Kathleen Kara Fitzpatrick

Is Outpatient Cognitive Remediation Therapy Feasible to Use in Randomized Clinical Trials for Anorexia Nervosa

OBJECTIVE There are limited data supporting specific treatments for adults with anorexia nervosa (AN). Randomized clinical trials (RCTs) for adults with AN are characterized by high attrition limiting the feasibility of conducting and interpreting existing studies. High dropout rates may be related to the inflexible and obsessional cognitive style of patients with AN. This study evaluated the feasibility of using cognitive remediation therapy (CRT) to reduce attrition in RCTs for AN. METHOD Forty-six participants (mean age of 22.7 years and mean duration of AN of 6.4 years) were randomized to receive eight sessions of either CRT or cognitive behavioral therapy (CBT) over 2 months followed by 16 sessions of CBT for 4 months. RESULTS During the 2-month CRT vs. CBT treatment, rates of attrition were lower in CRT (13%) compared with that of CBT (33%). There were greater improvements in cognitive inefficiencies in the CRT compared with that of the CBT group at the end of 2 months. There were no differences in other outcomes. DISCUSSION These results suggest that CRT is acceptable and feasible for use in RCTs for outpatient treatment of AN. CRT may reduce attrition in the short term. Adequately powered future studies are needed to examine CRT as an outpatient treatment for AN.

Set-shifting among adolescents with anorexia nervosa.

OBJECTIVE Set-shifting difficulties are documented for adults with anorexia nervosa (AN). However, AN typically onsets in adolescents and it is unclear if set-shifting difficulties are a result of chronic AN or present earlier in its course. This study examined whether adolescents with short duration AN demonstrated set-shifting difficulties compared to healthy controls (HC). METHOD Data on set-shifting collected from the Delis-Kaplan executive functioning system and Wisconsin card sort task (WCST) as well as eating psychopathology were collected from 32 adolescent inpatients with AN and compared with those from 22 HCs. RESULTS There were no differences in set-shifting in adolescents with AN compared to HCs on most measures. DISCUSSION The findings suggest that set-shifting difficulties in AN may be a consequence of AN. Future studies should explore set-shifting difficulties in a larger sample of adolescents with the AN to determine if there is sub-set of adolescents with these difficulties and determine any relationship of set-shifting to the development of a chronic from of AN.

Do executive functioning deficits underpin binge eating disorder? A comparison of overweight women with and without binge eating pathology

OBJECTIVE Deficits in executive function (EF)-including inhibitory control, cognitive flexibility, decision-making, and working memory-may be risk or maintenance factors for binge eating disorder (BED). However, there is mixed evidence regarding EF deficits in individuals with BED. Significant methodological weaknesses (e.g., use of a single EF measure, omission of relevant covariates) in the current literature represent one reason for lack of consensus. METHOD This study compared EF in a sample of overweight women with (n = 31) and without (n = 43) full or subthreshold BED, with the aim of conducting a multifaceted investigation of the neurocognitive profile of BED. A neuropsychological battery of EF was administered to all participants. RESULTS After controlling for IQ and age, individuals with binge eating displayed significantly poorer performance on tasks of problem-solving and inhibitory control, and displayed higher prioritization of immediate versus delayed rewards, but the two groups did not appear to differ on set-shifting, working memory, and risk taking. Differences in inhibitory control were no longer statistically significant when depressive symptomology was added as a covariate and correction for multiple comparisons was applied. Exploratory analyses indicated that full and sub-threshold BED groups did not differ in EF. DISCUSSION Results partially support the hypothesis of relative EF deficits in individuals with BED, suggesting that binge eating may be maintained by cognitive factors distinct from those of obesity. Future research should aim to replicate with a larger sample, control for a wider range of psychiatric comorbidities, and examine whether EF deficits predict treatment outcome.

