Bryony Bamford

Treating severe and enduring anorexia nervosa: a randomized controlled trial

BACKGROUND There are no evidence-based treatments for severe and enduring anorexia nervosa (SE-AN). This study evaluated the relative efficacy of cognitive behavioral therapy (CBT-AN) and specialist supportive clinical management (SSCM) for adults with SE-AN. METHOD Sixty-three participants with a diagnosis of AN, who had at least a 7-year illness history, were treated in a multi-site randomized controlled trial (RCT). During 30 out-patient visits spread over 8 months, they received either CBT-AN or SSCM, both modified for SE-AN. Participants were assessed at baseline, end of treatment (EOT), and at 6- and 12-month post-treatment follow-ups. The main outcome measures were quality of life, mood disorder symptoms and social adjustment. Weight, eating disorder (ED) psychopathology, motivation for change and health-care burden were secondary outcomes. RESULTS Thirty-one participants were randomized to CBT-AN and 32 to SSCM with a retention rate of 85% achieved at the end of the study. At EOT and follow-up, both groups showed significant improvement. There were no differences between treatment groups at EOT. At the 6-month follow-up, CBT-AN participants had higher scores on the Weissman Social Adjustment Scale (WSAS; p = 0.038) and at 12 months they had lower Eating Disorder Examination (EDE) global scores (p = 0.004) and higher readiness for recovery (p = 0.013) compared to SSCM. CONCLUSIONS Patients with SE-AN can make meaningful improvements with both therapies. Both treatments were acceptable and high retention rates at follow-up were achieved. Between-group differences at follow-up were consistent with the nature of the treatments given.

Exploring quality of life in the eating disorders.

OBJECTIVE The present study aimed to investigate the impact of Body Mass Index (BMI), duration of illness and severity of illness on quality of life within a sample of individuals in treatment for an eating disorder. In addition this study explored differences in specific areas of quality of life (Psychological, Physical/Cognitive, Work/School and Financial) according to specific eating disorder diagnoses. METHOD Participants (N = 156) were adults currently receiving treatment for an eating disorder. Eating disorder symptomatology and quality of life were assessed using self-report questionnaires. BMI, duration of illness and eating disorder diagnosis was obtained during a clinical interview. RESULTS Severity of the eating disorder and BMI were predictors of low quality of life. Duration of illness, contrary to clinical expectations was not a significant predictor of poor quality of life. In terms of differences across diagnostic groups, individuals with a diagnosis of anorexia nervosa in this sample were found to have lower psychological and physical/cognitive quality of life than those with an EDNOS or BN diagnoses.

Caregiving and coping in carers of people with anorexia nervosa admitted for intensive hospital care

OBJECTIVE The aim of the study was to examine how carers cope practically and emotionally with caring for individuals with anorexia nervosa who require intensive hospital care. METHOD This study explores objective burden (time spent with caregiving and number of tasks), subjective burden (psychological distress), and social support in a sample of parents (n = 224) and partners (n = 28) from a consecutive series of patients (n = 178) admitted to inpatient units within the United Kingdom. RESULTS Most time was spent providing emotional support and less with practical tasks. Time spent with caregiving was associated with carer distress and was fully mediated by carer burden. This was ameliorated by social support. Partners received minimal support from others, and we found similar levels of burden and distress for mothers and partners. DISCUSSION The data indicate that professional and social support alleviates carer distress and may be of particular value for partners who are more isolated than parents. The data also suggest that time spent with practical support may be of more value than emotional support.

Cognitive behavioural therapy for individuals with longstanding anorexia nervosa: Adaptations, clinician survival and system issues

Despite recent advances in the treatment of anorexia nervosa, some individuals will progress to a severe and enduring illness, with associated physical, psychological and social consequences. Working with these patients, however, may leave clinicians feeling overwhelmed, risking difficulties in the therapeutic relationship including disengagement or despair. Cognitive behaviour therapy has shown some promise in the treatment of eating disorders, yet some features may not be appropriate for this group. In this paper, we outline the ways in which we have adapted cognitive behaviour therapy to best meet the complex and challenging needs of this group. We stress the importance of maintaining a reassuring, accepting and motivational approach in combination with clear goal setting and boundaries.

Therapeutic alliance in two treatments for adults with severe and enduring anorexia nervosa.

OBJECTIVE The aim of this study was to investigate the strength and role of therapeutic alliance in a trial comparing Cognitive Behavioral Therapy for anorexia nervosa (CBT-AN) and Specialist Supportive Clinical Management for the treatment of severe and enduring AN (SE-AN). METHOD Participants were 63 adult females with SE-AN presenting to an outpatient, multisite randomized controlled trial conducted at two clinical sites. Participants completed measures assessing their perception of the quality of the therapeutic relationship, eating disorder (ED) symptomatology, and depressive symptomatology. RESULTS Beyond the effect of early treatment change and treatment assignment, early therapeutic alliance was a significant predictor of Restraint and Shape Concern at follow-up (ps < .02). Late therapeutic alliance was a significant predictor of weight change, depressive symptomatology, and ED symptomatology at end of treatment and follow-up (ps < .008), with the exception of Shape Concern at follow-up (p = .07). DISCUSSION The results suggest that therapeutic alliance can be effectively established in the treatment of SE-AN and may be relevant for treatment response, particularly in late treatment, on some aspects of ED and depressive symptomatology.

