness- and muscularity-oriented disordered eating. Two structural equation models were tested in Chinese older men and women.

RESULTS

The integrated model showed good model fit and described meaningful variance in thinness- and muscularity-oriented disordered eating in Chinese older men and women. Higher appearance pressures were uniquely related to higher muscularity-oriented disordered eating in men. Across both gender groups, higher thinness internalization was uniquely related to higher thinness- and muscularity-oriented disordered eating, and in women only, higher muscularity internalization was uniquely related to lower thinness-oriented disordered eating. In men, higher upward and downward body image comparisons were uniquely related to higher and lower, respectively, muscularity-oriented disordered eating. In women, higher upward body image comparisons were only uniquely related to higher muscularity-oriented disordered eating while higher downward body image comparisons were uniquely related to both outcomes. Higher body shame was uniquely related to higher thinness-oriented disordered eating across both groups and in men alone, higher body shame was also uniquely related to higher muscularity-oriented disordered eating.

DISCUSSION

Findings, which tested the integration of tripartite influence, objectification, and social comparison theories, inform the prevention and treatment of disordered eating in Chinese older populations.

PUBLIC SIGNIFICANCE

The present study is the first to describe theories of disordered eating (tripartite influence, objectification, and social comparison) in Chinese older adults. Findings suggested good model fit and the integrated models described meaningful variance in thinness- and muscularity-oriented disordered eating in Chinese older women and men. Findings extend existing theories of disordered eating and, pending further study, may inform theory-driven prevention and treatment approaches in Chinese older adults.

The integrated treatment of eating disorders, posttraumatic stress disorder, and psychiatric comorbidity: a commentary on the evolution of principles and guidelines

Psychiatric comorbidity is the norm in the assessment and treatment of eating disorders (EDs), and traumatic events and lifetime PTSD are often major drivers of these challenging complexities. Given that trauma, PTSD, and psychiatric comorbidity significantly influence ED outcomes, it is imperative that these problems be appropriately addressed in ED practice guidelines. The presence of associated psychiatric comorbidity is noted in some but not all sets of existing guidelines, but they mostly do little to address the problem other than referring to independent guidelines for other disorders. This disconnect perpetuates a "silo effect," in which each set of guidelines do not address the complexity of the other comorbidities. Although there are several published practice guidelines for the treatment of EDs, and likewise, there are several published practice guidelines for the treatment of PTSD, none of them specifically address ED + PTSD. The result is a lack of integration between ED and PTSD treatment providers, which often leads to fragmented, incomplete, uncoordinated and ineffective care of severely ill patients with ED + PTSD. This situation can inadvertently promote chronicity and multimorbidity and may be particularly relevant for patients treated in higher levels of care, where prevalence rates of concurrent PTSD reach as high as 50% with many more having subthreshold PTSD. Although there has been some progress in the recognition and treatment of ED + PTSD, recommendations for treating this common comorbidity remain undeveloped, particularly when there are other co-occurring psychiatric disorders, such as mood, anxiety, dissociative, substance use, impulse control, obsessive-compulsive, attention-deficit hyperactivity, and personality disorders, all of which may also be trauma-related. In this commentary, guidelines for assessing and treating patients with ED + PTSD and related comorbidity are critically reviewed. An integrated set of principles used in treatment planning of PTSD and trauma-related disorders is recommended in the context of intensive ED therapy. These principles and strategies are borrowed from several relevant evidence-based approaches. Evidence suggests that continuing with traditional single-disorder focused, sequential treatment models that do not prioritize integrated, trauma-focused treatment approaches are short-sighted and often inadvertently perpetuate this dangerous multimorbidity. Future ED practice guidelines would do well to address concurrent illness in more depth.

Optimizing relapse prevention and changing habits (REACH+) in anorexia nervosa

INTRODUCTION

Relapse rates in anorexia nervosa (AN) are high, even after full weight restoration. This study aims to develop a relapse prevention treatment that specifically addresses persistent maladaptive behaviors (habits). Relapse Prevention and Changing Habits (REACH+) aims to support patients in developing routines that promote weight maintenance, encourage health, and challenge habits that perpetuate illness. The clinical trial design uses the Multiphase Optimization STrategy (MOST) framework to efficiently identify which components of treatment contribute to positive outcomes.

METHODS

Participants will be 60 adults with AN who have achieved weight restoration in an inpatient setting. Treatment will consist of 6 months of outpatient telehealth sessions. REACH+ consists of behavior, cognitive, and motivation components, as well as food monitoring and a skill consolidation phase. A specialized online platform extends therapy between sessions. Participants will be randomly assigned to different versions of each component in a fractional factorial design. Outcomes will focus on maintenance of remission, measured by rate of weight loss and end-of-trial status. Interventions that contribute to remission will be included in an optimized treatment package, suitable for a large-scale clinical trial of relapse prevention in AN.

Mindfulness, disordered eating, and impulsivity in relation to glycemia among adolescents with type 1 diabetes and suboptimal glycemia from the Flexible Lifestyles Empowering Change (FLEX) intervention trial

OBJECTIVE

To assess the relationship between mindfulness and glycemia among adolescents with type 1 diabetes (T1D) with suboptimal glycemia, and evaluate the potential mediation by ingestive behaviors, including disordered eating, and impulsivity.

