Maintenance treatment for eating disorders following inpatient or day treatment: outcomes of intensive outpatient group and individual CBT treatments.

Relapse is a substantial problem in eating disorders. Until recently, there have been few investigations into maintenance treatments aimed at helping patients maintain improvements made in treatment. This study compared the outcomes of group-based intensive outpatient versus individual cognitive behavioural therapy (CBT)-based maintenance treatments for eating disorders, following inpatient or day treatment. In this sequential cohort study, patients received the type of maintenance treatment (intensive outpatient group or individual CBT) available at the time. A total of 221 patients with eating disorders were included, and data were examined retrospectively. Cox regression was used to determine whether treatment type predicted rate of return to clinically significant symptoms over the 12 months following inpatient or day treatment. Intensive outpatient group versus individual CBT maintenance treatment did not predict differential rate or trajectory of return to clinically significant symptoms in diagnostic subgroups and the overall sample. Maintenance treatment type did not predict changes in weight/shape concerns between end-of-inpatient or day treatment) and 6- or 12-month follow-up (after controlling for diagnosis). Although the treatments appeared similarly effective in helping patients maintain gains made in intensive treatment, individual CBT may be a more time- and cost-efficient approach to delivering maintenance treatment.

Rapid response to intensive treatment for bulimia nervosa and purging disorder: A randomized controlled trial of a CBT intervention to facilitate early behavior change.

OBJECTIVE: Rapid response to cognitive behavior therapy (CBT) for eating disorders (i.e., rapid and substantial change to key eating disorder behaviors in the initial weeks of treatment) robustly predicts good outcome at end-of-treatment and in follow up. The objective of this study was to determine whether rapid response to day hospital (DH) eating disorder treatment could be facilitated using a brief adjunctive CBT intervention focused on early change. METHOD: 44 women (average age 27.3 [8.4]; 75% White, 6.3% Black, 6.9% Asian) were randomly assigned to 1 of 2 4-session adjunctive interventions: CBT focused on early change, or motivational interviewing (MI). DH was administered as usual. Outcomes included binge/purge frequency, Eating Disorder Examination-Questionnaire and Difficulties in Emotion Regulation Scale. Intent-to-treat analyses were used. RESULTS: The CBT group had a higher rate of rapid response (95.7%) compared to MI (71.4%; p = .04, V = .33). Those who received CBT also had fewer binge/purge episodes (p = .02) in the first 4 weeks of DH. By end-of-DH, CBT participants made greater improvements on overvaluation of weight and shape (p = .008), and emotion regulation (ps < .008). Across conditions, there were no significant baseline differences between rapid and nonrapid responders (ps > .05). CONCLUSIONS: The results of this study demonstrate that rapid response can be clinically facilitated using a CBT intervention that explicitly encourages early change. This provides the foundation for future research investigating whether enhancing rates of rapid response using such an intervention results in improved longer term outcomes. (PsycINFO Database Record

Empirically defining rapid response to intensive treatment to maximize prognostic utility for bulimia nervosa and purging disorder.

Rapid response (RR) to eating disorder treatment has been reliably identified as a predictor of post-treatment and sustained remission, but its definition has varied widely. Although signal detection methods have been used to empirically define RR thresholds in outpatient settings, RR to intensive treatment has not been investigated. This study investigated the optimal definition of RR to day hospital treatment for bulimia nervosa and purging disorder. Participants were 158 patients who completed ≥6 weeks of day hospital treatment. Receiver operating characteristic (ROC) analysis was used to create four definitions of RR that could differentiate between remission and nonremission at the end of treatment. Definitions were based on binge/vomit episode frequency or percent reduction from pre-treatment, during either the first four or first two weeks of treatment. All definitions were associated with higher remission rates in rapid compared to nonrapid responders. Only one definition (i.e., ≤3 episodes in the first four weeks of treatment) predicted sustained remission (versus relapse) at 6- and 12-month follow-up. These findings provide an empirically derived definition of RR to intensive eating disorder treatment, and provide further evidence that early change is an important prognostic indicator.

Adjunctive graded body image exposure for eating disorders: A randomized controlled initial trial in clinical practice.

OBJECTIVE: Graded body image exposure is a key component of CBT for eating disorders (EDs). However, despite being a highly anxiety-provoking intervention, its specific effectiveness is unknown. The aims of this initial study were to investigate the feasibility and preliminary effectiveness of individualized graded body image exposure to a range of feared/avoided body image-related situations in a sample of partially remitted ED patients. METHOD: Forty-five female adult participants were randomly assigned to maintenance treatment as usual (MTAU) only or MTAU plus five sessions of graded body image exposure. RESULTS: The graded body image exposure intervention led to large improvements in body avoidance as measured by two different methods. In addition, there was evidence of a significant impact of body image exposure on the overvaluation of shape, but not weight, 5 months after treatment. DISCUSSION: Taken together, the current results provide evidence of the feasibility of adjunctive individualized graded body image exposure within a clinical treatment program and suggest that graded body image exposure reduces body avoidance behaviors in partially remitted ED patients. Our findings suggest that individualized graded body image exposure shows promise as an intervention targeting the overvaluation of shape in EDs.

