Gill Todd

A pilot study of a randomised trial of cognitive analytical therapy vs educational behavioral therapy for adult anorexia nervosa.

The aim of this study was to compare two forms of outpatient treatment, educational behavioural treatment and cognitive analytical therapy for adult anorexia nervosa. Thirty patients were randomly allocated to the two treatments. At one year, the group had gained 6.8 kg, 19/30 (63%) had a good or intermediate recovery in terms of nutritional outcome. The group given cognitive analytical treatment reported significantly greater subjective improvement but there were no differences in other outcome parameters. In conclusion outpatient treatment of adult onset anorexia nervosa leads to an improvement in two thirds of cases. Larger studies will be needed to determine the most effective form of treatment in this group.

First step in managing bulimia nervosa: controlled trial of therapeutic manual

Abstract Objective: To test the short term efficacy of a self directed treatment manual for bulimia nervosa. Design: Randomised controlled trial of the manual against cognitive behavioural therapy and a waiting list. Setting: Tertiary referral centre. Subjects: 81 consecutive referrals presenting with bulimia nervosa or atypical bulimia nervosa. Main outcome measures: Frequency of binge eating, vomiting, and other behaviours to control weight as well as abstinence from these behaviours. Results: Cognitive behavioural treatment produced a significant reduction in the frequency of binge eating, vomiting, and other behaviours to control weight. The manual significantly reduced frequency of binge eating and weight control behaviours other than vomiting, and there was no change in the group on the waiting list. Full remission was achieved in five (24%) of the group assigned to cognitive behavioural treatment, nine (22%) of the group who used the manual, and two (11%) of the group on the waiting list. Conclusions: A self directed treatment manual may be a useful first intervention in the treatment of bulimia nervosa.

Predictors of outcome for two treatments for bulimia nervosa: Short and long term

OBJECTIVE This study examined pretreatment variables to predict outcome in two treatments for bulimia nervosa. METHOD Patients were offered either 16 weeks of cognitive-behavioral therapy (CBT) or a self-treatment manual followed by up to 8 weeks of CBT (sequential group). Using complete data, stepwise regression analyses were performed. RESULTS It was found that a longer duration of illness and lower binge frequency predicted a better outcome both at the end of treatment (p < .001) and at 18 months of follow-up (p < .005). In the sequential group, lower pretreatment binge frequency predicted better outcome at the end of treatment (p < .05) and at 18 months of follow-up (p < .05). In the CBT group, longer duration of illness predicted better outcome at the end of treatment (p < .02). DISCUSSION It is concluded that (1) those with more frequent binging may require a more intense intervention and (2) those who have been ill longer may be more motivated to respond to treatment.

A description of multiple family workshops for carers of people with anorexia nervosa

Carers of people with eating disorders are uncertain about how best to help and express the need for information. Fifty per cent of carers (usually parents) exhibit clinically significant anxiety and/or depression. This may result from a difficulty coping with the manifestations of anorexia nervosa (AN) in the sufferer. In turn, eating disorder symptoms can be maintained by family reactions to the illness. Thus, carers own symptoms, plus their uncertainty about how to help, impinge upon the AN sufferer, exacerbating their symptoms and behaviours. In this paper, we describe an intervention which uses cognitive behavioural therapy principles to alleviate carers depression and anxiety and motivational interviewing to target behaviours that maintain eating disorder symptoms, for example high expressed emotion and poor communication. This is given in the form of an educational workshop for two families.

Interpersonal Maintaining Factors in Eating Disorder: Skill Sharing Interventions for Carers

The aim of this paper is to describe an intervention designed to share information and skills with carers of people with an eating disorder. The NICE guidelines recommend outpatient management as the first line of treatment for all forms of eating disorders. Hence family members are called upon to provide support within the community. However they are often at a loss as to how best to help. It is common for carers to become anxious, depressed, discouraged and lonely. This can color judgment and some reactions to eating disorder symptoms can be harmful rather than helpful. In both naturalistic studies and randomized controlled trials, family factors have been implicated either as moderators or mediators of outcome. For example high expressed emotion (criticism, hostility and over protection) can adversely impact on the illness. Families can inadvertently be drawn in by the nature of the illness to adjust and accommodate their lives around the symptoms or even enable the continuation of some symptoms. Carers recognize their need for information about how to manage the problem. Sharing information and skills with family members can correct some of the unhelpful attributions and reactions to the illness and can empower non-professional carers to contribute to the process of treatment.