RESEARCH DESIGN AND METHODS

We used linear mixed models for hemoglobin A1c (HbA1c) and linear regression for continuous glucose monitoring (CGM) to study the relationship of mindfulness [Child and Adolescent Mindfulness Measure (CAMM)] and glycemia in adolescents with T1D from the 18-month Flexible Lifestyles Empowering Change (FLEX) trial. We tested for mediation of the mindfulness-glycemia relationship by ingestive behaviors, including disordered eating (Diabetes Eating Problem Survey-Revised), restrained eating, and emotional eating (Dutch Eating Behavior Questionnaire); and impulsivity (total, attentional, and motor, Barrett Impulsiveness Scale).

RESULTS

At baseline, participants (n = 152) had a mean age of 14.9 ± 1.1 years and HbA1c of 9.4 ± 1.2% [79 ± 13 mmol/mol]. The majority of adolescents were non-Hispanic white (83.6%), 50.7% were female, and 73.0% used insulin pumps. From adjusted mixed models, a 5-point increase in mindfulness scores was associated with a -0.19% (95%CI -0.29, -0.08, p = 0.0006) reduction in HbA1c. We did not find statistically significant associations between mindfulness and CGM metrics. Mediation of the relationship between mindfulness and HbA1c by ingestive behaviors and impulsivity was not found to be statistically significant.

CONCLUSIONS

Among adolescents with T1D and suboptimal glycemia, increased mindfulness was associated with lower HbA1c levels. Future studies may consider mindfulness-based interventions as a component of treatment for improving glycemia among adolescents with T1D, though more data are needed to assess feasibility and efficacy.

Randomized Clinical Trial Evaluating AcceptME-A Digital Gamified Acceptance and Commitment Early Intervention Program for Individuals at High Risk for Eating Disorders

Eating disorders (ED) constitute a serious public health issue affecting predominantly women and appearing typically in adolescence or early adulthood. EDs are extremely difficult to treat, as these disorders are ego-syntonic, and many patients do not seek treatment. It is vital to focus on the development of successful early-intervention programs for individuals presenting at risk and are on a trajectory towards developing EDs. This study is a randomized controlled trial evaluating an innovative digital gamified Acceptance and Commitment early-intervention program (AcceptME) for young females showing signs and symptoms of an ED and at high risk for an ED. Participants (n = 92; Mage = 15.30 years, SD = 2.15) received either AcceptME (n = 62) or a waitlist control (n = 30). Analyses indicated that the AcceptME program effectively reduced weight and shape concerns with large effects when compared to waitlist controls. Most participants scored below the at-risk cut-off (WCS score < 52) in the AcceptME at end-of-intervention (57.1%) compared to controls (7.1%), with odds of falling into the at-risk group being 14.5 times higher for participants in the control group. At follow-up, 72% of completers reported scores below the at-risk cut-off in the AcceptME group. The intervention also resulted in a decrease in ED symptomatology and increased body image flexibility. Overall, results suggest that the AcceptME program holds promise for early-intervention of young women at risk for developing an ED.

ACTonFood. Acceptance and Commitment Therapy-Based Group Treatment Compared to Cognitive Behavioral Therapy-Based Group Treatment for Weight Loss Maintenance: An Individually Randomized Group Treatment Trial

The purpose of this Individually Randomized Group Treatment Trial was to compare an Acceptance and Commitment Therapy-based (ACT) group intervention and a Cognitive Behavioral Therapy-based (CBT) group intervention for weight loss maintenance in a sample of adult patients with obesity seeking treatment for weight loss. One hundred and fifty-five adults (BMI: Kg/m² = 43.8 [6.8]) attending a multidisciplinary rehabilitation program for weight loss were randomized into two conditions: ACT and CBT. Demographical, physical, and clinical data were assessed at the beginning of the program (t₀), at discharge (t₁), and at 6-month follow-up (t₂). The following measures were administered: The Acceptance and Action Questionnaire-II (AAQ-II) and the Clinical Outcome in Routine Evaluation-Outcome Measure (CORE-OM). Generalized linear mixed models were performed to assess differences between groups. Moderation effects for gender and Eating Disorders (ED) have been considered. From baseline to discharge, no significant differences between interventions were found, with the only exception of an improvement in the CORE-OM total score and in the CORE-OM subjective wellbeing subscale for those in the CBT condition. From discharge to follow-up, ACT group participants showed significant results in terms of weight loss maintenance, CORE-OM total score, and CORE-OM and AAQ-II wellbeing, symptoms, and psychological problems subscales. Gender moderated the effects of time and intervention on the CORE-OM subscale reporting the risk for self-harm or harm of others. The presence of an eating disorder moderated the effect of time and intervention on the CORE-OM total score, on the CORE-OM symptoms and psychological problems subscales, and on the AAQ-II. Patients who received the ACT intervention were more likely to achieve a ≥5% weight loss from baseline to follow-up and to maintain the weight loss after discharge. The ACT intervention was thus effective in maintaining weight loss over time.

