Effects of inpatient treatment on compulsive exercise in adults with longstanding eating disorders: Secondary analysis from a randomized controlled trial with 12-month follow-up.

PURPOSE: This study aimed to examine changes in compulsive exercise among adults with eating disorders (ED) admitted for inpatient treatment in a randomized controlled trial comparing cognitive behavioral therapy (CBT) and compassion-focused therapy (CFT) and whether such changes were influenced by treatment condition, childhood trauma, or level of compulsive exercise. METHOD: A total of 130 adults admitted to inpatient treatment for EDs mean (SD) age 30.9 (9.7) years, mean illness duration 14.2 (8.9) years, were randomized to receive CBT or CFT and analyzed using multilevel modeling. Assessments included Eating Disorders Examination - Interview, Compulsive Exercise Test and Childhood Trauma Questionnaire. RESULTS: Mean total CET score at baseline was 14.7 (4.0) with no difference between the treatment groups. A total of 63 (48.5%) had CET score ≥ 15, indicating clinical levels. There was an overall time effect on reduction in CET total and all CET subscale scores except Lack of enjoyment, and CFT provided greater reduction compared to CBT on the CET subscale Mood improvements. Patients with clinical CET score levels showed greater reduction on CET total and the subscales Avoidance, Weight, and Rigidity across time compared to persons with non-clinical CET score. Childhood trauma did not predict changes in CET total or subscale scores. DISCUSSION: Both CBT and CFT improve overall compulsive exercise. The greater effect of CFT than CBT on exercise as a maladaptive mood regulator calls for further research on how affective oriented psychotherapies can not only reduce compulsive exercise but also promote functional exercise among persons with EDs. PUBLIC SIGNIFICANCE STATEMENT: Understanding and addressing compulsive exercise in adults with eating disorders is crucial. This study comparing cognitive-behavioral therapy and compassion-focused therapy shows both improve compulsive exercise. Importantly, compassion-focused therapy has a greater impact as an emotion-focused regulator. This emphasizes the need for further exploration into how emotion-focused therapies can reduce compulsive exercise and promote healthier, functional physical activity for individuals with eating disorders.

Alliance processes in eating disorders with childhood maltreatment sequelae: Preliminary implications.

BACKGROUND: Effective eating disorder (ED) treatments are drastically needed for patients with experiences of sustained and prolonged emotional, physical and sexual childhood maltreatment (CM) that often results in post-traumatic sequelae such as severe, complex posttraumatic stress disorder (cPTSD). EDs with comorbid cPTSD (cPTSD-ED) have protracted treatment courses and poorer prognoses. AIM: To summarise the knowledge base on cPTSD-ED with specific emphasis on disturbances in self-organisation (DSO) in relation to therapeutic alliance (TA) processes. METHOD: Expert opinions based on current relevant literature are critically examined. RESULTS: Preliminary insights on change and alliance processes suggest that neglecting to address emotional-relational processes in the conceptualisation and treatment of cPTSD-ED impedes treatment progress. CONCLUSION: We hypothesise that the DSO construct inherent in cPTSD-ED calls for a focus on TA processes in addition to traditional ED treatment elements such as nutritional rehabilitation and behaviour change, and regardless of ED treatment provided. More process research on a larger scale is urgently called for.

Change processes related to long-term outcomes in eating disorders with childhood trauma: An explorative qualitative study.

To date, eating disorder (ED) treatments are lacking for ED patients with psychiatric sequelae of childhood trauma, and successful outcomes are scarce. Therefore, the aim of this study was to explore therapeutic change processes from a patient perspective in relation to good versus poor long-term ED outcome at 1-year follow-up. Outcome categories were based on clinician assessment of ED behavior and diagnoses, body mass index, and Eating Disorder Examination Questionnaire scores. Eleven White, cisgendered female ED patients with childhood trauma were interviewed after a 3-month inpatient treatment: data was analyzed with elements from grounded theory and interpretative phenomenological analysis. The qualitative analysis rendered change-related descriptions (9 subcategories) and obstacles to change (6 subcategories), and 3 process-related domains differentiated good from poor long-term outcome: trauma exposure (4 subcategories), patient agency (6 subcategories), and patient-therapist dynamics (3 subcategories). First, sensory and emotional trauma exposure in good outcome informants was contrasted with avoiding or not addressing trauma and body in poor outcome informants. Second, promotion of patient agency while receiving support in the good outcome group was contrasted to an orientation toward others' needs, distrust in own abilities, and difficulties showing vulnerability in the poor outcome group. Third, poor outcome informants described either a distanced or immersed/idealizing relationship to their therapist, as opposed to more balanced between self-assertion and vulnerability in good outcome informants. Our findings raise new hypotheses that trauma work, fostering patient agency, and focusing on relational dynamics in patient-therapist dyad may be important in producing enduring ED outcomes for these patients. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Alliance and symptom improvement in inpatient treatment for eating disorder patients: A study of within-patient processes.

