Comparative efficacy and acceptability of psychological interventions for the treatment of adult outpatients with anorexia nervosa: a systematic review and network meta-analysis.

BACKGROUND: No consistent first-option psychological interventions for adult outpatients with anorexia nervosa emerges from guidelines. We aimed to compare stand-alone psychological interventions for adult outpatients with anorexia nervosa with a specific focus on body-mass index, eating disorder symptoms, and all-cause dropout rate. METHODS: In this systematic review and network meta-analysis, we assessed randomised controlled trials about stand-alone pharmacological or non-pharmacological treatments of adult outpatients with anorexia nervosa, defined according to standardised criteria, with data for at least two timepoints relating to either body-mass index or global eating disorder psychopathology. We searched Cochrane CENTRAL, CINAHL, MEDLINE, and PsychINFO for published and unpublished literature from inception until March 20, 2020. The primary outcomes were the change in body mass index and clinical symptoms, and the secondary outcome was all-cause dropout rate, which were all assessed for treatment as usual, cognitive behavioural therapy (CBT), Maudsley anorexia treatment for adults, family-based treatment, psychodynamic-oriented psychotherapies, a form of CBT targeting compulsive exercise, and cognitive remediation therapy followed by CBT. Global and local inconsistencies for the network meta-analysis were measured, and CINeMA was used to assess the confidence in evidence for primary outcomes. The protocol is registered in PROSPERO (CRD42017064429). FINDINGS: Of 14 003 studies assessed for their title and abstract, 16 (0·1%) randomised controlled trials for psychological treatments were included in the systematic review, of which 13 (0·1%) contributed to the network meta-analysis, with 1047 patients in total (of whom 1020 [97·4%] were female). None of the interventions outperformed treatment as usual in our primary outcomes, but the all-cause dropout rate was lower for CBT than for psychodynamic-oriented psychotherapies (OR 0·54, 95% CI 0·31-0·93). Heterogeneity or inconsistency emerged only for a few comparisons. Confidence in the evidence was low to very low. INTERPRETATION: Compared with treatment as usual, specific psychological treatments for adult outpatients with anorexia nervosa can be associated with modest improvements in terms of clinical course and quality of life, but no reliable evidence supports clear superiority or inferiority of the specific treatments that are recommended by clinical guidelines internationally. Our analysis is based on the best data from existing clinical studies, but these findings should not be seen as definitive or universally applicable. There is an urgent need to fund new research to develop and improve therapies for adults with anorexia nervosa. Meanwhile, to better understand the effects of available treatments, participant-level data should be made freely accessible to researchers to eventually identify whether specific subgroups of patients are more likely to respond to specific treatments. FUNDING: Flinders University, National Institute for Health Research Oxford Health Biomedical Research Centre.

A randomised controlled trial of three psychological treatments for anorexia nervosa.

BACKGROUND: There is a lack of evidence pointing to the efficacy of any specific psychotherapy for adults with anorexia nervosa (AN). The aim of this study was to compare three psychological treatments for AN: Specialist Supportive Clinical Management, Maudsley Model Anorexia Nervosa Treatment for Adults and Enhanced Cognitive Behavioural Therapy. METHOD: A multi-centre randomised controlled trial was conducted with outcomes assessed at pre-, mid- and post-treatment, and 6- and 12-month follow-up by researchers blind to treatment allocation. All analyses were intention-to-treat. One hundred and twenty individuals meeting diagnostic criteria for AN were recruited from outpatient treatment settings in three Australian cities and offered 25-40 sessions over a 10-month period. Primary outcomes were body mass index (BMI) and eating disorder psychopathology. Secondary outcomes included depression, anxiety, stress and psychosocial impairment. RESULTS: Treatment was completed by 60% of participants and 52.5% of the total sample completed 12-month follow-up. Completion rates did not differ between treatments. There were no significant differences between treatments on continuous outcomes; all resulted in clinically significant improvements in BMI, eating disorder psychopathology, general psychopathology and psychosocial impairment that were maintained over follow-up. There were no significant differences between treatments with regard to the achievement of a healthy weight (mean = 50%) or remission (mean = 28.3%) at 12-month follow-up. CONCLUSION: The findings add to the evidence base for these three psychological treatments for adults with AN, but the results underscore the need for continued efforts to improve outpatient treatments for this disorder. Trial Registration Australian New Zealand Clinical Trials Registry (ACTRN 12611000725965) http://www.anzctr.org.au/.