The effectiveness of an individualized form of day hospital treatment.

The traditional group format of day hospital treatment for eating disorders restricts individual tailoring of treatment, which is challenging when complex cases are referred. In 2007 we introduced a new program that included individual sessions. Patients referred to this program were older, had longer illness duration, and more pre-treatment symptoms than the original group program. These clients also had more psychopathology, and were more likely to have a diagnosis of anorexia nervosa binge/purge subtype. Weight gain and abstinence from symptoms were less likely for patients in this new program. However, premature discharge, rapid response, symptom frequencies, and relapse rates did not differ.

Predictors of rapid relapse in bulimia nervosa.

OBJECTIVE: Relapse remains a significant concern in bulimia nervosa, with some patients relapsing within months of treatment completion. The purpose of the study was to identify predictors of relapse within the first 6 months following treatment. METHOD: The 116 participants were bingeing and/or vomiting ≥ 8 times per month before day hospital (DH), and had ≤ 2 episodes per month in the last month of DH and the first month after DH. Rapid relapse was defined as ≥ 8 episodes per month for 3 months starting within 6 months. RESULTS: The rate of rapid relapse was 27.6%. Patients who relapsed soon after DH had higher frequencies of bingeing and vomiting before treatment, engaged in less body avoidance before treatment and were more likely to be slow responders to treatment. Weight and shape concerns and body checking were not significant predictors. DISCUSSION: More frequent bulimic symptoms accompanied by less body avoidance may indicate an entrenchment in the illness which in turn augurs a labored and transient response to DH treatment that is difficult to sustain after intensive treatment ends.

"Diagnostic shift" from eating disorder not otherwise specified to bulimia nervosa using DSM-5 criteria: a clinical comparison with DSM-IV bulimia.

In the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the diagnostic threshold for binging and compensation in bulimia nervosa (BN) decreased from twice to once weekly for 3 months. This study investigates the validity of this change by examining whether BN patients and those whose diagnoses "shift" to BN with DSM-5 are similar in their psychological functioning. EDNOS patients whose symptoms met DSM-5 BN criteria (n=25) were compared to DSM-IV BN patients (n=146) on clinically relevant variables. No differences were found on: BMI; weight-based self-evaluation; perfectionism; depression and anxiety symptoms; or readiness for change. Differences were found on one Eating Disorder Inventory subscale (i.e., bulimia), with the BN group reporting higher scores, consistent with group definitions. These findings support the modified criteria, suggesting that psychopathology both directly and indirectly related to eating disorders is comparable between those with once weekly versus more frequent bulimic episodes.

Rapid and slow responders to eating disorder treatment: a comparison on clinically relevant variables.

OBJECTIVE: Speed of response to eating disorder treatment is a reliable predictor of relapse, with rapid response predicting improved outcomes. This study investigated whether rapid, slow, and nonresponders could be differentiated on clinically relevant variables, and possibly identified prior to treatment. METHOD: Female patients (N = 181) were classified as rapid, slow, or nonresponders based on the speed and magnitude with which they interrupted their bingeing and/or vomiting symptoms, and were compared on eating disorder behaviors and psychopathology and general psychopathology. RESULTS: The rapid response group was marginally older and had a slightly shorter course of treatment than the slow response group. The rapid response group also had significantly fewer pretreatment binge episodes, and a longer course of treatment than the nonresponse group. However, the three response groups were not significantly different on any other examined variables. DISCUSSION: The only pretreatment variable that differentiated response groups was symptom frequency, in that rapid responders had fewer binge episodes than nonresponders. No pre-existing variables differentiated rapid and slow response. Given that few individual pre-existing differences that might account for speed of response were identified, the clinical importance of facilitating a rapid response to treatment for all patients is discussed.

The Weight Influenced Self-Esteem Questionnaire (WISE-Q): factor structure and psychometric properties.

Weight-based self-esteem (WBSE) is hypothesized to be the core cognitive feature of eating disorders. The Weight Influenced Self-Esteem Questionnaire (WISE-Q) was designed to measure the influence of a negatively perceived body image on multiple dimensions of self-esteem, which we believe to be one aspect of WBSE. Study 1 sought to determine the factor structure of the WISE-Q as well as to examine the reliability and concurrent validity of WISE-Q scores among eating disorder and undergraduate student participants. In Study 2, validity was further investigated by examining changes in WISE-Q scores with treatment. The WISE-Q has two factors representing generalized and expected WBSE. Evidence of internal and test-retest reliability was found. Also, the pattern of correlations between WISE-Q scores and other constructs was in line with predictions. As expected, WISE-Q scores improved with treatment yet remained high.

