Comparing integrative cognitive-affective therapy and guided self-help cognitive-behavioral therapy to treat binge-eating disorder using standard and naturalistic momentary outcome measures: A randomized controlled trial.

OBJECTIVE: Innovative treatments and outcome measures are needed for binge-eating disorder (BED). This randomized controlled trial compared Integrative Cognitive-Affective Therapy (ICAT-BED), an individual psychotherapy targeting momentary behavioral and emotional precipitants of binge eating, with an established cognitive-behavioral guided self-help (CBTgsh) treatment using standard and ecological momentary assessment (EMA) outcome measures. METHOD: A total of 112 participants were randomized to 17 weeks of treatment (21 sessions for ICAT-BED and 10 sessions for CBTgsh). Binge-eating frequency was assessed with the Eating Disorder Examination (EDE) as well as EMA using cell phone-based real-time, naturalistic assessment at end of treatment (EOT) and 6-month follow-up. Hypothesized maintenance mechanisms were assessed using self-report questionnaires. RESULTS: Binge-eating frequency as measured by the EDE and real-time assessment showed significant reductions at EOT and follow-up, with no significant differences between treatments. Hypothesized maintenance mechanisms, including emotion regulation, cognitive self-discrepancy, self-directed style, as well as measures of associated eating disorder psychopathology, depression, anxiety, impulsivity, and negative affect, showed similar improvement at EOT and follow-up with no differences between treatments. Abstinence rates at EOT (ICAT-BED: 57.1%; CBTgsh: 42.9%) and 6-month follow-up (ICAT-BED: 46.4%; CBTgsh: 42.9%) were not significantly different. Treatment retention was significantly higher for ICAT-BED (87.5%) than CBTgsh (71.4%). DISCUSSION: These findings suggest that ICAT-BED and CBTgsh were associated with similar improvements in binge eating, psychopathology, and putative maintenance mechanisms as measured by traditional self-report and momentary, naturalistic assessments and that these changes were generally sustained at 6-month follow-up.

Eating Pathology After Bariatric Surgery: an Updated Review of the Recent Literature.

PURPOSE OF REVIEW: The goal of this paper was to extend the prior literature on eating pathology following bariatric surgery by highlighting themes in data published over the past 3 years and identifying limitations and future directions for research. RECENT FINDINGS: Changes in eating pathology after bariatric surgery remain consistent with previous research. Specifically, diagnostic prevalence rates and incidence of related behaviors generally decrease following surgery. However, some research supports that these factors increase and/or remit over time following surgery, and that they subsequently have a negative impact on weight loss outcomes. While recent findings have extended knowledge on eating pathology following bariatric surgery, the overall body of literature is still relatively limited. Additional research is needed, including work focusing on the standardization of eating pathology definitions, development/validation of standardized eating pathology instruments for bariatric surgery patients, and predictors of risk for continued or new onset eating pathology following surgery.

The effects of psychotherapy treatment on outcome in bulimia nervosa: Examining indirect effects through emotion regulation, self-directed behavior, and self-discrepancy within the mediation model.

OBJECTIVE: The purpose of this investigation was to examine the indirect effects of Integrative Cognitive-Affective Therapy (ICAT-BN) and Cognitive-Behavioral Therapy-Enhanced (CBT-E) on bulimia nervosa (BN) treatment outcome through three hypothesized maintenance variables: emotion regulation, self-directed behavior, and self-discrepancy. METHOD: Eighty adults with BN were randomized to 21 sessions of ICAT-BN or CBT-E. A regression-based bootstrapping approach was used to test the indirect effects of treatment on outcome at end of treatment through emotion regulation and self-directed behavior measured at mid-treatment, as well as the indirect effects of treatment at follow-up through emotion regulation, self-directed behavior, and self-discrepancy measured at end of treatment. RESULTS: No significant differences in outcome between treatment conditions were observed, and no significant direct or indirect effects were found. Examination of the individual paths within the indirect effects models revealed comparable treatment effects. Across treatments, improvements in emotion regulation and self-directed behavior between baseline and mid-treatment predicted improvements in global eating disorder scores but not binge eating and purging frequency at end of treatment. Baseline to end of treatment improvements in emotion regulation and self-directed behavior also predicted improvements in global eating disorder scores at follow-up. Baseline to end of treatment improvements in emotion regulation predicted improvements in binge eating and baseline to end of treatment increases in positive self-directed behavior predicted improvements in purging at follow-up. DISCUSSION: These findings suggest that emotion regulation and self-directed behavior are important treatment targets and that ICAT-BN and CBT-E are comparable in modifying these psychological processes among individuals with BN.

