Rebecca Murphy

Cognitive Behavioral Therapy for Eating Disorders

Cognitive behavioral therapy (CBT) is the leading evidence-based treatment for bulimia nervosa. A new “enhanced” version of the treatment appears to be more potent and has the added advantage of being suitable for all eating disorders, including anorexia nervosa and eating disorder not otherwise specified. This article reviews the evidence supporting CBT in the treatment of eating disorders and provides an account of the “transdiagnostic” theory that underpins the enhanced form of the treatment. It ends with an outline of the treatments main strategies and procedures.

How do psychological treatments work? Investigating mediators of change.

Little is known about how psychological treatments work. Research on treatment-induced mediators of change may be of help in identifying potential causal mechanisms through which they operate. Outcome-focused randomised controlled trials provide an excellent opportunity for such work. However, certain conceptual and practical difficulties arise when studying psychological treatments, most especially deciding how best to conceptualise the treatment concerned and how to accommodate the fact that most psychological treatments are implemented flexibly. In this paper, these difficulties are discussed, and strategies and procedures for overcoming them are described.

A transdiagnostic comparison of enhanced cognitive behaviour therapy (CBT-E) and interpersonal psychotherapy in the treatment of eating disorders

Eating disorders may be viewed from a transdiagnostic perspective and there is evidence supporting a transdiagnostic form of cognitive behaviour therapy (CBT-E). The aim of the present study was to compare CBT-E with interpersonal psychotherapy (IPT), a leading alternative treatment for adults with an eating disorder. One hundred and thirty patients with any form of eating disorder (body mass index >17.5 to <40.0) were randomized to either CBT-E or IPT. Both treatments involved 20 sessions over 20 weeks followed by a 60-week closed follow-up period. Outcome was measured by independent blinded assessors. Twenty-nine participants (22.3%) did not complete treatment or were withdrawn. At post-treatment 65.5% of the CBT-E participants met criteria for remission compared with 33.3% of the IPT participants (p < 0.001). Over follow-up the proportion of participants meeting criteria for remission increased, particularly in the IPT condition, but the CBT-E remission rate remained higher (CBT-E 69.4%, IPT 49.0%; p = 0.028). The response to CBT-E was very similar to that observed in an earlier study. The findings indicate that CBT-E is potent treatment for the majority of outpatients with an eating disorder. IPT remains an alternative to CBT-E, but the response is less pronounced and slower to be expressed. Current controlled trials ISRCTN 15562271.

Do adolescents with eating disorder not otherwise specified or full-syndrome bulimia nervosa differ in clinical severity, comorbidity, risk factors, treatment outcome or cost?

OBJECTIVE We wanted to know whether adolescents with eating disorder not otherwise specified (EDNOS) differ from those with bulimia nervosa (BN) in clinical features, comorbidity, risk factors, treatment outcome or cost. METHOD Adolescents with EDNOS (n = 24) or BN (n = 61) took part in a trial of family therapy versus guided self-care. At baseline, eating disorder symptoms, risk factors, and costs were assessed by interview. Patients were reinterviewed at 6 and 12 months. RESULTS Compared with EDNOS, BN patients binged, vomited and purged significantly more, and were more preoccupied with food. Those with EDNOS had more depression and had more current and childhood obsessive-compulsive disorder. 66.6% of EDNOS versus 27.8% of BN patients were abstinent from bingeing and vomiting at 1 year. Diagnosis did not moderate treatment outcome. Costs did not differ between groups. CONCLUSION EDNOS in adolescents is not trivial. It has milder eating disorder symptoms but more comorbidity than BN.

Interpersonal Psychotherapy for Eating Disorders

Interpersonal psychotherapy (IPT) is a leading evidence-based treatment for those eating disorders in which binge eating is a feature. This article begins with a consideration of the rationale for using IPT to treat patients with eating disorders. This is followed by a review of the evidence supporting its use and a brief description of treatment including an illustrative clinical case vignette. The article closes with a discussion of possible future directions for research on IPT for eating disorders.Interpersonal psychotherapy (IPT) is a leading evidence-based treatment for those eating disorders in which binge eating is a feature. This article begins with a consideration of the rationale for using IPT to treat patients with eating disorders. This is followed by a review of the evidence supporting its use and a brief description of treatment including an illustrative clinical case vignette. The article closes with a discussion of possible future directions for research on IPT for eating disorders. Copyright

Why do adolescents with bulimia nervosa choose not to involve their parents in treatment

