Rebecca M. Shingleton

Using technology within the treatment of eating disorders: a clinical practice review.

The focus of this clinical practice review is to provide clinicians a framework for incorporating technology into the treatment of eating disorders (EDs). We detailed studies that were published within the past 11 years (2002-2012) and that included at least 10 participants. Our primary aims were to describe how technology has been used to enhance the delivery of ED treatment as well as report the effectiveness of these technology-based interventions. We also provided clinical applications and considerations for clinicians who wish to use technology within their own practice. We found that a range of technologies (e.g., televideo, e-mail, CD-ROM, Internet, text message) have been used as a means to either deliver or enhance treatment at various levels of care (e.g., therapy, guided self-help, treatment adjunct). The majority of the studies were based on cognitive-behavioral principles and included samples diagnosed with bulimia nervosa (BN), binge eating disorder (BED), or subclinical levels of BN or BED. Most researchers reported positive results, with a few caveats such as technology-based interventions may not be optimal for individuals with more severe pathology, and some individuals described wanting more personal interaction. The overarching finding was that technology may be successfully integrated within ED treatment and may offer new ways to extend ED interventions to individuals who may not otherwise have access to specialty ED care.

Eating behavior in anorexia nervosa: before and after treatment.

OBJECTIVE The purpose of this study was to assess eating behavior in patients with anorexia nervosa before and after weight normalization and healthy controls using a standardized, multiple-item lunch meal paradigm. METHOD Eighteen patients were studied shortly after inpatient admission and again after gaining to a BMI ≥ 19.5 kg m(-2) . Fifteen healthy controls were studied twice, ∼2-3 months apart. RESULTS When underweight, patients with AN consumed fewer total calories (364 ± 208 kcal) and a lower percentage of calories from fat (18% ± 10%) compared to controls (775 ± 228 kcal, p = 0.001; 38% ± 7%, p = 0.001). After weight normalization, despite a modest increase in total calories (364 ± 208 kcal vs. 516 ± 273 kcal, p = 0.04) and in percent of calories from fat (18% ± 10% vs. 23% ± 9%, p = 0.04), patients continued to consume fewer total calories and a reduced percent of calories from fat compared to controls (758 ± 346 kcal, p = 0.03; 38% ± 18%, p = 0.004). DISCUSSION Patients with AN, even after acute treatment, consume fewer total calories and fewer calories from fat, compared to healthy controls. The reduced overall intake and persistent avoidance of fat may contribute to relapse, and therefore are potential therapeutic targets.

Multiple measures of rapid response as predictors of remission in cognitive behavior therapy for bulimia nervosa

Bulimia nervosa (BN) treatment studies consistently observe that substantial reductions in purging frequency after four weeks of treatment predict outcome. Although baseline levels of other variables have been compared to change in purging, measures of early change in other domains have not been examined. This study aimed to compare percentage change in purging, depression, and cognitive eating disorder (ED) symptoms for associations with BN remission post-treatment and at six months follow-up. Data from N = 43 patients with BN in a clinical trial comparing the broad and focused versions of enhanced cognitive behavior therapy (CBT-E; Fairburn, 2008) were utilized. Measures included self-reported purging frequency, Beck Depression Inventory (BDI) score, and a mean of items from the Eating Disorder Inventory Body Dissatisfaction and Drive for Thinness subscales. Results indicated that both percentage change in purging frequency and percentage change in BDI score at week four/session eight were significantly associated with remission at termination. The optimal cutoffs for purging change and BDI score change were 65% decrease and 25% decrease respectively. Only change in BDI score at week four significantly predicted remission at six-month follow-up. These data suggest that change in depressive symptoms may be as important as ED symptom change to predict outcome in some groups.

Gender differences in clinical trials of binge eating disorder: An analysis of aggregated data.

OBJECTIVE The aim of the study was to examine gender differences in baseline and outcome variables in clinical trials for binge eating disorder (BED). METHOD Data from 11 randomized controlled psychosocial treatment studies were aggregated (N = 1,325: 208 male, 1,117 female). Baseline and outcome symptoms were assessed via the interview and questionnaire versions of the Eating Disorder Examination (EDE). Multilevel analyses were conducted investigating gender differences at baseline and posttreatment, defined as EDE scores, objective binge episode (OBE) reduction, and OBE remission at termination. RESULTS Few males from low socioeconomic status or minority groups participated in the outcome studies. Males reported significantly lower EDE global, shape, weight, and eating concerns at baseline. No main effects of gender were found in treatment outcome scores when controlling for baseline differences; however, baseline EDE global score (which showed gender differences at baseline) and OBEs directly predicted outcome for both males and females. A significant interaction between gender, treatment length, and shape/weight concerns indicated that males with lower shape/weight concerns achieved OBE remission in shorter treatments, whereas men with high shape/weight concerns and women with either high or low shape/weight concerns were more likely to achieve OBE remission in treatments of longer duration. CONCLUSIONS These results suggest BED treatment studies must improve their recruitment of men and appeal to men with lower shape/weight concerns. Additionally, longer term treatments, although more efficacious for women and men with more severe shape/weight concerns, may not be necessary for men with low shape/weight concerns. (PsycINFO Database Record