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, ßs = 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.

Clinical utility of subtyping binge eating disorder by history of anorexia or bulimia nervosa in a treatment sample.

OBJECTIVE: This study examined whether having a history of anorexia nervosa (AN) or bulimia nervosa (BN) is associated with response to treatment in adults with binge eating disorder (BED). METHOD: Data from 189 adults diagnosed with BED who were randomly assigned to one of three group cognitive-behavioral (CBT) treatments were analyzed to compare those with and without a history of AN/BN. RESULTS: A total of 16% of the sample had a history of AN/BN. The BED subgroup with a history of AN/BN presented with higher rates of mood disorders and greater eating-related symptom severity at baseline. Participants with a history of AN/BN also had higher global eating disorder (ED) symptoms at end of treatment (EOT), and more frequent objective binge-eating episodes at EOT and 12-month follow-up. DISCUSSION: These findings suggest that in adults with BED, a history of AN/BN is predictive of greater eating-related symptom severity following group-based CBT and poorer short- and long-term binge-eating outcomes. These findings suggest that considering ED history in the treatment of adults with BED may be clinically useful.

Binge eating, binge eating disorder and loss of control eating: effects on weight outcomes after bariatric surgery.

There is increasing evidence that patients who have problems with binge eating (BE) or BE disorder (BED) are quite common among the severely obese, including bariatric surgery candidates. The literature suggests that in many cases such eating behaviours improve after bariatric surgery, although this is not uniformly true. The current paper reviews the data on the development of BE, BED and loss of control (LOC) eating after bariatric surgery and the impact of these problems on long-term weight outcome. A search was made of various databases regarding evidence of BE, BED and LOC eating post-operatively in bariatric surgery patients. The data extracted from the literature suggests that 15 research studies have now examined this question. Fourteen of the available 15 studies suggest that the development of problems with BE, BED or LOC eating post-bariatric surgery is associated with less weight loss and/or more weight regain post-bariatric surgery. These data suggests that it is important to identify individuals at high risk for these problems, to follow them post-operatively, and, if appropriate interventions can be developed if such behaviours occur in order to maximize weight loss outcomes.

Psychiatric aspects of bariatric surgery.

While most conventional treatments for individuals with severe obesity have a modest and short lived impact bariatric surgery has been consistently shown to result in long-term marked weight loss and significant improvement in medical comorbidities. Empirical data suggest a high prevalence of mental disorders among bariatric surgery candidates. This article reviews specific areas of psychopathology, problems in using psychopharmacological medications post-surgery, body contouring, and recommendations for pre and post-surgery care. Available research indicates a decrease in psychiatric symptoms post-surgery. However, in some patients the improvement appears to erode over time. Therefore, bariatric surgery patients should be monitored not only before surgery but also following surgery and referred for mental health treatment if problems develop.

A cost effectiveness analysis of stepped care treatment for bulimia nervosa.

BACKGROUND: The cost effectiveness of various treatment strategies for bulimia nervosa (BN) is unknown. AIMS: To examine the cost effectiveness of stepped care treatment for BN. METHOD: Randomized trial conducted at four clinical centers with intensive measurement of direct medical costs and repeated measurement of subject quality of life and family/significant other time involvement. Two hundred ninety-three women who met DSM-IV criteria for BN received stepped care treatment or cognitive behavioral therapy. Cost effectiveness ratios were compared. RESULTS: The cost per abstinent subject was $12,146 for stepped care, and $20,317 for cognitive behavioral therapy. Quality of life ratings improved significantly with treatment, and family/significant other time burden diminished substantially. DISCUSSION: In this trial, stepped care for BN appeared cost effective in comparison to cognitive behavioral therapy. Treatment was associated with improved quality of life and diminished time costs of illness.

Therapeutic factors affecting the cognitive behavioral treatment of bulimia nervosa via telemedicine versus face-to-face delivery.