OBJECTIVE: This study examined the reciprocal relationship between alliance and symptoms during treatment for patients with eating disorders (ED). METHODS: Ninety one patients with EDs received inpatient cognitive-behavioral therapy treatment over 14 weeks. The study used repeated measurements during treatment and collected alliance and symptom measures. The analysis separated the effects of alliance and symptoms into between- and within-patient effects in a multilevel analysis. RESULTS: The results show a reciprocal relationship with between-patient alliance predicting ED symptoms and between-patient ED symptoms predicting alliance the subsequent weeks. However, for within-patient effects only alliance predicted ED symptoms the subsequent week. DISCUSSION: The results nuance the effect of the alliance in this patient group, and paint a complex picture of alliance in the psychotherapy process.

Cognitive behavioral therapy versus compassion focused therapy for adult patients with eating disorders with and without childhood trauma: A randomized controlled trial in an intensive treatment setting.

OBJECTIVE: Treatments for eating disorders are moderately effective, with cognitive behavior therapy (CBT) providing the strongest evidence. However, it remains important to investigate other interventions, particularly for eating disorders with greater complexity (e.g., substantial comorbidity; trauma history) or for patients who have not responded adequately to previous treatments. METHOD: This randomized controlled trial compared CBT against compassion-focused therapy for eating disorders (CFT-E), where half of the sample had a childhood trauma history. The study was pre-registered and adequately powered. A total of 130 patients were randomly assigned to CBT or CFT-E and were assessed at pre-treatment, post-treatment and one-year follow-up. The primary outcome measure was the total score on the Eating Disorder Examination-Interview (EDE), and secondary outcome measures were the Symptom Checklist-90, Inventory of Interpersonal Problems-64 and Post-Traumatic Symptom Scale. Attrition during treatment was low (13%), suggesting good acceptability. RESULTS: Eating pathology (EDE scores) reduced substantially overall, with large effect sizes, and there were no differences between therapies. However, at follow-up, for patients with a childhood trauma history, CFT-E maintained benefits better than CBT. CONCLUSION: While both CBT and CFT-E resulted in significant reductions in eating pathology, CFT-E showed superior maintenance of benefits for patients with a history of childhood trauma at one-year follow-up, underlining the necessity of tailored interventions for specific patient subgroups.

Covert therapeutic micro-processes in non-recovered eating disorders with childhood trauma: an interpersonal process recall study.

METHOD: To uncover therapeutic micro-processes from the perspectives of eating disorder (ED) treatment non-responders with childhood trauma (CT) late effects, we explored in-session experiences of poor long-term outcome patients. Female inpatients aged 28-59 (M = 40.2, SD = 5.0) from a randomised trial comparing Compassion Focused Therapy for EDs (n = 3) with Cognitive Behavioural Therapy for EDs (n = 3) were interviewed with video-assisted recall about a self-selected session. Data were analysed through Interpretative Phenomenological Analysis (IPA) with Grounded Theory (GT) elements. RESULTS: Covert patient strategies included self-effacement, regulating therapeutic distance to open up, and engaging with reflective rather than experiential interventions. First, self-effacement included submissive, passive or pretend responses to perceived criticising or violating therapist behaviours as well as other orientation and submission for approval. Second, some preferred a close patient-therapist alliance with therapist self-disclosure and reciprocity was a requirement for opening up; others required distance. Third, informants detached from experiential trauma work while engaging in joint reflection on post-trauma responses. CONCLUSION: Informants were preoccupied with calibrating the emotional-relational landscape in session; we hypothesized that psychological insecurity and affective intolerance from CT limit their freedom to explore own in-session experiences.

A patient perspective on individual ED treatment processes is scarce for difficult-to-treat eating disorders (EDs) with childhood trauma (CT). We therefore interviewed six poor long-term outcome inpatients through video-assisted recall about a self-selected therapy session. Patients' covert in-session strategies included self-effacing behaviours in relation to their therapist, their respective preferences for closeness or distance to their therapist to be able to open up in session, and being more prone to engage in therapists' reflective interventions rather than experiential. In sum, patients were preoccupied with calibrating the emotional­relational landscape between patient and therapist in session, which were strategies that went undetected. We hypothesized that a lack of psychological security and affective tolerance limit patients freedom to explore own experiences from the perspective of traumatic attachment and self-differentiation theory.

