Hubert Lacey

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.

Eating disorders in older women: does late onset anorexia nervosa exist?

OBJECTIVE The objective of this study is to determine whether eating disorders can present for the first time in older people. METHOD This is a descriptive study of patients above the age of 50 years who have presented to a national eating disorder center within the last 10 years. RESULTS Thirty-two patients were identified; data were available for 26 of these patients and 11 agreed for further interview and questionnaire completion. There were no cases where the eating disorder had its onset late in life. Of the 11 interviewed, six participants retained a diagnosis of anorexia nervosa, four had Eating Disorder Not Otherwise Specified and only one was recovered. Comorbid depression was universal in those still suffering with an eating disorder diagnosis, and their level of social functioning was impaired. DISCUSSION Anorexia nervosa is a chronic and enduring mental illness that, although rare, can be found in older people. In our sample, we found no evidence of late-onset disorders; all described cases were lifelong.

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.

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.

Therapeutic factors in short-term group therapy for women with bulimia

Several recent studies indicate that short-term group therapy, either alone or in conjunction with other therapeutic interventions, is effective in the treatment of bulimia. The nature of the therapeutic effect in group treatments of bulimia has yet to be elucidated. The study reported here represents a first step toward establishing what bulimic patients regard as important therapeutically in their experience of group therapy. The findings suggest that patients regard “nonspecific” factors such as realising shared experience, learning from the experience of others, and gaining hope from observing positive change in others as important as the more “specific” factors such as gaining understanding into the nature of their difficulties. These findings have implications for the design and execution of treatment programs.

Telephone counselling—the EDA approach

In 1989 the Eating Disorders Association established a telephone counselling programme for clients with bulimia nervosa. This programme is described in detail. Results of the counselling, conducted over a 2-year period, on 26 patients, are reported. Results show a significant reduction in binge-eating, vomiting and laxative abuse. Those remaining bulimic differed significantly from those recovered in that they had a longer history of illness. Patients rated telephone counselling more highly than face-to-face counselling in terms of convenience, anonymity and confidentiality. The majority felt trust would be enhanced with personal contact. It would appear that a structured telephone counselling programme for patients with bulimia nervosa may offer a viable, effective to conventional counselling. This may provide one answer to the treatment of these patients in areas where services are lacking. Copyright

Progress in eating disorder research

Recent research has continued to add to the body of knowledge on the epidemiology, prevention, treatment and long-term outcome of eating disorders. There has been a significant increase in the number of publications exploring the possible biological correlates of these illnesses. Follow-up studies continue to confirm the high levels of morbidity and mortality associated with anorexia and bulimia nervosa, and highlight the need for ongoing research into treatment and preventative measures. This review will summarize the past year of publications in these areas in addition to the recent research on osteoporosis and reproduction.

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.

Predictors of therapeutic alliance in two treatments for adults with severe and enduring anorexia nervosa

BackgroundTherapeutic alliance (TA) has been found to be a significant predictor of outcome for patients with severe and enduring anorexia nervosa (SE-AN), accounting for more variance than treatment type. To better understand how to promote TA for this population, the aim of the current study was to investigate predictors of TA in adults with SE-AN.MethodsParticipants were 63 adult females with SE-AN presenting to an outpatient, multi-site randomized controlled trial conducted at two clinical sites. Participants’ perception of the quality of their therapeutic relationship, demographic information, and eating disorder symptomatology were assessed via interview and questionnaire measures.ResultsBaseline ratings of how successful participants believed treatment would be for them was the only variable to significantly predict early (p = .01), mid (p = .009), and late treatment alliance (p = .03). No other variables investigated predicted the quality of patient rated TA at any point in treatment (ps > .57).ConclusionsResults suggest instilling hope in treatment outcome may enhance TA, and in turn, outcomes for patients with SE-AN in outpatient therapy.