Why are we waiting? The relationship between low admission weight and end of treatment weight outcomes

Inpatient eating disorder units are increasingly being asked to admit patients at lower BMIs, often delaying hospital treatment until medically unavoidable. This paper aims to explore the impact of this trend on treatment outcome. Eighty-two adults with anorexia nervosa admitted to a national inpatient eating disorder ward were assessed for BMI at admission, length of hospitalisation, discharge BMI and re-admission within 1-year post-treatment. In the current study, admission BMI was unrelated to amount of weight gain during treatment or to length of hospital stay. As such patients admitted at lower BMIs had significantly lower BMIs on discharge from treatment. Low admission BMIs were related to significantly higher likelihoods of re-admission within 1 year. This study provides strong evidence for the benefit of early treatment episodes and with more successful treatment outcomes being related to higher weights at start of treatment.

BodyWise: evaluating a pilot body image group for patients with anorexia nervosa.

Body image disturbance can be enduring and distressing to individuals with eating disorders and effective treatments remain limited. This pilot study evaluated a group-based treatment-BodyWise-developed for use in full and partial hospitalization with patients with anorexia nervosa at low weight. A partial crossover waitlist design was used. BodyWise (N = 50) versus treatment as usual (N = 40) were compared on standardized measures of body image disturbance. Results demonstrated significant improvement in the group compared to treatment as usual for the primary outcome measure (Eating Disorder Examination-Questionnaire Shape Concern subscale) and other manifestations of body image disturbance including body checking and body image quality of life. BodyWise appeared acceptable to participants, and was easy to deliver within the pragmatics of a busy eating disorder service. There is potential for its wider dissemination as a precursor to more active body image interventions.

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

BackgroundDespite 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.MethodsA 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).ResultsThree 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).ConclusionsStudy 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.

Confirmatory factor analysis for two questionnaires of caregiving in eating disorders.

Objective: Caring for someone diagnosed with an eating disorder (ED) is associated with a high level of burden and psychological distress which can inadvertently contribute to the maintenance of the illness. The Eating Disorders Symptom Impact Scale (EDSIS) and Accommodation and Enabling Scale for Eating Disorders (AESED) are self-report scales to assess elements of caregiving theorised to contribute to the maintenance of an ED. Further validation and confirmation of the factor structures for these scales are necessary for rigorous evaluation of complex interventions which target these modifiable elements of caregiving. Method: EDSIS and AESED data from 268 carers of people with anorexia nervosa (AN), recruited from consecutive admissions to 15 UK inpatient or day patient hospital units, were subjected to confirmatory factor analysis to test model fit by applying the existing factor structures: (a) four-factor structure for the EDSIS and (b) five-factor structure for the AESED. Results: Confirmatory factor analytic results support the existing four-factor and five-factor structures for the EDSIS and the AESED, respectively. Discussion: The present findings provide further validation of the EDSIS and the AESED as tools to assess modifiable elements of caregiving for someone with an ED.

Assessing quality of life in the eating disorders: the HeRQoLED-S.

Evaluation of: Las Hayas C, Quintana JM, Padierna JA, Bilbao A, Muñoz P. Use of Rasch methodology to develop a short version of the Health Related Quality of Life for Eating Disorders questionnaire: a prospective study. Health Qual. Life Outcomes 8, 29 (2010). Quality of life has become of increasing interest for health professionals since the 1980s and is now incorporated into assessment, treatment and evaluation of many health interventions. Within the arena of eating disorders, adequate consideration of quality of life within treatment and research has been slower, but is now coming into line with wider physical and mental health fields. A number of eating disorder-specific measures have been developed that aim to assess perceived quality of life while also minimizing response bias, which can be attributable to the ego-syntonicity of the eating disorders. While these measures are of great importance, further work is still required to assess the reliability and validity of these scales and to adapt the current available measures to increase their suitability for incorporation into clinical and research protocols. The current discussed paper by Las Hayas et al. aims to evaluate the Health Related Quality of Life for the Eating Disorders – version 2 (HeRQoLEDv2) for reliability and validity, to develop a short form of this questionnaire, the Health Related Quality of Life for the Eating disorders – Short form (HeRQoLED-S) using Rasch methodology and to further assess the HeRQoLED-S for reliability and validity. The authors confirm their hypothesized internal structure of the scales and present evidence for the reliability of the short scale. However, the short measure should be subject to more rigorous analysis of its reliability and construct validity in order to provide evidence as to its relationship to quality of life as perceived by eating disorder individuals.