OBJECTIVE: Recently, Mitchell et al. (Behav Res Ther, 46, 581-592, 2008) conducted a randomized controlled trial of an empirically supported treatment for bulimia nervosa (BN) delivered face-to-face (FTF-CBT) or via telemedicine (TV-CBT). Results suggested that the TV-CBT and FTF-CBT were generally equivalent in effectiveness. The objective of the current study was to examine ratings of therapeutic alliance factors in TV-CBT and FTF-CBT. METHOD: Data obtained from 116 adults who met criteria for BN or eating disorder-not otherwise specified with binge eating or purging weekly and six doctoral-level psychologists who delivered the therapy were used in the analyses. RESULTS: Therapists generally endorsed greater differences between the treatment delivery methods than patients. Patients tended to make significantly higher ratings of therapeutic factors than therapists. DISCUSSION: TV-CBT is an acceptable method for the delivery of BN treatment compared to FTF-CBT, and TV-CBT is more easily accepted as a treatment delivery method by patients than therapists.

Associations of Pregnancy After Bariatric Surgery with Long-Term Weight Trajectories and Birth Weight: LABS-2 Study.

OBJECTIVE: This study aimed to examine whether pregnancy following bariatric surgery affects long-term maternal weight change and offspring birth weight. METHODS: Using data from the Longitudinal Assessment of Bariatric Surgery (LABS)-2 study, linear regression was used to evaluate percent change in total body weight over a 5-year follow-up period among reproductive-aged women who underwent Roux-en-Y gastric bypass or laparoscopic adjustable gastric banding as well as evaluate the association of bariatric procedure type and offspring birth weight. RESULTS: Of 727 women with preoperative age of 36.1 (6.3) years (mean [SD]) and BMI of 46.9 (7.0) kg/m2 , 80 (11%) reported at least one pregnancy. After adjusting for covariates, percent change in total body weight was not significantly different between women who became pregnant and those who did not during a 5-year follow-up period (ß = 2.02; 95% CI: -1.03 to 5.07; P = 0.19). Additionally, mean birth weight was not significantly different between mothers who underwent Roux-en-Y gastric bypass versus laparoscopic adjustable gastric banding (P = 0.99). CONCLUSIONS: Postoperative pregnancy did not diminish long-term weight loss in women in the LABS-2 study. The finding of comparable weight loss is relevant for providers counseling women of reproductive age on weight-loss expectations and family planning following bariatric surgery.

A randomized trial comparing the efficacy of cognitive-behavioral therapy for bulimia nervosa delivered via telemedicine versus face-to-face.

OBJECTIVE: A major problem in the delivery of mental health services is the lack of availability of empirically supported treatment, particularly in rural areas. To date no studies have evaluated the administration of an empirically supported manual-based psychotherapy for a psychiatric condition via telemedicine. The aim of this study was to compare the relative efficacy and acceptability of a manual-based cognitive-behavioral therapy (CBT) for bulimia nervosa (BN) delivered in person to a comparable therapy delivered via telemedicine. METHOD: One hundred twenty-eight adults meeting DSM-IV criteria for BN or eating disorder-not otherwise specified with binge eating or purging at least once per week were recruited through referrals from clinicians and media advertisements in the targeted geographical areas. Participants were randomly assigned to receive 20 sessions of manual-based, CBT for BN over 16 weeks delivered either face-to-face (FTF-CBT) or via telemedicine (TV-CBT) by trained therapists. The primary outcome measures were binge eating and purging frequency as assessed by interview at the end of treatment, and again at 3- and 12-month follow-ups. Secondary outcome measures included other bulimic symptoms and changes in mood. RESULTS: Retention in treatment was comparable for TV-CBT and FTF-CBT. Abstinence rates at end-of-treatment were generally slightly higher for FTF-CBT compared with TV-CBT, but differences were not statistically significant. FTF-CBT patients also experienced significantly greater reductions in eating disordered cognitions and interview-assessed depression. However, the differences overall were few in number and of marginal clinical significance. CONCLUSIONS: CBT for BN delivered via telemedicine was both acceptable to participants and roughly equivalent in outcome to therapy delivered in person.

Perfectionism and eating disorders: current status and future directions.