The relationship between body weight and dietary restraint is explained by body dissatisfaction and body image inflexibility among young adults in China

OBJECTIVE

Eating disorders and obesity are commonly recognized as key public health concerns worldwide. Although rates of obesity and disordered eating have traditionally been lower in China than Western countries, these rates are on the rise. As such, interest is growing in identifying mechanisms that may address these conditions. While associations between body weight and dissatisfaction are well established, burgeoning research aims to examine how these factors are related to dietary restraint and body image inflexibility. This study aimed to explore the possible mediation effect of body dissatisfaction and body image inflexibility between body weight (body mass index) and dietary restraint. Furthermore, we explored how these relationships differed across men and women.

METHODS

A sample of 1068 young adults (563 females and 505 males) in China participated in the study. Participants completed the Eating Disorder Inventory and Three-Factor Eating Questionnaire as well as the Body Image-Acceptance and Action Questionnaire.

RESULTS

Results showed that: (1) body dissatisfaction and body image inflexibility fully mediated the relationship between body mass index and dietary restraint; (2) this model fit both genders, although differences were found in the regression coefficients between the mediation model for men and women.

CONCLUSION

These findings support body image dissatisfaction and inflexibility as mediators of the relationship between body weight and dietary restraint, highlighting these as potential mechanisms for treatment.

LEVEL OF EVIDENCE

Level III, case-control analytic study.

Relative associations of body image avoidance constructs with eating disorder pathology in a large college student sample

Models of eating disorder development point to the significant role body image avoidance plays in the development and perpetuation of eating disorder pathology (EDP), highlighting the importance of continued conceptual development. For example, approaches to assessing and conceptualizing body image avoidance vary in the extent to which they emphasize topography (i.e., common forms of avoidance), or their function (i.e., the conditions under which they occur). This study considered four body image avoidance constructs and their relative incremental contribution to predicting concurrent EDP in a college student population (N = 1228). Participants self-reported both the form and function of body image avoidance, including specific behaviors, appearance fixing and avoidant coping, and body image flexibility. A measure of the form of body image avoidance emerged as the best predictor of EDP, both in terms of consistently predicting aspects of disordered eating and in terms of accounting for the largest proportions of unique variance. Body image flexibility also contributed significantly to the prediction of cognitive and emotional aspects of concurrent EDP above and beyond self-report of common forms of avoidance only. Both form and function may be important when assessing and intervening on body image avoidance to prevent EDP.

Cognitive Restructuring vs. Defusion: Impact on craving, healthy and unhealthy food intake

Coping with food cravings is crucial for weight management. Individuals tend to use avoidance strategies to resist food cravings and prevent overeating, but such strategies may not result in the benefits sought. This study compared the effects of two cognitive techniques (Restructuring vs. Defusion) for dealing with food cravings in terms of their impact on healthy vs. unhealthy eating behavior (i.e., consumption of chocolate and/or carrots following the intervention). Sixty-five participants (M_age = 19.65 years) received either a 30-minute face-to-face instruction on cognitive restructuring (CR) or cognitive defusion (CD) along with 15 min of practice, or 45 min of obesity education and discussion (control). To examine craving and eating choices following the intervention, participants received bags of chocolate and carrots and were asked to carry these with them at all times over the next week, exchanging the bags every 2 days. Participants in the CD group ate fewer chocolates (M = 11.74) compared to CR (M = 17.06) and Control groups (M = 29.18) during the experimental week. The groups did not differ in number of carrot pieces eaten, though the CD group ate more carrots than chocolates. CD resulted in fewer self-reported cravings compared to CR and CO groups. At a final taste test, both CD and CR groups ate significantly fewer chocolates compared to the CO group. CD appears to be an effective technique in managing food craving and to present some advantages over CR.

The unique associations between self-compassion and eating disorder psychopathology and the mediating role of rumination

Mindfulness reduces eating disorder (ED) psychopathology. Self-compassion is a related but distinct construct that may predict other clinical outcomes more strongly than does mindfulness. Previous evidence suggests that self-compassion is associated with less ED psychopathology, although no studies have compared the unique effects of self-compassion and mindfulness. Moreover, few studies have explored mechanisms of this association. The current survey study explored the unique association between self-compassion and ED psychopathology, controlling for mindfulness, as well as whether depressive rumination mediates this association. One hundred and ninety undergraduates completed questionnaires assessing self-compassion, mindfulness, depressive rumination, and ED psychopathology at baseline and five months later. In cross-sectional and longitudinal analyses, self-compassion predicted ED psychopathology even when controlling for mindfulness. By contrast, mindfulness did not predict ED psychopathology when controlling for self-compassion. Depressive rumination mediated the unique association between self-compassion and ED psychopathology in cross-sectional but not longitudinal analyses. The current findings suggest that self-compassion may be a more proximal predictor of ED psychopathology than is mindfulness. Additional research will need to further explore whether depressive rumination is a mechanism of this effect.