Can Adaptive Treatment Improve Outcomes in Family-Based Therapy for Adolescents with Anorexia Nervosa? Feasibility and Treatment Effects of a Multi-Site Treatment Study

OBJECTIVE Adolescents with Anorexia Nervosa (AN), treated with family-based treatment (FBT) who fail to gain 2.3 kg by the fourth week of treatment have a 40-50% lower chance of recovery than those who do. Because of the high risk of developing enduring AN, improving outcomes in this group of poor responders is essential. This study examines the feasibility and effects of a novel adaptive treatment (i.e., Intensive Parental Coaching-IPC) aimed at enhancing parental self-efficacy related to re-feeding skills in poor early responders to FBT. METHOD 45 adolescents (12-18 years of age) meeting DSM TR IV criteria for AN were randomized in an unbalanced design (10 to standard FBT; 35 to the adaptive arm). Attrition, suitability, expectancy rates, weight change, and psychopathology were compared between groups. OUTCOMES There were no differences in rates of attrition, suitability, expectancy ratings, or most clinical outcomes between randomized groups. However, the group of poor early responders that received IPC achieved full weight restoration (>95% of expected mean BMI) by EOT at similar rates as those who had responded early. CONCLUSIONS The results of this study suggest that it is feasible to use an adaptive design to study the treatment effect of IPC for those who do not gain adequate weight by session 4 of FBT. The results also suggest that using IPC for poor early responders significantly improves weight recovery rates to levels comparable to those who respond early. A sufficiently powered study is needed to confirm these promising findings.

Therapeutic alliance in two treatments for adolescent anorexia nervosa.

OBJECTIVE The aim of this study was to examine the relationship between therapeutic alliance and treatment outcome (remission status) in family-based treatment (FBT) and adolescent-focused therapy (AFT) for adolescents with anorexia nervosa (AN). METHOD Independent observers rated audiotapes of early therapy sessions using the Working Alliance Inventory-Observer Version (WAI-o). Outcome was defined using established cut-points for full and partial remission. To control for effects of early symptom improvement, changes in weight- and eating-related psychopathology prior to the alliance session were calculated and entered as a covariate in each analysis. RESULTS Participants in AFT had significantly higher alliance scores; however, overall scores were high in both therapies. The alliance was not a predictor of full remission for either treatment, though it was a non-specific predictor for partial remission. DISCUSSION Therapeutic alliance is achievable in adolescents with AN in both AFT and FBT, but demonstrated no relationship to full remission of the disorder.

Evidenced-based Treatments for Children and Adolescents with Eating Disorders: Family Therapy and Family-facilitated Cognitive-Behavioral Therapy

This article summarizes recent research on effective treatments for children and adolescents with eating disorders and illustrates two of the main evidenced based approaches through case descriptions. There are few systematic studies of treatments for children and adolescent eating disorders despite the serious medical and psychological problems attendant to them. One form of family therapy developed at the Maudsley Hospital in London has been the subject of several small to medium sized studies that support the effectiveness of the approach for adolescents with Anorexia Nervosa. The main tenets of the approach include parental empowerment to be active in re-feeding their emaciated children through decreasing parental guilt and anxiety. There are no published controlled trials of any treatment for adolescent Bulimia Nervosa (BN). There are, however, a large number of treatment studies of adults with BN suggesting that cognitive behavioral therapy (CBT) is the treatment of choice for the disorders. A case description of the use of a modified form of CBT for adolescent BN is provided.

Central Coherence in Adolescents with Bulimia Nervosa Spectrum Eating Disorders

BACKGROUND Weak central coherence-a tendency to process details at the expense of the gestalt-has been observed among adults with bulimia nervosa (BN) and is a potential candidate endophenotype for eating disorders (EDs). However, as BN behaviors typically onset during adolescence it is important to assess central coherence in this younger age group to determine whether the findings in adults are likely a result of BN or present earlier in the evolution of the disorder. This study examines whether the detail-oriented and fragmented cognitive inefficiency observed among adults with BN is observable among adolescents with shorter illness duration, relative to healthy controls. METHOD The Rey-Osterrieth Complex Figure Test (RCFT) was administered to a total of 47 adolescents with DSM5 BN, 42 with purging disorder (PD), and 25 healthy controls (HC). Performance on this measure was compared across the three groups. RESULTS Those with BN and PD demonstrated significantly worse accuracy scores compared to controls in the copy and delayed recall condition with a moderate effect size. These findings were exacerbated when symptoms of BN increased. DISCUSSION Poorer accuracy scores reflect a fragmented and piecemeal strategy that interferes with visual-spatial integration in BN spectrum disorders. This cognitive inefficiency likely contributes to broad difficulties in executive functioning in this population especially in the context of worsening bulimic symptoms. The findings of this study support the hypothesis that poor global integration may constitute a cognitive endophenotype for BN.