The literature examining the relation between perfectionism and eating disorders was reviewed and content and methodological comparisons were made with the perfectionism literature in anxiety disorders and depressive disorders. A PsychInfo search using the key words "perfectionism/perfect/perfectionistic," "anorexia," "bulimia," and "eating disorders" was performed and the generated list of papers was supplemented based on a review of reference lists in the papers. A total of 55 papers published between 1990 and 2005 were identified that assessed perfectionism among individuals with diagnosed eating disorders. The key research questions were distilled from these publications and empirical findings were summarized for each question, followed by a comparison with perfectionism papers in the anxiety and depressive disorder literatures. Also, key research design methodological parameters were identified and comparisons made across the three literatures: eating disorders, anxiety disorders, depressive disorders. The current review concludes with conceptual and methodological recommendations for researchers interested in perfectionism and eating disorders.

Coping strategies in bulimia nervosa treatment: impact on outcome in group cognitive-behavioral therapy.

This study's purpose was to examine the extent to which participants (N = 143) receiving cognitive-behavioral therapy for bulimia nervosa (BN) reported implementing therapeutic strategies to abstain from BN behaviors, and to assess whether use of specific strategies predicts outcome at treatment end and 1- and 6-month follow-up. Frequency of outcome expectancies (OE), stimulus-response prevention (SRP), and social support-seeking (SSS) strategies significantly increased by end of treatment. By 1-month follow-up, use of SSS, not OE or SRP, declined significantly relative to treatment end. Although frequency of coping strategy use at treatment end did not predict 1-month BN symptom remission, SSS use at 1-month follow-up predicted 6-month remission. Findings highlight the importance of social support to maintain treatment gains.

Post-operative psychosocial predictors of outcome in bariatric surgery.

Although there are several recent reviews of the pre-operative factors that influence treatment outcome for bariatric surgery, commensurate efforts to identify and review the predictive validity of post-operative variables are lacking. This review describes the post-operative psychosocial predictors of weight loss in bariatric surgery. Results suggest empirical support for post-operative binge eating, uncontrolled eating/grazing, and presence of a depressive disorder as negative predictors of weight loss outcomes; whereas, adherence to dietary and physical activity guidelines emerged as positive predictors of weight loss. With the exception of depression, psychological comorbidities were not consistently associated with weight loss outcomes. Results highlight the need for post-operative assessment of disordered eating and depressive disorder, further research on the predictive value of post-operative psychosocial factors, and development of targeted interventions.

What is "grazing"? Reviewing its definition, frequency, clinical characteristics, and impact on bariatric surgery outcomes, and proposing a standardized definition.

BACKGROUND: Grazing, characterized by a repetitive eating pattern, has received increased attention among bariatric surgery patients. However, different definitions and terminology have been used, preventing the accurate measurement of this phenomenon and comparison of data across studies. OBJECTIVE: To review existing definitions and associated clinical features of grazing among different samples and to propose a standardized definition that will allow for consistency in future work. SETTING: University and Clinical Research Institute. METHODS: Of the 39 studies found, 9 provided an original definition and 12 provided data of its association with weight outcomes. Six were studies of nonbariatric surgery populations. Based on this literature review, the most common criteria used in previous studies to define grazing were included in a survey that was sent to 24 individuals who have published work in the field. These experts were asked to provide their opinion on what should constitute grazing. RESULTS: Grazing is a frequent behavior in the bariatric surgery population as well as in eating disordered and community samples. Its association with psychopathology is not clear, but its negative impact on weight outcomes after bariatric surgery generally has been supported. Survey data provided a consensus regarding the definition of grazing as an eating behavior characterized by the repetitive eating (more than twice) of small/modest amounts of food in an unplanned manner, with what we characterize as compulsive and noncompulsive subtypes. CONCLUSIONS: Given the clinical relevance of grazing among bariatric surgery patients, a unique definition is crucial to better study its associated features and impact on different populations.

Race/ethnicity, education, and treatment parameters as moderators and predictors of outcome in binge eating disorder.

