Shannon L. Zaitsoff

How do adolescents with bulimia nervosa rate the acceptability and therapeutic relationship in family-based treatment?

OBJECTIVE To describe therapeutic alliance and treatment acceptability ratings of adolescents with bulimia nervosa (BN) participating in family-based treatment (FBT-BN) and to explore how participant characteristics relate to these constructs. METHOD Adolescents with BN (n = 80) in a randomized controlled trial comparing FBT-BN and individual supportive psychotherapy (SPT), completed the Eating Disorder Examination, Rosenberg Self-esteem Scale, and Beck Depression Inventory prior to treatment. The Helping Relationship Questionnaire, patient expectancy for treatment, treatment suitability, and self-reported estimates of improvement ratings were obtained at multiple points throughout treatment. RESULTS Therapeutic alliance and treatment acceptability ratings were positive in both treatments and generally did not differ. Within FBT-BN, more severe eating disorder symptomatology pretreatment was related to lower alliance ratings mid-treatment (p < .05). However, reductions in binge and purge behaviors over the course of treatment were not related to alliance or acceptability for participants in FBT-BN (all ps > .10). CONCLUSION Contrary to expectations of FBT-BN, adolescents receiving both treatments develop a strong alliance with the therapist.

Eating disorder psychopathology as a marker of psychosocial distress and suicide risk in female and male adolescent psychiatric inpatients

OBJECTIVE The aim of this study was to examine psychosocial correlates of specific aspects of eating disorder (ED) psychopathology (ie, dietary restriction, body dissatisfaction, binge eating, and self-induced vomiting) in psychiatrically hospitalized adolescent girls and boys. METHOD A total of 492 psychiatric inpatients (286 adolescent girls and 206 adolescent boys), aged 12 to 19 years, completed self-report measures of psychosocial and behavioral functioning, including measures of suicide risk and ED psychopathology. Associations between ED psychopathology and psychosocial functioning were examined separately by sex and after controlling for depressive/negative affect using Beck Depression Inventory scores. RESULTS Among the adolescent boys and girls, after controlling for depressive/negative affect, ED psychopathology was significantly associated with anxiety, low self-esteem, and current distress regarding childhood abuse. Among adolescent girls, after controlling for depressive/negative affect, ED psychopathology was significantly related to hopelessness and suicidality. Among adolescent boys, after controlling for depressive/negative affect, ED psychopathology was positively related to self-reported history of sexual abuse and various externalizing problems (drug abuse, violence, and impulsivity). CONCLUSION In psychiatrically hospitalized adolescents, ED psychopathology may be an important marker of broad psychosocial distress and behavioral problems among girls and boys, although the nature of the specific associations differs by sex.

Body-Related Social Comparison and Disordered Eating among Adolescent Females with an Eating Disorder, Depressive Disorder, and Healthy Controls

The purpose of this study was to investigate the association between body-related social comparison (BRSC) and eating disorders (EDs) by: (a) comparing the degree of BRSC in adolescents with an ED, depressive disorder (DD), and no psychiatric history; and (b) investigating whether BRSC is associated with ED symptoms after controlling for symptoms of depression and self-esteem. Participants were 75 girls, aged 12–18 (25 per diagnostic group). To assess BRSC, participants reported on a 5-point Likert scale how often they compare their body to others’. Participants also completed a diagnostic interview, Eating Disorders Inventory-2 (EDI-2), Beck Depression Inventory-II (BDI-II), and Rosenberg Self-Esteem Scale (RSE). Compared to adolescents with a DD and healthy adolescents, adolescents with an ED engaged in significantly more BRSC (p ≤ 0.001). Collapsing across groups, BRSC was significantly positively correlated with ED symptoms (p ≤ 0.01), and these associations remained even after controlling for two robust predictors of both ED symptoms and social comparison, namely BDI-II and RSE. In conclusion, BRSC seems to be strongly related to EDs. Treatment for adolescents with an ED may focus on reducing BRSC.

A Case Series of Family-Based Therapy for Weight Restoration in Young Adults with Anorexia Nervosa

This case series aims to examine the preliminary efficacy, acceptability and feasibility of Family-Based Treatment to promote weight restoration in young adults with anorexia nervosa. Four young adults with sub/threshold anorexia nervosa were provided 11–20 sessions of Family-Based Treatment for young adults with pre-, post- and follow-up assessments. At post- and follow-up, 3/4 participants were in the normal weight range, 3/4 were in the non-clinical range on the Eating Disorders Examination and reported being not/mildly depressed. At post-treatment, 2/4 were in the good psychosocial functioning range and by follow-up, 3/4 were in this range. These results suggest that Family-Based Treatment for young adults with anorexia nervosa is a promising treatment.