Mind the gap: Improving the dissemination of CBT.

Empirically supported psychological treatments have been developed for a range of psychiatric disorders but there is evidence that patients are not receiving them in routine clinical care. Furthermore, even when patients do receive these treatments there is evidence that they are often not well delivered. The aim of this paper is to identify the barriers to the dissemination of evidence-based psychological treatments and then propose ways of overcoming them, hence potentially bridging the gap between research findings and clinical practice.

Toward an understanding of risk factors for anorexia nervosa: a case-control study.

BACKGROUND: Prospective, longitudinal studies of risk factors for anorexia nervosa (AN) are lacking and existing cross-sectional studies are generally narrow in focus and lack methodological rigor. Building on two studies that used the Oxford Risk Factor Interview (RFI) to establish time precedence and comprehensively assess potential risk correlates for AN, the present study advances this line of research and represents the first case-control study of risk factors for AN in the USA. METHOD: The RFI was used for retrospective assessment of a broad range of risk factors, while establishing time precedence. Using a case-control design, 50 women who met DSM-IV criteria for AN were compared to those with non-eating disorder DSM-IV psychiatric disorders (n=50) and those with no psychiatric disorder (n=50). RESULTS: Women with psychiatric disorders reported higher rates of negative affectivity, maternal and paternal parenting problems, family discord, parental mood and substance disorder, and physical and sexual abuse than women with no psychiatric disorder. Women with AN specifically reported greater severity and significantly higher rates of negative affectivity, perfectionism and family discord, and higher parental demands than women with other psychiatric disorders. The role of weight and shape concerns was most salient in the year preceding onset of AN. CONCLUSIONS: Convergent data identifying common risk factors as well as those more severe in the development of AN are emerging to inform longitudinal risk factor and prevention studies for this disorder.

The interpretation of symptoms of severe dietary restraint.

A recent cognitive-behavioural theory of eating disorders proposes that people with eating disorders interpret symptoms of dietary restraint in terms of control. The primary aim of the present study was to test this hypothesis. A second aim was to test the hypothesis derived from clinical observation that people with eating disorders view these symptoms positively. Forty-four participants meeting DSM-IV criteria for a clinical eating disorder and 80 control participants with no history of an eating disorder completed an ambiguous scenario paradigm and self-report measures of eating disorder features and depression. Patients with eating disorders were significantly more likely to interpret symptoms of dietary control in terms of control, providing support for the cognitive-behavioural theory. There was only partial support for the second hypothesis. The implications for the new cognitive-behavioural theory and therapy are discussed.

Binge eating disorder in extreme obesity.

OBJECTIVE: To determine whether extremely obese binge eating disorder (BED) subjects (BED defined by the Eating Disorder Examination) differ from their extremely obese non-BED counterparts in terms of their eating disturbances, psychiatric morbidity and health status. DESIGN: Prospective clinical comparison of BED and non-BED subjects undergoing gastric bypass surgery (GBP). SUBJECTS: Thirty seven extremely obese (defined as BMI > or = 40 kg/m(2)) subjects (31 women, six men), aged 22-58 y. MEASUREMENTS: Eating Disorder Examination 12th Edition (EDE), Three Factor Eating Questionnaire (TFEQ), Structured Clinical Interview for the Diagnostic and Statistical Manual-IV (SCID-IV), Short-Form Health Status Survey (SF-36), and 24 h Feeding Paradigm. RESULTS: Twenty-five percent of subjects were classified as BED (11% met full and 14% partial BED criteria) and 75% of subjects were classified as non-BED. BED (full and partial) subjects had higher eating disturbance in terms of eating concern and shape concern (as found by the EDE), higher disinhibition (as found by the TFEQ), and they consumed more liquid meal during the 24 h feeding paradigm. No difference was found in psychiatric morbidity between BED and non-BED in terms of DSM-IV Axis I diagnosis. The health status scores of both BED and non-BED subjects were significantly lower than US norms on all subscales of the SF-36, particularly the BED group. CONCLUSION: Our findings support the validity of the category of BED within a population of extremely obese individuals before undergoing GBP. BED subjects differed from their non-BED counterparts in that they had a greater disturbance in eating attitudes and behavior, a poorer physical and mental health status, and a suggestion of impaired hunger/satiety control. However, in this population of extremely obese subjects, the stability of BED warrants further study.