OBJECTIVE: Binge eating disorder (BED) is prevalent among individuals from minority racial/ethnic groups and among individuals with lower levels of education, yet the efficacy of psychosocial treatments for these groups has not been examined in adequately powered analyses. This study investigated the relative variance in treatment retention and posttreatment symptom levels accounted for by demographic, clinical, and treatment variables as moderators and predictors of outcome. METHOD: Data were aggregated from 11 randomized, controlled trials of psychosocial treatments for BED conducted at treatment sites across the United States. Participants were N = 1,073 individuals meeting criteria for BED including n = 946 Caucasian, n = 79 African American, and n = 48 Hispanic/Latino participants. Approximately 86% had some higher education; 85% were female. Multilevel regression analyses examined moderators and predictors of treatment retention, Eating Disorder Examination (EDE) global score, frequency of objective bulimic episodes (OBEs), and OBE remission. RESULTS: Moderator analyses of race/ethnicity and education were nonsignificant. Predictor analyses revealed African Americans were more likely to drop out of treatment than Caucasians, and lower level of education predicted greater posttreatment OBEs. African Americans showed a small but significantly greater reduction in EDE global score relative to Caucasians. Self-help treatment administered in a group showed negative outcomes relative to other treatment types, and longer treatment was associated with better outcome. CONCLUSIONS: Observed lower treatment retention among African Americans and lesser treatment effects for individuals with lower levels of educational attainment are serious issues requiring attention. Reduced benefit was observed for shorter treatment length and self-help administered in groups.

Subtypes of binge eating disorder based on psychiatric history.

OBJECTIVE: This investigation sought to identify subtypes of binge eating disorder (BED) based on history of mood disorder (MOOD) and substance use disorder (SUD). METHOD: Eighty-four women who met criteria for BED were administered semistructured interviews and completed self-report questionnaires assessing eating pathology, depressive symptoms, self-esteem, body dissatisfaction, and personality traits. RESULTS: Thirty-nine participants (46.4%) had a lifetime history of a SUD and 60 (71.4%) had a lifetime history of a MOOD. The SUD subtype was associated with a greater impulsivity and frequency of binge eating episodes compared with the no SUD subtype. The MOOD subtype participants reported greater distress, more psychopathology, less dietary restraint, lower self-esteem, more frequent binge eating, higher levels of negative affect, and more frequent trauma and abuse history than the no MOOD subtype. DISCUSSION: The results of this study indicate that subtypes of BED on the basis of MOOD and SUD may be associated with a more severe variant of the disorder.

Psychological and dietary treatments of binge eating disorder: conceptual implications.

OBJECTIVE: The authors review the available literature on psychological and dietary treatment approaches for binge eating disorder (BED). METHODS: Studies were grouped according to psychological versus dietary approaches to BED. Studies were reviewed in terms of general implications, but particular emphasis was placed on drop-out rates, abstinence from binge eating, and weight loss. RESULTS: Drop-out rates from psychological or dietary approaches to treatment averaged 20% and the presence of binge eating did not confer a greater risk of drop-out among obese individuals. Both psychological and dietary approaches to treatment produced abstinence rates from binge eating of approximately 50% at the 12-month follow-up. Both psychological and dietary approaches show modest efficacy of short-term weight loss, but these effects are generally not sustained in long-term follow-up assessments. DISCUSSION: Psychological and dietary approaches to BED treatment show reasonable efficacy in binge eating reduction, but limited efficacy in weight loss. These findings are discussed in terms of the validity of the BED construct and the need for more psychopathology studies of BED.

Report of the National Institutes of Health workshop on overcoming barriers to treatment research in anorexia nervosa.

OBJECTIVE: Anorexia nervosa (AN) is associated with serious medical morbidity and has the highest mortality rate of all psychiatric disorders. The National Institutes of Health (NIH) Workshop on Overcoming Barriers to Treatment Research in Anorexia Nervosa convened on September 26-27, 2002 to address the dearth of treatment research in this area. The goals of this workshop were to discuss the stages of illness and illness severity, pharmacologic interventions, psychological interventions, and methodologic considerations. METHOD: The program consisted of a series of brief presentations by moderators, each followed by a discussion of the topic by workshop participants, facilitated by the session chair. RESULTS: This report summarizes the major discussions of these sessions and concludes with a set of recommendations related to the development of treatment research in AN based on these findings. DISCUSSION: It is crucial that treatment research in this area be prioritized.