Efficacy and intensity of day hospital treatment for eating disorders.

The purpose of the study was to compare the effectiveness of 4-day versus 5-day day hospital (DH) treatment and to document effectiveness based on a large sample size. Participants were 801 patients, diagnosed with an eating disorder, who participated in DH treatment from 1985 to 2009. The study followed a sequential cohort ABA design. Higher intensity DH was associated with higher rates of abstinence from bingeing and vomiting and larger improvements in depression and body dissatisfaction. Higher intensity DH provided no consistent advantage in rates of weight restoration or improvement on other indices of psychological functioning. These findings suggest that the optimal intensity of treatment may vary depending on treatment goals, but 5-day DH is recommended for eating disorders.

Alexithymia and eating disorders: a critical review of the literature.

Alexithymia is characterized by difficulties identifying feelings and differentiating between feelings and bodily sensations, difficulties communicating feelings, and a concrete cognitive style focused on the external environment. Individuals with eating disorders have elevated levels of alexithymia, particularly difficulties identifying and describing their feelings. A number of theoretical models have suggested that individuals with eating disorders may find emotions unacceptable and/or frightening and may use their eating disorder symptoms (i.e., restricting food intake, bingeing, and/or purging) as a way to avoid or cope with their feelings. The current critical review synthesizes the literature on alexithymia and eating disorders and examines alexithymia levels across eating disorders (i.e., anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified), the role of alexithymia in binge eating disorder, and the influence of alexithymia on the development of eating disorders as well as treatment outcome. The clinical implications of the research conducted to date and directions for future research are discussed.

The natural course of eating pathology in female university students.

This study investigated the natural course of eating pathology in a sample of female university students. Seventy-nine students were recruited in their first month of the university, 24 of whom endorsed objective binge eating and inappropriate compensatory behaviors based on an initial screening interview. Testing sessions occurred every 6 months for the following 2 1/2 years and included the assessment of eating pathology, general psychopathology and well-being, weight, and exposure to psychological or psychiatric treatment. Data were analyzed using a mixed-effects linear regression model. Whereas general psychopathology decreased during the study, eating pathology was fairly stable. The symptomatic participants experienced significantly more weight fluctuations over the course of the study than did in the control participants. None of the symptomatic participants sought treatment for their eating and eating pathology showed little evidence of spontaneous remission. Larger, follow-up studies of changes to untreated eating pathology over time are recommended.

"I feel fat": an experimental induction of body displacement in disordered eating.

Body displacement, the theory that predicts that individuals with eating disorders will displace negative feelings about themselves onto their body, was tested experimentally in this study. Unrestrained eaters (n = 61), restrained eaters (n = 33), and individuals with eating disorders (n = 26) were randomly assigned to a control condition or an ineffectiveness induction. In the ineffectiveness condition participants were asked to recall and reflect on a past experience when they felt useless or incapable (i.e., ineffective). Results showed that individuals with eating disorders who were made to feel ineffective reported more implicit appearance/body concern than those in the control condition. Unrestrained and restrained eaters did not show this effect. This is the first experimental study to support body displacement theory. These data can be used clinically to educate and encourage patients with eating disorders to address thoughts and feelings related to ineffectiveness directly, instead of displacing this distress onto their body and potentially perpetuating their eating disorder.

Habitual starvation and provocative behaviors: two potential routes to extreme suicidal behavior in anorexia nervosa.

Anorexia nervosa (AN) is perhaps the most lethal mental disorder, in part due to starvation-related health problems, but especially because of high suicide rates. One potential reason for high suicide rates in AN may be that those affected face pain and provocation on many fronts, which may in turn reduce their fear of pain and thereby increase risk for death by suicide. The purpose of the following studies was to explore whether repetitive exposure to painful and destructive behaviors such as vomiting, laxative use, and non-suicidal self-injury (NSSI) was a mechanism that linked AN-binge-purging (ANBP) subtype, as opposed to AN-restricting subtype (ANR), to extreme suicidal behavior. Study 1 utilized a sample of 787 individuals diagnosed with one or the other subtype of AN, and structural equation modeling results supported provocative behaviors as a mechanism linking ANBP to suicidal behavior. A second, unexpected mechanism emerged linking ANR to suicidal behavior via restricting. Study 2, which used a sample of 249 AN patients, replicated these findings, including the second mechanism linking ANR to suicide attempts. Two potential routes to suicidal behavior in AN appear to have been identified: one route through repetitive experience with provocative behaviors for ANBP, and a second for exposure to pain through the starvation of restricting in ANR.

Maintenance treatment for anorexia nervosa: a comparison of cognitive behavior therapy and treatment as usual.