Death and dementia.

OBJECTIVE: To investigate the last phase of dementia and the causes of death; comparing autopsy and death certificate diagnoses. DESIGN: Prospective, 11-year, longitudinal study of behavioural and psychological changes in dementia, with autopsy follow-up. SETTING: Participants with dementia, living at home with a carer. All lived in Oxfordshire, UK. PARTICIPANTS: Ninety-one people with dementia (Alzheimer's disease and/or vascular dementia) who died during the course of the study. MEASURES: At four-monthly intervals, carers were interviewed about the participants' behaviour using the Present Behavioural Examination. Participants were also assessed cognitively. Causes of death were established from death certificates and, where possible, from post-mortem examination. RESULTS: The main immediate cause of death recorded at autopsy was pneumonia (57%), followed by cardiovascular disease (16%) and pulmonary embolus (14%). This agreed with the immediate cause of death on 53% of death certificates. Pulmonary embolism and bronchopneumonia were under-reported on death certificates. Dementia was mentioned on 73% of death certificates. The dementing illness lasted for a mean of 8.5 years with 58% dying in a debilitated state associated with severe dementia. In the period before death, 35% were unable to walk, 58% were hypophagic, 73% were incontinent of urine, 21% incontinent of faeces and 76% entered an institution permanently for a mean period of 18 months. CONCLUSION: Family and professional carers of people with dementia can be given some information about prognosis to help them plan for the likely outcome of dementia.

Gender differences in the relationship between personality dimensions and relative body weight.

OBJECTIVE: The relationship between body mass index (BMI: kg/m(2)) and personality seems to differ for men and women, although these effects may be driven by the extremes of the BMI distribution. It is unclear whether these associations exist for most individuals in the relatively normal range of BMI scores, excluding the thinnest and heaviest extremes in the population. We tested the association of BMI with neuroticism, extraversion, and psychoticism with a trimmed BMI sample. RESEARCH METHODS AND PROCEDURES: Using a cross-sectional design, we tested the association of BMI with the aforementioned psychological variables in a British population-based sample. Participants were 7889 adult men and women (30 to 50 years old) selectively sampled from four counties in west England. Participants reported their height and weight and completed the Eysenck Personality Inventory (EPQ). We tested the association of BMI with the EPQ subscales among individuals with BMI >or=19.16 kg/m(2) and

A comparison of black and white women with binge eating disorder.

OBJECTIVE: Binge eating disorder was introduced in DSM-IV as a psychiatric disorder needing further study. This community-based study describes the relationship between race and clinical functioning in black and white women with and without binge eating disorder. METHOD: A group of 150 women with binge eating disorder (52 black, 98 white) and a race-matched group of 150 healthy comparison subjects were recruited from the community. Eating and psychiatric symptoms were assessed through interviews and self-report. RESULTS: Black and white women with binge eating disorder differed significantly on numerous eating disorder features, including binge frequency, restraint, history of other eating disorders, treatment-seeking behavior, and concerns with eating, weight, and shape. Black and white healthy comparison subjects differed significantly in obesity rates. CONCLUSIONS: For both black and white women, binge eating disorder was associated with significant impairment in clinical functioning. Yet, racial differences in clinical presentation underscore the importance of considering race in psychopathology research.

Wandering in dementia: a longitudinal study.