Technology-delivered adaptations of motivational interviewing for health-related behaviors: A systematic review of the current research

OBJECTIVES The aims of this paper were to describe and evaluate the methods and efficacy of technology-delivered motivational interviewing interventions (TAMIs), discuss the challenges and opportunities of TAMIs, and provide a framework for future research. METHODS We reviewed studies that reported using motivational interviewing (MI) based components delivered via technology and conducted ratings on technology description, comprehensiveness of MI, and study methods. RESULTS The majority of studies were fully-automated and included at least one form of media rich technology to deliver the TAMI. Few studies provided complete descriptions of how MI components were delivered via technology. Of the studies that isolated the TAMI effects, positive changes were reported. CONCLUSION Researchers have used a range of technologies to deliver TAMIs suggesting feasibility of these methods. However, there are limited data regarding their efficacy, and strategies to deliver relational components remain a challenge. Future research should better characterize the components of TAMIs, empirically test the efficacy of TAMIs with randomized controlled trials, and incorporate fidelity measures. PRACTICE IMPLICATIONS TAMIs are feasible to implement and well accepted. These approaches offer considerable potential to reduce costs, minimize therapist and training burden, and expand the range of clients that may benefit from adaptations of MI.

Striatal dopamine type 2 receptor availability in anorexia nervosa

The neurobiology of anorexia nervosa remains incompletely understood. Here we utilized PET imaging with the radiotracer [(11)C]raclopride to measure striatal dopamine type 2 (D2) receptor availability in patients with anorexia nervosa. 25 women with anorexia nervosa who were receiving treatment in an inpatient program participated, as well as 25 control subjects. Patients were scanned up to two times with the PET tracer [(11)C]raclopride: once while underweight, and once upon weight restoration. Control subjects underwent one PET scan. In the primary analyses, there were no significant differences between underweight patients (n=21) and control subjects (n=25) in striatal D2 receptor binding potential. Analysis of subregions (sensorimotor striatum, associative striatum, limbic striatum) did not reveal differences between groups. In patients completing both scans (n=15), there were no detectable changes in striatal D2 receptor binding potential after weight restoration. In this sample, there were no differences in striatal D2 receptor binding potential between patients with anorexia nervosa and control subjects. Weight restoration was not associated with a change in striatal D2 receptor binding. These findings suggest that disturbances in reward processing in this disorder are not attributable to abnormal D2 receptor characteristics, and that other reward-related neural targets may be of greater relevance.

Binge/purge thoughts in nonsuicidal self-injurious adolescents: An ecological momentary analysis

OBJECTIVE Adolescents who self-injure often engage in bingeing/purging (BP). Ecological momentary assessment (EMA) has potential to offer insight into the relationship between self-injury and BP. The aims of this study were to examine the frequency and context of BP using EMA in a sample of nonsuicidal self-injurious (NSSI) adolescents. METHOD Thirty adolescents with a history of NSSI responded to questions regarding self-destructive thoughts/behaviors using a palm-pilot device. Descriptive analyses compared thought/behavior contexts during reports of BP and NSSI thoughts/behaviors (occurring together vs. individually). RESULTS BP thoughts were present in 22 (73%) participants, occurring on 32% of the person-days recorded; 59% of these participants actually engaged in BP behavior. Seventy-nine percent of BP thoughts co-occurred with other self-destructive thoughts. Adolescents were more often with friends/peers than alone or with family when having BP thoughts. Worry and pressure precipitated both BP and NSSI thoughts, but perceived criticism and feelings of rejection/hurt were associated more often with BP thoughts than with NSSI thoughts. DISCUSSION BP thoughts and behaviors were common in this sample, often occurring with other self-destructive thoughts. Future EMA research is needed to address the function of BP symptoms, the contextual variables that increase risk for BP thoughts, and the factors that predict the transition of thoughts into behaviors in adolescents with and without self-injury.

Focused vs. Broad enhanced cognitive behavioral therapy for bulimia nervosa with comorbid borderline personality: A randomized controlled trial.