OBJECTIVE: The aim of this study was to compare two maintenance treatment conditions for weight-restored anorexia nervosa (AN): individual cognitive behavior therapy (CBT) and maintenance treatment as usual (MTAU). METHOD: This study was a nonrandomized clinical trial. The participants were 88 patients with AN who had achieved a minimum body mass index (BMI) of 19.5 and control of binge eating and purging symptoms after completing a specialized hospital-based program. Forty-six patients received 1 year of manualized individual CBT and 42 were in an assessment-only control condition (i.e., MTAU) for 1 year. This condition was intended to mirror follow-up care as usual. Participants in both the conditions were assessed at 3-month intervals during the 1-year study. The main outcome variable was time to relapse. RESULTS: When relapse was defined as a BMI

Timing and prediction of relapse in a transdiagnostic eating disorder sample.

OBJECTIVE: To identify factors that predict relapse in eating disorders to direct the development of effective relapse prevention interventions. METHOD: Fifty-eight participants who had partially remitted from their eating disorder after intensive treatment were prospectively followed for up to 24 months. A transdiagnostic sample was included based on current recommendations. RESULTS: The 12-month survival rate was 0.59, indicating that 41% of the sample had relapsed at this time, and four factors emerged as significant predictors of relapse. These factors included more severe pretreatment caloric restriction, higher residual symptoms at discharge, slower response to treatment, and higher weight-related self-evaluation. CONCLUSION: Clinical recommendations based on these data include encouraging clients to adopt the recommended behavioral changes immediately at the beginning of treatment, and to make complete symptom control a priority. In addition, addressing weight-related self-evaluation and teaching clients to detach from this schema that connects weight/shape with self-esteem may be an effective and feasible step toward relapse prevention.

"Just looking at food makes me gain weight": experimental induction of thought-shape fusion in eating-disordered and non-eating-disordered women.

Thought-shape fusion (TSF) is a cognitive distortion that can be induced experimentally and is associated with eating pathology. The current study was conducted in order to elucidate the effects of TSF induction in females with eating disorders (n=35), as well as in restrained eaters (n=38) and unrestrained eaters (n=39). It was hypothesized that TSF induction would result in anxiety, guilt, increased feelings of fatness, perceived weight gain and feelings of moral wrong-doing relative to an anxiety and control induction. It was further hypothesized that restrained eaters and individuals with eating disorders would exhibit a stronger reaction to a TSF induction than would unrestrained eaters. The results indicated that, as predicted, TSF can be induced in individuals both with and without eating disorders, and individuals with eating disorders reported the highest levels of "state" TSF after the induction relative to the non-clinical controls. However, contrary to expectations, restrained eaters reported higher levels of perceived weight gain and moral wrong-doing after the anxiety induction (but not the TSF induction) relative to the control induction. Potential mechanisms for this pattern of results are discussed, and the clinical implications of research on TSF are also considered.

Body Weight and Body Image.

HEALTH ISSUE: Body weight is of physical and psychological importance to Canadian women; it is associated with health status, physical activity, body image, and self-esteem. Although the problems associated with overweight and obesity are indeed serious, there are also problems connected to being underweight. Weight prejudice and the dieting industry intensify body image concerns for Canadian women and can have a major negative impact on self-esteem. KEY FINDINGS: Women have lower BMIs than men, a lower incidence of being overweight and a higher incidence of being underweight. However, women across all weight categories are more dissatisfied with their bodies. Sixty percent of women are inactive, and women with a BMI of 27 or higher are more likely to be inactive than women with lower BMIs. The data show that women are aware of the health benefits of exercise, but there is a gap between knowledge and practice. When asked about barriers to health improvement, 39.7% of women cited lack of time and 39.2% lack of willpower. DATA GAPS AND RECOMMENDATIONS: Weight prejudice must be made unacceptable and positive body image should be encouraged and diversity valued. Health policies should encourage healthy eating and healthy activity. Health curricula for young students should include information about healthy eating, active lifestyle, and self-esteem. Physical activities that mothers can participate in with their families should be encouraged. Research should be funded to elucidate the most effective methods of getting women to become and remain physically active without focusing on appearance.

A word-stem completion task to assess implicit processing of appearance-related information.

OBJECTIVE: This paper reports on the development and utility of a new implicit measure of appearance-related information processing. METHODS: A 20-item word-stem completion task was constructed, in which each word stem could be completed with either an appearance-related word or at least one non-appearance alternative. The measure was tested in four different experiments, most investigating the impact of acute exposure to media-portrayed thin idealised female images. RESULTS: Exposure to media images or other appearance-related material led to the generation of more appearance- or weight-related words in both female and male samples. CONCLUSION: It was concluded that the word-stem task has empirical utility as a simple, self-paced and sensitive outcome measure in experimental studies of media exposure. We conceptualise the word-stem task as a measure of appearance- and weight-schema activation.