OBJECTIVE: This article analyzes the natural history of wandering behavior throughout the course of dementia. DESIGN: Prospective, 10-year, longitudinal study of wandering behavior in dementia, with autopsy follow-up. SETTING: Participants with dementia, living at home with a carer. All lived in Oxfordshire, UK. PARTICIPANTS: Eighty-six people with dementia who were living at home with a carer and who were able to walk unaided at entry to study. MEASURES: At 4-monthly intervals, the carers were interviewed using the Present Behavioural Examination to assess wandering behavior in detail; participants with dementia were assessed cognitively. Nine types of "wandering" behavior were distinguished. RESULTS: Changes in wandering behavior were not generally related to gender, age, or time since onset of dementia. Onset of different types of wandering behavior showed some relationship with cognitive state. Various forms of increased walking first appeared during moderate dementia, each type typically persisting for 1 to 2 years. Late dementia was characterized by decreased walking and immobility. CONCLUSIONS: Wandering behavior in dementia can cause great problems for carers. There are different causes for such changes, some of which are related to cognitive ability, for example increased confusion results in ineffectual "pottering" and getting lost. Increased walking at night corresponds with disruption of diurnal rhythm.

Influence of psychiatric disorder on the controlling behaviour of mothers with 1-year-old infants. A study of women with maternal eating disorder, postnatal depression and a healthy comparison group.

BACKGROUND: Certain styles of parental controlling behaviour influence child development. Work with mothers with eating disorders suggests that they may be particularly controlling of their infants. AIMS: To examine the nature and specificity of maternal controlling behaviour in mothers with eating disorders compared with mothers who had experienced postnatal depression and a healthy comparison group. METHOD: Mothers with eating disorders (n=34), postnatal depression (n=39) and a healthy comparison group (n=61) and their 12-month-old infants were observed during play and mealtimes, and blind ratings made of verbal and non-verbal control exerted by the mother. RESULTS: Mothers in the eating disorder group used more verbal control, especially strong control. There were no differences between the groups on gentle verbal control and physical contact. Maternal dietary restraint was the one feature of eating disorder psychopathology associated with the use of verbal control. Marital criticism was also associated with the extent of verbal controlling behaviour. CONCLUSIONS: Aspects of maternal control of infants were found to be specific to maternal eating disorder psychopathology.

Bias in binge eating disorder: how representative are recruited clinic samples?

The aim of this study was to investigate sampling bias as it affects recruited clinic samples of binge eating disorder (BED). Demographic and clinical characteristics of a recruited clinic sample were compared with a community sample. The 2 groups met the same operational definition of BED and were assessed using the same primarily interview-based methods. Ethnicity, severity of binge eating, and social maladjustment were found to increase treatment seeking among participants with BED rather than levels of psychiatric distress or comorbidity. These findings suggest that previous studies using recruited clinic samples have not biased estimates of psychiatric comorbidity in BED.

Modification of eating attitudes and behavior in adolescent girls: A controlled study.

OBJECTIVE: The aim of this study was to evaluate the effectiveness of a school-based eating disorder prevention program designed to reduce dietary restraint and concern about shape and weight among adolescent girls. METHOD: A total of 474 girls aged 13-14 years received the program as part of their normal school curriculum. An assessment-only control group included 386 pupils. Measures of eating disorder features, self-esteem, and knowledge were administered before and after the intervention and at 6-month follow-up. RESULTS: Immediately following the intervention, there was a small reduction in dietary restraint and attitudes to shape and weight in the index group, whereas there was no change in the control group. This reduction was not maintained at 6-month follow-up although the dietary restraint scores of the index group remained lower than those of the control group. DISCUSSION: This prevention program achieved change in eating attitudes and behavior, although the change was modest in size and not sustained. Focusing on a high-risk subgroup of dieters might be a more fruitful primary prevention strategy.

Comparison of binge eating disorder and bulimia nervosa in a community sample.

OBJECTIVE: This study examined the relationship between binge eating disorder (BED), a newly proposed eating disorder, and bulimia nervosa (BN). METHOD: Three groups recruited from the community were compared: women with BED (n = 150), women with purging BN (n = 48), and women with nonpurging BN (n = 14). RESULTS: The three groups did not differ significantly in education, weight or shape concern, and current or lifetime prevalence of nine major mental disorders. Women with BED, compared with women with purging BN, were older, less likely to have a history of anorexia nervosa, and less likely to have been treated for an eating disorder. Obesity was more commonly associated with BED than with either subtype of BN. DISCUSSION: Our results lend some support to BED as an eating disorder distinct from purging BN. More research is needed to clarify the position of nonpurging BN relative to BED and purging BN.