Evaluation of Weigh Forward: A group intervention delivered by dietitians and psychologists within a National Health Service specialist weight management service

There is limited evidence of the effectiveness of non-surgical interventions for severe obesity. Our aim was to evaluate a group intervention delivered by a National Health Service (NHS) specialist weight management service to contribute to the evidence base and inform the development of future services. Participants in this prospective cohort study were patients attending NHS Grampian Specialist Weight Management Services. The intervention was an interactive 12-session group programme based on evidence-based psychological model, with combined dietetic and psychological knowledge and support provided. The primary outcome was mean weight change at the end of the intervention and for 12-mo follow-up (including programme completers, baseline observation carried forward [BOCF], last observation carried forward). Secondary outcome measures included mood, anxiety, binge eating and quality of life. A total of 166 patients accepted a place on the group programme, mean body mass index was 48.9 kg/m² . Mean weight loss at 6 mo was 5.6 kg and 35.2% of those who completed the group (n = 88) lost ≥5%. Using BOCF, 18.7% lost ≥5% at 6 mo. Those who remained in the programme maintained their weight loss 12 and 18 mo after the start of the intervention. Significant improvements were also found in psychological variables, including reduced depression, anxiety, binge eating and improved emotion regulation. This real-world evaluation of an NHS intervention for patients with severe obesity suggests that individuals who engage achieve a moderate weight loss, which most maintain a year later, although further research is needed to strengthen this conclusion.

Distress tolerance across self-report, behavioral and psychophysiological domains in women with eating disorders, and healthy controls

BACKGROUND AND OBJECTIVES

The tendency to engage in impulsive behaviors when distressed is linked to disordered eating. The current study comprehensively examines emotional responses to a distress tolerance task by utilizing self-report, psychophysiological measures (respiratory sinus arrhythmia [RSA], skin conductance responses [SCRs] and tonic skin conductance levels [SCLs]), and behavioral measures (i.e., termination of task, latency to quit task).

METHODS

26 healthy controls (HCs) and a sample of treatment-seeking women with Bulimia Nervosa (BN), Binge Eating Disorder (BED) and Anorexia Nervosa (AN) (N = 106) completed the Paced Auditory Serial Addition Task- Computerized (PASAT-C). Psychophysiological measurements were collected during baseline, PASAT-C, and recovery, then averaged for each time period. Self-reported emotions were collected at baseline, post-PASAT-C and post-recovery.

RESULTS

Overall, we found an effect of Time, with all participants reporting greater negative emotions, less happiness, lower RSA, more SCRs and higher tonic SCLs after completion of the PASAT-C relative to baseline. There were no differences in PASAT-C performance between groups. There was an effect of Group for negative emotions, with women with BN, BED and AN reporting overall higher levels of negative emotions relative to HCs. Furthermore, we found an effect of Group for greater urges to binge eat and lower RSA values among BED, relative to individuals with BN, AN and HCs.

LIMITATIONS

This study is cross-sectional and lacked an overweight healthy control group.

CONCLUSION

During the PASAT-C, individuals with eating disorders (EDs) compared to HCs report higher levels of negative emotions, despite similar physiological and behavioral manifestations of distress.

Turning the Corner: A Comparison of Collegiate Athletes’ and Non-Athletes’ Turning Points in Eating Disorder Recovery

The purpose of this qualitative study was to identify turning points in eating disorder recovery in collegiate female athletes compared to non-athletes. The sample included 12 varsity athletes and 17 non-athlete college students who previously met criteria for Anorexia Nervosa (AN; n = 17); Bulimia Nervosa (BN; n = 3); Binge Eating Disorder (n = 1); or both AN and BN (n = 8). Participants completed individual interviews and responses were analyzed inductively. There was some commonality in the athletes’ and non-athletes’ experiences. For example, the most frequent turning point for both groups was Insight/Self Realization. Regarding the next three most frequent turning points, athletes reported Sport Performance, Confrontation, and Support/Concern from Others, whereas non-athletes reported Professional Treatment, Hitting a Low, and Support/Concern from Others. This study contributes to the sparse literature on competitive athletes’ recovery. Results indicated that athletes’ turning points differed from non-athletes; therefore, findings are discussed concerning athlete-specific treatment recommendations and suggestions for coaches.

Factors that assist and hinder efforts towards recovery from eating disorders: A comparison of collegiate female athletes and non-athletes

This study compared female intercollegiate athletes' and non-athletes' experiences of working towards recovery from an eating disorder. Participants (55 athletes, 99 non-athletes) responded to open-ended questions about factors that influenced their progress towards recovery. Both subgroups reported that Supportive Relationships and Cognitive/Emotional Shifts were most helpful. The third most frequent helpful factor for athletes was Sport Performance Concerns, for non-athletes it was Treatment. Athletes' most frequent hindering factors were Negative Emotions/Cognitions, Sport Pressures, and Hurtful Modelling, while non-athletes reported Negative Emotions/Cognitions, Lack of Support, and Hurtful Modelling. Sport-specific factors were among the most common themes in athletes' responses; therefore, athletes' recovery experiences and treatment needs appear unique.