The Role of the Therapeutic Alliance in Eating Disorder Treatment Outcomes: A Systematic Review

The therapeutic alliance has proven to be an important construct in psychotherapy outcomes research for numerous psychiatric disorders. Given that dropout rates from treatment are especially high for individuals with eating disorders, it is critical to clarify the role that the therapeutic alliance plays in predicting treatment outcomes for this specific population. MEDLINE, CINAHL, and PsycINFO databases were systematically reviewed for studies that formally measured the therapeutic alliance construct and at least one other treatment variable in the context of eating disorder treatment. We identified 19 studies that indicate the therapeutic alliance may be an important factor in eating disorder treatment, yet reflect on the paucity of research on this topic in the context of treatment outcomes for both adult and adolescent populations. Current trends and limitations in the literature are highlighted to guide future research and ultimately improve clinical outcomes for patients with eating disorders.

A meta‐analysis of the relation between therapeutic alliance and treatment outcome in eating disorders

The therapeutic alliance has demonstrated an association with favorable psychotherapeutic outcomes in the treatment of eating disorders (EDs). However, questions remain about the inter-relationships between early alliance, early symptom improvement, and treatment outcome. We conducted a meta-analysis on the relations among these constructs, and possible moderators of these relations, in psychosocial treatments for EDs. Twenty studies met inclusion criteria and supplied sufficient supplementary data. Results revealed small-to-moderate effect sizes, βs = 0.13 to 0.22 (p < .05), indicating that early symptom improvement was related to subsequent alliance quality and that alliance ratings also were related to subsequent symptom reduction. The relationship between early alliance and treatment outcome was partially accounted for by early symptom improvement. With regard to moderators, early alliance showed weaker associations with outcome in therapies with a strong behavioral component relative to nonbehavioral therapies. However, alliance showed stronger relations to outcome for younger (vs. older) patients, over and above the variance shared with early symptom improvement. In sum, early symptom reduction enhances therapeutic alliance and treatment outcome in EDs, but early alliance may require specific attention for younger patients and for those receiving nonbehaviorally oriented treatments.

Temporal Associations Between Disordered Eating and Nonsuicidal Self-Injury: Examining Symptom Overlap Over 1 Year☆

Disordered eating (DE) and nonsuicidal self-injury (NSSI) commonly co-occur. This study compared several models of the longitudinal relationship between DE and NSSI, including concurrent and prospective models, and examined the possible moderating roles of self-objectification, impulsivity, and emotion dysregulation in these relationships. Individuals with NSSI (N=197) recruited from online forums completed measures of NSSI and DE every 3 months for 1 year. We tested the associations between NSSI and DE using hierarchical linear models. Results supported a concurrent relationship, wherein frequency of NSSI positively covaried with concurrent DE severity. Body surveillance moderated the concurrent relationship between NSSI and DE. Individuals who engaged in more body surveillance endorsed high levels of DE pathology, whereas those lower in body surveillance engaged in more frequent NSSI only at higher levels of DE. In addition, whereas DE did not prospectively predict NSSI, frequency of NSSI predicted more severe DE 3 months later. The prospective relationship between DE and later NSSI was moderated by emotion dysregulation, such that highly dysregulated individuals had a stronger relationship between DE and later NSSI, whereas this relationship was not significant among individuals low in emotion dysregulation. These findings add valuable information regarding the co-occurrence of self-damaging behaviors.

A qualitative analysis of aspects of treatment that adolescents with anorexia identify as helpful.

This study aimed to identify aspects of treatment that adolescents with anorexia nervosa (AN) believe are helpful or unhelpful. Adolescent females receiving treatment for AN or subthreshold AN (n=21) were prompted during semi-structured interviews to generate responses to open-ended questions on what they felt would be most helpful or unhelpful in treating adolescents with eating disorders. Eight codes were developed and the two most frequently endorsed categories were (1) Alliance, where the therapist demonstrates clinical expertise and also expresses interest in the patient (n=21, 100.0%), and (2) Client Involvement in treatment (n=16, 76.2%). These top two categories were shared by participants with AN versus subthreshold AN and participants with high versus low readiness to change their dietary restriction behaviours. Development of the coding scheme and sample participant responses will be discussed. The integration of identified factors into empirically supported treatments for adolescent AN, such as Family-based Treatment, will be considered. This study provides initial information regarding aspects of treatment that adolescents identify as most helpful or unhelpful in their treatment.

Therapeutic engagement: Perspectives from adolescents with eating disorders

This study aimed to identify factors that adolescents with eating disorders (ED) consider important for therapeutic engagement, and to examine similarities and differences in the number of identified factors considered important for therapeutic engagement based on diagnostic status and readiness and motivation to change dietary restriction behaviors. Treatment seeking adolescent females (n=34, Mage=16.33, SD=1.34) with an ED were prompted to generate responses to 4 constructs related to therapeutic engagement: (1) Trust, (2) Agreement on therapeutic goals, (3) Confidence in Ability to Change and (4) Feelings of Inclusion in therapeutic decisions. A coding scheme for each construct was developed using a random sample of responses, and each category within a construct was rated as present or absent for each participant. Frequencies and percentages of participants who reported each category within each construct are reported. Additionally, findings indicate that the top two out of three categories reported within each construct were the same between participants with AN versus EDNOS, and between participants high and low in readiness and motivation to change dietary restriction behaviors. This study is a first step in identifying aspects of therapeutic engagement that are important to adolescents with ED, which may differ from adults.