A new cognitive behavioural approach to the treatment of obesity.

While behavioural approaches to the management of obesity are often successful in achieving clinically significant weight loss, the weight lost is generally regained. The great majority of patients return to their pre-treatment weight within 3 years. There have been attempts to improve the long-term effectiveness of behavioural treatment but the results have been disappointing. In this paper we suggest that, among other factors, this is because of the neglect of the contribution of cognitive factors to weight regain, and because there is often ambiguity over the goals of treatment. We present a cognitive behavioural analysis of the processes involved in weight regain, and we describe a new cognitive behavioural treatment derived from it. This treatment is designed to minimise the problem of weight regain by addressing psychological obstacles to the acquisition of, and long-term adherence to, effective weight-control behaviour.

Eating disorder examination questionnaire: norms for young adolescent girls.

This paper reports young adolescent female norms for the Eating Disorder Examination Questionnaire (EDE-Q). The standardization sample was comprised of 808 girls aged between 12 and 14 years from three single-sex schools (one private and two state schools). Means, standard deviations and percentile ranks for raw EDE-Q subscale scores are presented. Prevalence figures for key eating disorder behaviors over the previous two weeks were as follows: 4% self-induced vomiting; 1% laxative misuse; 0.4% diuretic misuse; and 8% regular binge eating.

The natural course of bulimia nervosa and binge eating disorder in young women.

BACKGROUND: Little is known about the relative course and outcome of bulimia nervosa and binge eating disorder. METHODS: Two community-based cohorts were studied prospectively over a 5-year year period. One comprised 102 participants with bulimia nervosa and the other 48 participants with binge eating disorder (21% [9/42] of whom had comorbid obesity). All participants were female and aged between 16 and 35 years at recruitment. The assessments were at 15-month intervals and addressed eating disorder features, general psychiatric symptoms, and social functioning. RESULTS: Both cohorts showed marked initial improvement followed by gradual improvement thereafter. Between half and two thirds of the bulimia nervosa cohort had some form of eating disorder of clinical severity at each assessment point, although only a minority continued to meet diagnostic criteria for bulimia nervosa. Each year about a third remitted and a third relapsed. The outcome of the binge eating disorder cohort was better, with the proportion with any form of clinical eating disorder declining to 18% (7 of 40) by the 5-year follow-up. The relapse rate was low among this cohort. There was little movement of participants across the 2 diagnostic categories and few sought treatment. Both groups gained weight, with 39% of the binge eating disorder cohort (14 of 36) meeting criteria for obesity at 5-year follow-up. CONCLUSIONS: These findings suggest that, among young women in the community, bulimia nervosa and binge eating disorder have a different course and outcome. Whereas the prognosis of those with bulimia nervosa was relatively poor, the great majority of those with binge eating disorder recovered.

Fluoxetine for bulimia nervosa following poor response to psychotherapy.

OBJECTIVE: This was an investigation of whether treatment with fluoxetine is useful for individuals with bulimia nervosa who do not respond to psychotherapy or relapse afterward. METHOD: Twenty-two patients with bulimia nervosa who had not responded to, or had relapsed following, a course of cognitive behavior therapy or interpersonal psychotherapy were randomly assigned to receive placebo (N=9) or fluoxetine (60 mg/day, N=13) for 8 weeks. RESULTS: The median frequency of binge eating in the previous 28 days declined from 22 to four episodes in the fluoxetine group but increased from 15 to 18 episodes in the placebo group. Similarly, purging frequency in the previous 28 days declined from 30 to six episodes in the fluoxetine group but increased from 15 to 38 episodes in the placebo group. CONCLUSIONS: Fluoxetine may be a useful intervention for patients with bulimia nervosa who have not responded adequately to psychological treatment.