Will I get fat? 22-year weight trajectories of individuals with eating disorders

OBJECTIVE

For some, fat phobia or fear of uncontrollable weight gain is diagnostic of eating disorders, often inhibiting treatment engagement and predicting symptom relapse. Prior research has reported weight changes at infrequent or long intervals, but rate, shape, and magnitude of long-term changes remain unknown. Our study examined 22-year longitudinal trajectories of body mass index (BMI) in women with anorexia nervosa (AN) and bulimia nervosa (BN).

METHOD

Participants were followed over 10 years (N = 225) and at 22-year follow-up (N = 175). Using latent growth curves, we examined: (1) shape and rate of intra-individual BMI change over 10 years; (2) predictors of BMI change over 10 years, (3) 22-year BMI outcomes; and (4) BMI changes over 10 years as predictors of 22-year BMI.

RESULTS

The best-fitting model captured overall intra-individual rates of BMI change in three intervals, showing moderate rate of BMI increase from intake to year 2, modest increase from year 2 to 5, and plateau from year 5 to 10. At 22 years, 14% were underweight, 69% were normal weight, and only 17% were overweight or obese. Greater increases from intake to year 2 predicted higher BMI at 22 years (β = 0.43, p < 0.01) and were predicted by intake diagnosis of AN-restricting (β = 0.31, p < 0.01) or AN-binge eating/purging (β = 0.29, p < 0.01).

DISCUSSION

BMI increased most rapidly during earlier years of the study for those with lower weight at study intake (i. e., AN) and plateaued over time, settling in the normal range for most. Psychoeducation about expected BMI trajectory may challenge patients' long-term fat phobic predictions.

Distress Tolerance Treatment for Weight Concern in Smoking Cessation Among Women: The WE QUIT Pilot Study

Fear of gaining weight after quitting cigarette smoking is a major barrier to smoking cessation among women. Distress tolerance, which refers to one's ability and willingness to tolerate physical and emotional discomfort, predicts successful behavior change. Novel interventions rooted in Acceptance and Commitment Therapy (ACT) have emerged that aim to increase distress tolerance and engagement in values-oriented behavior. In this study, we developed a 9-week, group-based distress tolerance intervention for weight concern in smoking cessation among women (DT-W). Using an iterative process, we piloted DT-W with two small groups ( n = 4 and n = 7) of female weight-concerned smokers. Results indicated that we successfully established the feasibility and acceptability of DT-W, which was well-attended and well-received. Biochemically verified 7-day point-prevalence abstinence rates at post-intervention, 1, 3, and 6 months were 64%, 36%, 27%, and 27%, respectively. We are now evaluating DT-W in a randomized controlled trial.

Acceptance and Commitment Therapy: A Transdiagnostic Behavioral Intervention for Mental Health and Medical Conditions

Psychological interventions have a long history of successful treatment of patients suffering from mental health and certain medical conditions. At the same time, psychotherapy research has revealed key areas of growth for optimizing patient care. These include identifying novel treatment delivery methods that increase treatment adherence, developing new strategies to more effectively address the ever-growing population of patients with comorbid conditions, and elucidating the mechanisms by which effective treatments work in order to further refine their design. Acceptance and commitment therapy (ACT) is an empirically supported psychotherapy that offers promise for patients suffering from a wide range of mental and physical conditions, while addressing these gaps and challenges in the field. ACT rests on the fundamental premise that pain, grief, disappointment, illness, and anxiety are inevitable features of human life, with the therapeutic goal of helping individuals productively adapt to these types of challenges by developing greater psychological flexibility rather than engaging in counterproductive attempts to eliminate or suppress undesirable experiences. This is achieved through committed pursuit of valued life areas and directions, even in the face of the natural desire to escape or avoid painful and troubling experiences, emotions, and thoughts. ACT is transdiagnostic (applies to more than one condition), process-focused, and flexibly delivered. In a relatively short period of time, ACT has been effectively implemented across a broad range of therapeutic settings, including mental health, primary care, and specialty medical clinics. ACT has also been delivered in a variety of formats, including 1-day group workshops, online and smartphone applications, and telehealth. Focus on how best to package and deliver treatment to meet the unique needs of different patient populations helps to ensure treatment adherence and has fostered successful application of ACT for patients in everyday clinical settings.

BEfree: A new psychological program for binge eating that integrates psychoeducation, mindfulness, and compassion

Binge eating disorder (BED) is associated with several psychological and medical problems, such as obesity. Approximately 30% of individuals seeking weight loss treatments present binge eating symptomatology. Moreover, current treatments for BED lack efficacy at follow‐up assessments. Developing mindfulness and self‐compassion seem to be beneficial in treating BED, although there is still room for improvement, which may include integrating these different but complimentary approaches. BEfree is the first program integrating psychoeducation‐, mindfulness‐, and compassion‐based components for treating women with binge eating and obesity.

Objective

To test the acceptability and efficacy up to 6‐month postintervention of a psychological program based on psychoeducation, mindfulness, and self‐compassion for obese or overweight women with BED.

Design

A controlled longitudinal design was followed in order to compare results between BEfree (n = 19) and waiting list group (WL; n = 17) from preintervention to postintervention. Results from BEfree were compared from preintervention to 3‐ and 6‐month follow‐up.