Five-year prospective study of personality disorders in adults with longstanding eating disorders.

OBJECTIVE: To (1) report the occurrence of personality disorders (PDs) in adults with eating disorders (EDs) during inpatient treatment, and at 1-, 2-, and 5-year follow-up, (2) compare the changes of PDs in anorexia nervosa (AN), bulimia nervosa (BN), and eating disorder not otherwise specified (EDNOS), and (3) investigate if recovered patients had lower frequency of PDs. METHOD: Seventy-four patients with EDs were assessed with Structured Clinical Interview for DSM-IV Axis II disorders during inpatient treatment, and at 1-, 2-, and 5-year follow-up. RESULTS: During inpatient treatment, 58 patients (78%) had one or more PDs and this was reduced to 32 (43%) at 5-year follow-up. Dimensional PD scores changed significantly over time in both AN, BN, and EDNOS, but no significant differences emerged among the ED groups. Recovered patients had lower frequency of PDs (p < 0.01). DISCUSSION: The substantial 5-year follow-up reductions in the frequency of PDs in patients with EDs present an optimistic clinical scenario for treating patients with comorbid ED and PD.

The Modum-ED Trial Protocol: Comparing Compassion-Focused Therapy and Cognitive-Behavioral Therapy in Treatment of Eating Disorders With and Without Childhood Trauma: Protocol of a Randomized Trial.

Background: The combination of eating disorder (ED) and the experience of childhood trauma leads to significant impairment and suffering. To improve treatment, it is critically important to study treatment effects, and the mechanism of these effects. The overall aim of the current project is to; (1) build knowledge on how to best treat patients with ED with and without childhood trauma, (2) develop our understanding about how change happens for these patients. We will do this by comparing two treatment models in an inpatient setting; Compassion-Focused Therapy (CFT) and cognitive-behavioral therapy (CBT) for ED. This paper describes the development, design and implementation of the trial. Methods and Design: Patients included in this randomized controlled trial will satisfy DSM-5 criteria for ED and approximately half of the patients will in addition have a history of childhood trauma. A total of 144 patients who have received either CFT or CBT are followed up 1 year after completion of the treatment. The study will collect a rich dataset of outcome measures at four time points, and process and sub-outcome measures at 13 time points. All patients will be assessed with the same clinical instruments based on current state-of-the-art methods. The primary outcome will be change in the severity of ED features as measured by the global ED examination score, and having a global ED examination score less than one standard deviation above the community mean, while secondary outcomes will relate to treatment effects on trauma symptoms, general symptoms, and quality of life. Discussion: This trial will make an important contribution to the need for evidence of effective treatment for patients with ED with or without childhood trauma. Ethics and Dissemination: The project is approved by the South-Eastern Regional Committee for Medical and Health Research Ethics of Norway (REC;2014/836). Clinical Trial Registration: ClinicalTrials.gov, http://www.Clinicaltrials.gov/ct2/show/NCT02649114.

The course of illness following inpatient treatment of adults with longstanding eating disorders: a 5-year follow-up.

OBJECTIVE: The objectives of this article were to study the course and outcome of longstanding eating disorders (ED) 5 years after completing treatment and to identify subgroups of patients with different course and outcome. METHOD: A total of 77 patients with a mean age of 30 years were assessed at the beginning and end of in-patient therapy and at 1-, 2- and 5-year follow-up, respectively. RESULTS: Of the 90% who participated in the 5-year follow-up, 46 patients (61%) had improved, and 30 (39%) did not meet diagnostic criteria for an ED. Cluster analysis identified a group of patient with no improvement over time. CONCLUSION: Overall, the course is favourable, but a subgroup of patients with no improvement over time may need intensified treatment efforts.

Co-occurrence of avoidant personality disorder and child sexual abuse predicts poor outcome in long-standing eating disorder.

Few consistent predictive factors for eating disorder have been identified across studies. In the current 5-year prospective study, the objective was to examine whether (a) personality disorder and child sexual abuse predict the course of severity of eating disorder symptoms after inpatient treatment and (b) how the predictors interact. A total of 74 patients with long-standing eating disorder and mean age of 30 years were assessed at the beginning and end of inpatient therapy and at 1-, 2-, and 5-year follow-up. A mixed model was used to examine the predictors. Avoidant personality disorder and child sexual abuse interacted in predicting high levels of eating disorder over a long-term course. These results suggest that eating disorder, avoidant personality disorder, and sequelae after child sexual abuse are potential targets for treatment that need further investigation.