BackgroundAlthough the use of family therapy for adolescents with anorexia nervosa is well established, there has been limited research into the efficacy of family therapy in adolescents with bulimia nervosa (BN). No previous research has investigated why individuals with BN do or do not involve their parents in treatment. This is an exploratory study aimed at determining whether there are any differences between these individuals in terms of eating disorder symptomatology, psychopathology, familial risk factors, patients’ perception of parental expressed emotion (EE) and family functioning.MethodsParticipants were 85 adolescents with BN or Eating Disorder Not Otherwise Specified, recruited to a randomised controlled evaluation of the cost-effectiveness of cognitive-behavioural guided self-care vs. family therapy. Participants were interviewed regarding the history of their eating disorder and completed self-report measures.ResultsPatients who did not involve their parents in treatment were significantly older, had more chronic eating disorder symptoms, exhibited more co-morbid and impulsive behaviours and rated their mothers higher in EE. However, they did not have more severe eating disorder symptomatology.ConclusionsThese preliminary findings, although in need of replication with a larger sample and limited by the attrition rate in some of the self-report measures, indicate that patients who did not involve their parents in treatment may perceive their mothers as having a more blaming and negative attitude towards the patient’s illness. Public awareness about BN needs to be raised, focusing on reducing the stigma and negative views attached to this illness.

Risk factors, correlates, and markers in early-onset bulimia nervosa and EDNOS

OBJECTIVE This study aimed to investigate the specific risk factors, correlates, and markers associated with the development of symptomatology of early-onset BN and subclinical BN. METHOD Two semi-structured interviews were used to examine symptomatology and antecedent factors of bulimic symptoms in a sample of British adolescents. RESULTS Adolescents with early-onset eating pathology were significantly more likely to report an earlier age of menarche than those developing the disorder at the typical age, and were found to have a different pathway of symptom development. DISCUSSION Increased awareness of this may help identify those particularly at risk for developing an early-onset of eating pathology.

Motivation to change in recent onset and long-standing bulimia nervosa: Are there differences?

REASON FOR THE STUDY: Little is known about how motivation to change evolves over the course of an eating disorder. The present study compared ‘stage of change’ and motivation, confidence and readiness to change in two groups of patients with bulimia nervosa (BN), adolescents with a short duration of illness and adults with a long duration of illness. METHOD: Patients completed the Severity of eating disorder symptomatology scale, Hospital Anxiety and Depression Scale and measures of stage of change and motivation, readiness and confidence to change their bulimic symptomatology at pre-treatment.MAIN FINDINGS: Short- and long duration groups did not differ in illness severity, comorbidity, stage of change, motivation, readiness, and confidence to change. There were, however, some differences between groups in terms of the relationship between motivational measures, illness severity, duration and comorbidity. CONCLUSIONS: There seem to be more similarities than differences between adolescents with short duration of illness and those with well-established BN in terms of their motivation to change.

Predictors and moderators of response to enhanced cognitive behaviour therapy and interpersonal psychotherapy for the treatment of eating disorders.

Consistent predictors, and more especially moderators, of response to psychological treatments for eating disorders have not been identified. The present exploratory study examined predictors and moderators of outcome in adult patients who took part in a randomised clinical trial comparing two leading treatments for these disorders, enhanced cognitive behavioural therapy (CBT-E) and interpersonal psychotherapy (IPT). Four potentially important findings emerged. Firstly, patients with a longer duration of disorder were less likely to benefit from either treatment. Second, across the two treatments the presence, at baseline, of higher levels of over-evaluation of the importance of shape predicted a less good treatment outcome. Third DSM-IV diagnosis did not predict treatment outcome. Fourth, with the exception of patients with baseline low self-esteem who achieved a better outcome with CBT-E, it was generally not possible to identify a subgroup of patients who would differentially benefit from one or other treatment.

Treating eating disorders using the internet.

Purpose of review This article evaluates the empirical standing of online treatment (eTherapy) for people with an established eating disorder. Recent findings There have been four randomized controlled trials of eTherapy for people with an eating disorder. All four focused on eating disorders characterized by binge eating and recruited adult participants direct from the community. The interventions were cognitive behavioural in nature, lasted between 3 and 7 months, and were accompanied by external support. In common with eTherapy for other mental health problems, there were problems engaging and retaining the users, and maximizing their implementation of the intervention. A minority (10–37%, intent-to-treat figures) improved substantially. Summary This is a new field. The findings of the four randomized controlled trials are consistent with the earlier reports indicating that guided eTherapy interventions of a cognitive behavioural nature are acceptable to (female) adults with a binge eating problem and that a subgroup improves substantially. More effective interventions are required and their use in different healthcare settings needs to be investigated. Direct-to-sufferer eTherapy interventions have the potential to increase access to effective forms of treatment and, in younger cases, they might serve as a form of secondary prevention.