Results

BEfree was effective in eliminating BED; in diminishing eating psychopathology, depression, shame and self‐criticism, body‐image psychological inflexibility, and body‐image cognitive fusion; and in improving obesity‐related quality of life and self‐compassion when compared to a WL control group. Results were maintained at 3‐ and 6‐month follow‐up. Finally, participants rated BEfree helpful for dealing with impulses and negative internal experiences.

Conclusions

These results seem to suggest the efficacy of BEfree and the benefit of integrating different components such as psychoeducation, mindfulness, and self‐compassion when treating BED in obese or overweight women.

Key Practitioner Message

The current study provides evidence of the acceptability of a psychoeducation, mindfulness, and compassion program for binge eating in obesity (BEfree);

Developing mindfulness and self‐compassionate skills is an effective way of diminishing binge eating, eating psychopathology and depression, and increasing quality of life in women with obesity;

Integrating psychoeducation, mindfulness, and compassion seem to be effective in diminishing binge eating, with results maintained up to 6‐month postintervention.

Body image flexibility mediates the effect of body image-related victimization experiences and shame on binge eating and weight

OBJECTIVES

The current study examined a path model testing the indirect effect of negative body-image related memories of being teased and bullied in childhood and adolescence on binge eating severity symptoms, via its effect on current body image shame and body image flexibility.

METHODS

Participants were 853 Portuguese women from the general community who completed a set of self-report measures of body image-related bullying and teasing experiences in childhood and adolescence, current body image shame, body image flexibility, binge eating symptoms, body mass index (BMI) and depressive symptoms.

RESULTS

The path model accounted for 40% of the variance of binge eating symptoms and 14% of the variance of BMI, and revealed a very good fit. Findings corroborated the plausibility of the hypothesized associations suggesting that negative body image-related memories and emotional experiences are significantly associated with binge eating symptoms and BMI, and that body image flexibility is a significant mediator of these associations. The examined relationships were preserved after controlling for the effect of depressive symptoms.

CONCLUSIONS

The current study's findings contribute to clarify the role that body image-related memories and emotional experiences may play on individuals' difficulties in regulating eating behaviour and weight, and provides preliminary support for the potential effect of body image flexibility as a self-regulatory process that operates in these associations.

Incorporating psychoeducation, mindfulness and self-compassion in a new programme for binge eating (BEfree): Exploring processes of change

This study explores the efficacy of BEfree, a 12-session group intervention that integrates psychoeducation, mindfulness, compassion and value-based action, in a sample of overweight and obese women with binge eating disorder ( N = 31). We used repeated measures analyses of variance and explored processes of change in binge eating and eating psychopathology. At post-intervention, participants decreased in binge eating severity, eating psychopathology, external shame, self-criticism, psychological inflexibility, body image cognitive fusion and increased self-compassion and engagement with valued actions. These results were maintained at 3- and 6-month follow-up. The changes in binge eating were mediated by the changes in the psychological processes promoted by BEfree.

How well does Anorexia Nervosa fit with personal values? An exploratory study

BACKGROUND

Despite an increasing clinical interest in the use of personal values as a motivational tool in psychological therapies for Anorexia Nervosa (AN), research is limited. This study explored personal values among individuals with AN, with a particular focus on the 'fit' between participants' values and their AN.

METHODS

A qualitative research design was employed in this study. In-depth, semi-structured interviews were carried out among eight female outpatients and inpatients with a diagnosis of AN or Eating Disorder Not Otherwise Specified - AN type (EDNOS-AN type). Data was analysed using Interpretative Phenomenological Analysis (IPA; Smith, Jarman & Osborne, 1999).

RESULTS

Three super-ordinate themes emerged from analysis: 'Balancing Values' (difficulty finding balance in relating to and acting on values), 'Congruence and Clashes between AN and Values' (experiences of AN representing a mixed-fit with values) and 'From Ambivalence to Motivation' (ambivalence toward both AN and recovery - in the context of its mixed-fit with values - and experiences of values as a motivational tool in recovery).

CONCLUSIONS

Study findings support a role for psychological therapies in working with personal values as a means of promoting recovery in AN, through supporting individuals to explore AN's workability in the context of their values. Further research investigating the optimal stage of treatment to work with values as a motivational tool is warranted.

A preliminary investigation of the relationship between dispositional mindfulness and eating disorder symptoms among men in residential substance use treatment

The comorbidity between eating disorders (EDs) and substance use disorders (SUDs) is of particular concern given the high rates of mortality, relapse and poor treatment outcomes associated with both disorders. As a result, there has been a growing impetus within the field to elucidate factors that might influence and aid treatment for this comorbidity. One such factor is dispositional mindfulness, as past literature has demonstrated a significant relationship between mindfulness and both EDs and SUDs. However, we are unaware of any research that has examined the relationship between dispositional mindfulness and ED symptoms in a sample of men in residential treatment for SUDs. Medical records from 152 men were included in the current study. Alcohol and drug use and problems, ED symptoms, and dispositional mindfulness were assessed with self-report measures. Hierarchical regression analysis indicated that dispositional mindfulness was inversely related to ED symptoms after controlling for alcohol use, drug use, and age. Although results are preliminary and continued research in this area is needed, our findings suggest that there may be potential usefulness in targeting and enhancing mindfulness among patients in residential treatment for SUDs with co-occurring psychiatric symptoms (e.g., EDs).