The importance of loss of control while eating in adolescents with purging disorder

OBJECTIVE Although many individuals with purging disorder (PD) report loss of control (LOC) eating, it is unclear whether they differ from those who do not, or from other eating disorders involving purging and/or LOC. METHOD We compared PD with LOC (PD-LOC), PD without LOC (PD-noLOC), bulimia nervosa (BN), and anorexia nervosa-binge/purge subtype (AN-B/P) on measures of eating-related and general psychopathology in treatment-seeking adolescents. RESULTS PD-LOC comprised ∼30% of PD diagnoses. PD-LOC and PD-noLOC did not differ from one another, or from BN and AN-B/P, on most measures of psychopathology, with some exceptions. PD-noLOC was similar to AN-B/P (p = 0.99) and significantly different from BN on eating concerns (p < 0.001), while PD-LOC was similar to BN, AN-B/P, and PD-noLOC on this measure (ps ≥ 0.06). PD-LOC reported higher self-esteem than BN, AN-B/P, and PD-noLOC (ps < 0.001). DISCUSSION PD was largely similar to other eating disorders characterized by purging, regardless of whether LOC eating was present.

Development and evaluation of a treatment fidelity instrument for family-based treatment of adolescent anorexia nervosa

OBJECTIVE This study provides data on the psychometric properties of a newly developed measure of treatment fidelity in Family-Based Treatment (FBT) for adolescent anorexia nervosa (AN). The Family Therapy Fidelity and Adherence Check (FBT-FACT) was created to evaluate therapist adherence and competency on the core interventions in FBT. METHOD Participants were 45 adolescents and their families sampled from three randomized clinical trials evaluating treatment for AN. Trained fidelity raters evaluated 19 therapists across 90 early session recordings using the FBT-FACT. They also rated an additional 15 session 1 recordings of an alternate form of family therapy-Systemic Family Therapy for the purpose of evaluating discriminant validity of the FBT-FACT. The process of development and the psychometric properties of the FBT-FACT are presented. RESULTS Overall fidelity ratings for each session demonstrated moderate to strong inter-rater agreement. Internal consistency of the measure was strong for sessions 1 and 2 and poor for session 3. Principal components analysis suggests sessions 1 and 2 are distinct interventions. DISCUSSION The FBT-FACT demonstrates good reliability and validity as a measure of treatment fidelity in the early phase of FBT.

Feasibility Study Combining Art Therapy or Cognitive Remediation Therapy with Family-based Treatment for Adolescent Anorexia Nervosa: Family-based Treatment in Anorexia Nervosa

Adolescents with anorexia nervosa who have obsessive-compulsive (OC) features respond poorly to family-based treatment (FBT). This study evaluated the feasibility of combining FBT with either cognitive remediation therapy (CRT) or art therapy (AT) to improve treatment response in this at-risk group. Thirty adolescents with anorexia nervosa and OC features were randomized to 15 sessions of FBT + CRT or AT. Recruitment rate was 1 per month, and treatment attrition was 16.6% with no differences between groups. Suitability, expectancy and therapeutic relationships were acceptable for both combinations. Correlations between changes in OC traits and changes in cognitive inefficiencies were found for both combinations. Moderate changes in cognitive inefficiencies were found in both groups but were larger in the FBT + AT combination. This study suggests that an RCT for poor responders to FBT because of OC traits combining FBT with either CRT or AT is feasible to conduct. Copyright