OBJECTIVE A subset of individuals with bulimia nervosa (BN) have borderline personality disorder (BPD) symptoms, including chronic negative affect and interpersonal problems. These symptoms predict poor BN treatment outcome in some studies. The broad version of Enhanced Cognitive Behavior Therapy (CBT-E) was developed to address co-occurring problems that interfere with treatment response. The current study investigated the relative effects, predictors, and moderators of CBT-E for BN with BPD and co-occurring mood/anxiety disorders. METHOD Fifty patients with BN and threshold or sub-threshold BPD and current or recent Axis I mood or anxiety disorders were randomly assigned to receive focused CBT-E (CBT-Ef) or broad CBT-E (CBT-Eb) specifically including an interpersonal module and additional attention to mood intolerance. RESULTS Forty-two percent of the sample reported remission from binge eating and purging at termination. Significant changes across symptom domains were observed at termination and at 6-month follow-up. Though CBT-Ef predicted good outcomes in multivariate models, the severity of affective/interpersonal problems moderated treatment effects: participants with higher severity showed better ED outcomes in CBT-Eb, whereas those with lower severity showed better outcomes in CBT-Ef. Severity of affective/interpersonal BPD symptoms at baseline predicted negative outcomes overall. Follow-up BPD affective/interpersonal problems were predicted by baseline affective/interpersonal problems and by termination EDE score. DISCUSSION This study supports the utility of CBT-E for patients with BN and complex comorbidity. CBT-Ef appears to be more efficacious for patients with relatively less severe BPD symptoms, whereas CBT-Eb appears to be more efficacious for patients with more severe BPD symptoms.

Alliance-focused therapy for anorexia nervosa: integrative relational and behavioral change treatments in a single-case experimental design.

Evidence supporting outpatient treatments for anorexia nervosa (AN) is severely lacking, due to low retention and poor outcome. One explanation for drop-out is weak treatment alliances. A single-case experimental analysis accompanied by in-depth qualitative description is presented for Ms. O, who received a novel treatment for AN called Alliance Focused Treatment (AFT) that attends to ruptures in the alliance, interpersonal difficulties and emotional avoidance. At intake Ms. O met diagnostic criteria for AN, Major Depressive Disorder, and Social Phobia. She was characterized as having symptoms of Obsessive Compulsive, Avoidant, and Depressive personality disorders. Treatment began with a Baseline followed by the experimental (AFT) and comparison treatments (Behavioral Change Treatment [BCT]) using a replicated experimental single-case phase change design. Graphs of slopes of kilocalorie and alliance change facilitated observation of treatment effects. Ms. O participated in 16 sessions of AFT and 8 sessions of BCT with specific benefits. Ratings of the treatment alliance were consistently high and she evidenced significant changes in weight, quality of life, and personality pathology. Associations between rupture/repair episodes and kilocalorie increases were observed. The utility of the treatment relationship in facilitating emotional expression was evident. At posttreatment, Ms. O endorsed cognitive AN symptoms, although these were not explicitly treated. This study provides preliminary support for the feasibility and effect of AFT and BCT, and highlights the importance of the alliance in treating adults with AN. Further research on emotion regulation in AN and its effect on the treatment relationship are needed.

Motivational Text Message Intervention for Eating Disorders: A Single-Case Alternating Treatment Design Using Ecological Momentary Assessment ☆

OBJECTIVE This study tested a motivational text message treatment adjunct for individuals with eating disorders (EDs) who exhibited high dietary restraint/restriction. METHOD A replicated single-case alternating treatment design was used to examine (a) the feasibility of combining a brief motivational interview with subsequent text messages and (b) the influence of the text messages on eating behaviors and motivation to change in individuals with EDs (N=12). The protocol was 8weeks and the text messages were adjunctive to cognitive-behavioral therapy. RESULTS The intervention was well accepted (mean rating=7/10) and feasible within the context of monetary compensation (mean daily monitoring compliance =91%). Text messages did not impact behavioral outcomes: dietary restraint and kilocalorie intake. They had mixed effects on motivation to change dietary restraint, measured by the Readiness and Motivation Questionnaire (RMQ). When receiving text messages, RMQ precontemplation scores (desire to restrict) significantly increased, indicating decreased motivation; however, action scores (effort toward reducing dietary restraint) significantly increased, indicating increased motivation. These effects were moderated by weight status. Underweight individuals (n=4; body mass index [BMI]<19.0) reported increased ambivalence-that is, an increased desire to restrict and increased action toward reducing restriction-in response to the text messages. Normal weight participants (n=8; BMI>19.0) reported only increased action toward reducing restriction in response to the text messages. DISCUSSION These data demonstrate text messages are a potentially feasible and acceptable treatment adjunct and may be effective at increasing motivation to change for normal weight individuals, while their influence on underweight patients is more complex. These findings provide a foundation for future research in technology-based motivational interventions for EDs and offer preliminary evidence for using these methods among normal weight individuals.