Developing an Acceptance-Based Behavioral Treatment for Binge Eating Disorder: Rationale and Challenges

Binge eating disorder (BED), characterized by recurrent eating episodes in which individuals eat an objectively large amount of food within a short time period accompanied by a sense of loss of control, is the most common eating disorder. While existing treatments, such as cognitive behavioral therapy (CBT), produce remission in a large percentage of individuals with BED, room for improvement in outcomes remains. Two reasons some patients may continue to experience binge eating after a course of treatment are: (a) Difficulty complying with the prescribed behavioral components of CBT due to the discomfort of implementing such strategies; and (b) a lack of focus in current treatments on strategies for coping with high levels of negative affect that often drive binge eating. To optimize treatment outcomes, it is therefore crucial to provide patients with strategies to overcome these issues. A small but growing body of research suggests that acceptance-based treatment approaches may be effective for the treatment of binge eating. The goal of the current paper is to describe the development of an acceptance-based group treatment for BED, discuss the structure of the manual and the rationale and challenges associated with integrating acceptance-based strategies into a CBT protocol, and to discuss clinical strategies for successfully implementing the intervention.

A qualitative analysis of participants' reflections on body image during participation in a randomized controlled trial of acceptance and commitment therapy

BACKGROUND

Negative body image is a risk factor for development and relapse in eating disorders (ED). Many patients continue to be dissatisfied with their body shape or weight after treatment. This study presents a qualitative analysis of written reflections on body image from patients with an ED and a negative body image before and after an Acceptance and Commitment Therapy group treatment at a specialized ED-unit.

METHOD

Before and after the treatment participants (n = 47) answered a questionnaire with open ended questions on their thoughts on body image. Data were analyzed through conventional content analysis.

RESULTS

Body image meant different things for different participants. For some it had to do with how you evaluate your body, whereas others focused on whether their body image was realistic or not. Some emphasized their relationship with their body, while some described body image as strongly related to global self-esteem. These different views on the concept of body image affected the participants' descriptions of their own body image, and how they wanted it to change. Body image was considered a state that fluctuated from day to day. After treatment the participants described changes in their body image, for instance perceiving oneself as less judgmental towards one's body, and a shift in focus to the important things in life.

CONCLUSIONS

The participants had different views on body image and how they wished it to change. Thus treatment interventions targeting negative body image needs to address various aspects of this complex construct.

TRIAL REGISTRATION

This study is part of an RCT registered 02/06/2014 in Clinical Trials, registration number: NCT02058121.

Negative affect prior to and following overeating-only, loss of control eating-only, and binge eating episodes in obese adults

OBJECTIVE

The objective was to examine the trajectory of five types of negative affect (global negative affect, fear, guilt, hostility, sadness) prior to and following three types of eating episodes (overeating in the absence of loss of control [OE-only], loss of control eating in the absence of overeating [LOC-only], and binge eating) among obese adults using ecological momentary assessment (EMA).

METHOD

Fifty obese adults (84% female) completed a two-week EMA protocol during which they were asked to record all eating episodes and rate each episode on continua of overeating and loss of control. Momentary measures of global negative affect, fear, guilt, hostility, and sadness were assessed using an abbreviated version of the Positive and Negative Affect Schedule (PANAS). Trajectories for each of the five types of negative affect were modeled prior to and following episodes of OE-only, LOC-only, and binge eating.

RESULTS

Consistent with previous findings, global negative affect and Guilt increased prior to and decreased following binge eating episodes (all ps < .05). Guilt also decreased following OE-only episodes (p < .05).

DISCUSSION

These results are consistent with the affect regulation model of binge eating and suggest that binge eating may function to regulate global negative affect, and more specifically, guilt among obese adults. These data suggest that the relationship between negative affect and binge eating may not be unique to individuals with clinical eating disorders and indicate that targeting negative affect may be an effective strategy for the treatment of binge eating in the context of obesity.

Breaking the Silence: Disordered Eating and Big Five Traits in College Men

Men remain largely underrepresented in the eating disorder literature and few studies have investigated risk factors for disordered eating among men. The current study examined associations between Big Five personality traits and eating disorder symptoms in a sample of college men (N = 144). Participants completed the Eating Disorder Diagnostic Scale and Ten Item Personality Inventory online. Results suggested that openness was positively associated with purging-type behaviors and that emotional stability was positively related to symptoms of anorexia nervosa and global eating pathology. Findings highlight the prevalence of eating disorder symptoms among college men and suggest that these symptoms are associated with a different constellation of personality traits than is typically reported among women. Implications for targeted prevention and intervention programs and future research are discussed.