Disseminating skills to carers of people with eating disorders: an examination of treatment fidelity in lay and professional carer coaches

Family members of people with eating disorders (EDs) have high levels of stress and can use maladaptive methods of coping. We have developed an intervention, using motivational interviewing (MI) strategies that trains lay and professional carer coaches (CCs) to support carers of adolescents with EDs to use more adaptive coping procedures. The aim of this study is to measure treatment integrity in coaches with either academic or lived experience. Eleven coaches were trained and supervised by an expert trainer and an ‘expert by experience’ trainer. Six of the coaches had prior training in clinical work and/or psychology and five had personal experience of supporting a loved one with an ED. Two audio-taped sessions (Sessions 3 and 7) from each family coached (n = 22) were assessed for fidelity to MI. Half the sessions (50% n = 11) had a Motivational Interviewing Treatment Integrity global score above the suggested cut-off for recommended competency. Prior clinical training was related to higher treatment fidelity and experiential training (having coached a greater number of families) improved treatment fidelity in the lay carer group. These preliminary findings suggest that: “lay CCs” can be trained to deliver an intervention based on MI. Further exploration of a more effective means of training, monitoring and supervision is required to maximise the quality of the intervention.

Self-Help And Recovery guide for Eating Disorders (SHARED): Study protocol for a randomized controlled trial

BackgroundWe describe the theoretical rationale and protocol for Self-Help And Recovery guide for Eating Disorders (SHARED), a trial investigating whether a guided self-care intervention (Recovery MANTRA) is a useful addition to treatment as usual for individuals with anorexia nervosa. Recovery MANTRA, a 6-week self-care intervention supplemented by peer mentorship, is a module extension of the Maudsley Model of Treatment for Adults with Anorexia Nervosa and targets the maintenance factors identified by the cognitive-interpersonal model of the illness.MethodsPatients accessing outpatient services for anorexia nervosa are randomized to either treatment as usual or treatment as usual plus Recovery MANTRA. Outcome variables include change in body weight at the end of the intervention (primary) and changes in body weight and eating disorder symptoms at immediate and extended follow-up (6-months; secondary). Change is also assessed for the domains identified by the theoretical model, including motivation, hope, confidence to change, positive mood, cognitive flexibility, therapeutic alliance and social adjustment. Feedback from peer mentors is gathered to understand the impact on their own well-being of providing guidance.DiscussionResults from this exploratory investigation will determine whether a larger clinical trial is justifiable and feasible for this affordable intervention, which has potential for high reach and scalability.Trial registrationClinicalTrials.gov NCT02336841.

Collaborative Care: The New Maudsley Model

The aim of this article is to describe the rationale and practice of the New Maudsley collaborative care intervention for families of people with eating disorders. The intervention teaches carers the underpinning theory with practical examples on how to optimize their care giving, communication, and coping skills. This includes moderating high expressed emotion and reducing the tendency to accommodate and/or enable illness behaviors. Transcripts are used to give examples of this approach in action. The emerging evidence base indicates that this approach improves both carer and patient well-being and also is associated with a more efficient use of resources.

Development and reliability of a Motivational Interviewing Scenarios Tool for Eating Disorders (MIST-ED) using a skills-based intervention among caregivers

The aims of this study were to develop an eating disorder scenarios tool to assess the motivational interviewing (MI) skills of caregivers and evaluate the coding reliability of the instrument, and to test the sensitivity to change through a pre/post/follow-up design. The resulting Motivational Interview Scenarios Tool for Eating Disorders (MIST-ED) was administered to caregivers (n = 66) who were asked to provide oral and written responses before and after a skills-based intervention, and at a 3-month follow-up. Raters achieved excellent inter-rater reliability (intra-class correlations of 91.8% on MI adherent and 86.1% for MI non-adherent statements for written scenarios and 89.2%, and 85.3% for oral scenarios). Following the intervention, MI adherent statements increased (baseline = 9.4%, post = 61.5% and follow-up 47.2%) and non-MI adherent statements decreased (baseline = 90.6%, post = 38.5% and follow-up = 52.8%). This instrument can be used as a simple method to measure the acquisition of MI skills to improve coping and both response methods are adequate. The tool shows good sensitivity to improved skills.

First Step in Managing Bulimia Nervosa: Controlled Trial of Therapeutic Manual

OBJECTIVE To test the short term efficacy of a self directed treatment manual for bulimia nervosa. DESIGN Randomised controlled trial of the manual against cognitive behavioural therapy and a waiting list. SETTING Tertiary referral centre. SUBJECTS 81 consecutive referrals presenting with bulimia nervosa or atypical bulimia nervosa. MAIN OUTCOME MEASURES Frequency of binge eating, vomiting, and other behaviours to control weight as well as abstinence from these behaviours. RESULTS Cognitive behavioural treatment produced a significant reduction in the frequency of binge eating, vomiting, and other behaviours to control weight. The manual significantly reduced frequency of binge eating and weight control behaviours other than vomiting, and there was no change in the group on the waiting list. Full remission was achieved in five (24%) of the group assigned to cognitive behavioural treatment, nine (22%) of the group who used the manual, and two (11%) of the group on the waiting list. CONCLUSIONS A self directed treatment manual may be a useful first intervention in the treatment of bulimia nervosa.