One-Day Acceptance and Commitment Training Workshops in Medical Populations

Chronic medical illnesses often require a high level of self-management, which can be challenging, particularly over extended periods. The challenge is accentuated by comorbid depression or anxiety, which interfere with motivation and drive. Acceptance and Commitment Therapy is an empirically based behavioral intervention aimed at helping individuals develop greater psychological flexibility in the face of life's challenges. It provides a unified model of behavior change and has shown promise in treating depression and anxiety, as well as chronic medical conditions. Importantly, Acceptance and Commitment Therapy has been effectively implemented in various formats, including 1-day group workshops, well-suited for dissemination into medical settings. The purpose of this review is to provide an overview of studies of 1-day group workshops in medical populations and suggest future directions for further development of this promising area.

Accept, distract, or reframe? An exploratory experimental comparison of strategies for coping with intrusive body image thoughts in anorexia nervosa and body dysmorphic disorder

Negative body image is the hallmark of anorexia nervosa (AN) and body dysmorphic disorder (BDD). One aspect of body image, appearance-related thoughts, have shown to be a major contributor to relapse, thus further investigation of successful treatment strategies targeting these maladaptive thoughts are warranted. The present study tested an acceptance/mindfulness (AC), a cognitive restructuring (CR), and a distraction strategy with regard to their short-term effectiveness of reducing the frequency of thought occurrence and associated outcomes in participants with AN (n=20), BDD (n=21), and healthy controls (HC; n=22). Although all strategies led to a significant reduction of thought frequency, there was no group × strategy interaction effect in their reduction. Positive affect increased in the BDD group through the AC strategy, but decreased in healthy controls. Acceptance of the thought increased in the CR strategy in AN, whereas that strategy seemed to work least for BDD. Healthy controls showed most acceptance when using distraction. Taken together, the study suggests that all strategies might have their benefits and that it might be worthwhile further investigating differential indication of the strategies with regard to diagnosis and individual factors.

Review of smartphone applications for the treatment of eating disorders

mHealth tools may be a feasible modality for delivering evidence-based treatments and principles (EBPs), and may enhance treatment for eating disorders (EDs). However, research on the efficacy of mHealth tools for EDs and the extent to which they include EBPs is lacking. The current study sought to (i) review existing apps for EDs, (ii) determine the extent to which available treatment apps utilize EBPs, and (iii) assess the degree to which existing smartphone apps utilize recent advances in smartphone technology. Overall, existing ED intervention apps contained minimal EBPs and failed to incorporate smartphone capabilities. For smartphone apps to be a feasible and effective ED treatment modality, it may be useful for creators to begin taking utilizing the abilities that set smartphones apart from in-person treatment while incorporating EBPs. Before mHealth tools are incorporated into treatments for EDs, it is necessary that the feasibility, acceptability, and efficacy be evaluated.

Self-compassion moderates the relationship between body mass index and both eating disorder pathology and body image flexibility

The current study examined whether self-compassion, the tendency to treat oneself kindly during distress and disappointments, would attenuate the positive relationship between body mass index (BMI) and eating disorder pathology, and the negative relationship between BMI and body image flexibility. One-hundred and fifty-three female undergraduate students completed measures of self-compassion, self-esteem, eating disorder pathology, and body image flexibility, which refers to one's acceptance of negative body image experiences. Controlling for self-esteem, hierarchical regressions revealed that self-compassion moderated the relationships between BMI and the criteria. Specifically, the positive relationship between BMI and eating disorder pathology and the negative relationship between BMI and body image flexibility were weaker the higher women's levels of self-compassion. Among young women, self-compassion may help to protect against the greater eating disturbances that coincide with a higher BMI, and may facilitate the positive body image experiences that tend to be lower the higher one's BMI.

Acceptance and Commitment Therapy for Individuals With Problematic Emotional Eating

Emotional eating is characterized by eating in response to intense inner emotions, not hunger. This case-series study presents the outcomes from two adults with problematic emotional eating who voluntarily participated in 10 weekly sessions of Acceptance and Commitment Therapy. Emotional eating was self-monitored daily prior to and throughout the course of treatment. The average number of emotional eating episodes reported weekly across participants at pre-treatment was nine, which decreased to one per week at post-treatment, and was two per week at follow-up. Both participants also showed improvements in body image flexibility, a theoretically consistent process of change, and these improvements were maintained at 3-month follow-up. The results are discussed as well as implications for clinical practice and future research.

Emotionsregulation: Überblick und kritische Reflexion des aktuellen Forschungsstandes

Die Forschung zum Thema Emotionsregulation erfreut sich auch im Bereich der Klinischen Psychologie einer zunehmenden Beliebtheit. Allerdings stellt sich die Frage, inwieweit die Popularität des Konstrukts im Einklang mit dessen Validität und tatsächlicher heuristischer Fruchtbarkeit steht. Vor diesem Hintergrund ist es Ziel der vorliegenden Arbeit, einen aktuellen Überblick über Konzeptualisierungen, Erfassungsmethoden, Befunde zum Zusammenhang mit psychischen Störungen sowie Möglichkeiten der therapeutischen Nutzung des Konzeptes Emotionsregulation zu geben. Aufbauend auf einer kritischen Reflexion bisheriger Konzepte, Vorgehensweisen und Befunde werden Vorschläge gemacht, wie die Validität und die heuristische Fruchtbarkeit des Emotionsregulationsparadigmas weiter gefördert werden können.