Validating and developing a shortened version of the detail and flexibility (DFlex) questionnaire for eating disorders, anxiety and depression.

OBJECTIVE: To validate the original and a shortened version of the Detail and Flexibility (DFlex) Questionnaire. METHOD: Confirmatory factor analyses, internal consistency, and discriminant validity estimates were conducted within individuals with a diagnosis of an eating disorder (ED) (n = 124), an anxiety disorder and/or depression (n = 219), and a community sample (n = 852) (Part 1). Convergent validity of the DFlex through comparisons with the Autism Spectrum Quotient, Wisconsin Card Sorting Task, and Group Embedded Figures Task was undertaken within a combined ED and community sample (N = 68). Test-retest reliability of the DFlex was also examined across 2 years in a community sample (N = 85) (Part 2). RESULTS: The original factor structure of the DFlex was not supported. Hence, a shortened version, the DFlex-Revised, was developed. Good discriminant validity was obtained for the DFlex and DFlex-Revised, however, support for convergent validity was mixed. Finally, the 2-year test-retest reliability for the two DFlex versions was found to be low, suggesting potential malleability in construct over this timeframe. CONCLUSIONS: Further research is needed to validate the DFlex in clinical and non-clinical populations using different neurocognitive tests. Test-retest, using varied time intervals, should also be assessed.

Knowledge and attitudes towards eating disorders: A survey of psychiatrists and psychiatry trainees in New South Wales.

OBJECTIVE: To evaluate New South Wales (NSW) psychiatrists' and psychiatry trainees' knowledge and attitudes towards eating disorders (EDs). METHOD: A total of 1781 psychiatrists and trainees in NSW were invited to complete an anonymous questionnaire assessing ED confidence, knowledge and attitudes. RESULTS: A total of 51 doctors responded to the survey, with 38 completing all items. Significant knowledge gaps were revealed. Respondents expressed a desire for more ED training. CONCLUSION: Enhanced ED training in psychiatry education and incorporating the lived experience voice to improve attitudes appear necessary.

The mind-in-mind study: A pilot randomised controlled trial that compared modified mentalisation based treatment with supportive clinical management for patients with eating disorders without borderline personality disorder.

OBJECTIVE: Mentalisation-based treatment (MBT) aims to improve reflective functioning. There is a growing evidence base outlining positive clinical outcomes for the use of MBT in eating disorder patients with co-morbid borderline personality disorder (BPD). The use of MBT has not been studied for eating disorder patients without BPD. This pilot study is an exploratory randomised controlled trial in which outcomes from MBT are compared with standard clinical management in a cohort of patients diagnosed with an eating disorder but not BPD. The main objectives were two-fold-to explore the use of MBT as a therapeutic modality and to test the acceptability and feasibility of the protocol design. METHOD: Thirty-two participants were randomised to receive either MBT or standard treatment during an inpatient eating disorders program. All patients enrolled in the study were diagnosed with an eating disorder but did not meet DSM-5 criteria for BPD. On admission patients were categorised as very underweight (BMI 15.0-16.4 kg/m2 ), underweight (BMI 16.5-18.4 kg/m2 ) or healthy weight range (BMI ≥ 18.5-24.9 kg/m2 ). Upon discharge participants were further categorised as weight restored (BMI ≥ 18.5 kg/m2 ) or non-weight restored (BMI < 18.5 kg/m2 ). The primary outcome was the subscale score on the Reflective Functioning Questionnaire (RFQ-8). Secondary outcomes were subscale scores on the Eating Disorder Examination Questionnaire and the Depression, Anxiety and Stress Scale (DASS)-21. Participants were assessed at baseline and on discharge. Statistical significance was determined using repeated measurements analysis of variance (ANOVA). RESULTS: Both groups experienced improvements in eating disorder symptoms and measures of psychological well-being. Participants within the MBT group exhibited greater improvements in reflective capacity as defined by the RFQ-8 however these benefits appeared to be limited to patients who achieved weight restoration at discharge. The eligibility criteria-which excluded comorbid BPD-led to challenges in recruitment which limited the power of the study analysis. As participants with a range of different eating disorder diagnoses were included this led to complexities in estimating the treatment effect within a defined cohort. CONCLUSIONS: Although the small sample size must be noted as a limitation-the finding that weight restoration appears to be associated with improvements in reflective capacity in MBT would be worth exploring in a subsequent larger study. Modification of eligibility criteria and recruitment from a defined cohort may increase the efficiency of a future study.

A critical role for both CD40 and VLA5 in angiotensin II-mediated thrombosis and inflammation.

Angiotensin II (Ang-II)-induced hypertension is associated with accelerated thrombus formation in arterioles and leukocyte recruitment in venules. The mechanisms that underlie the prothrombotic and proinflammatory responses to chronic Ang-II administration remain poorly understood. We evaluated the role of CD40/CD40 ligand (CD40L) signaling in Ang-II-mediated microvascular responses and assessed whether and how soluble CD40L (sCD40L) contributes to this response. Intravital video microscopy was performed to analyze leukocyte recruitment and dihydrorhodamine-123 oxidation in postcapillary venules. Thrombus formation in cremaster muscle arterioles was induced by using the light/dye endothelial cell injury model. Wild-type (WT), CD40-/-, and CD40L-/- mice received Ang-II for 14 d via osmotic minipumps. Some mice were treated with either recombinant sCD40L or the VLA5 (very late antigen 5; α5ß1) antagonist, ATN-161. Our results demonstrate that CD40-/-, CD40L-/-, and WT mice that were treated with ATN-161 were protected against the thrombotic and inflammatory effects of Ang-II infusion. Infusion of sCD40L into CD40-/- or CD40L-/- mice restored the prothrombotic effect of Ang-II infusion. Mice that were treated with ATN-161 and infused with sCD40L were protected against accelerated thrombosis. Collectively, these novel findings suggest that the mechanisms that underlie Ang-II-dependent thrombotic and inflammatory responses link to the signaling of CD40L via both CD40 and VLA5.-Senchenkova, E. Y., Russell, J., Vital, S. A., Yildirim, A., Orr, A. W., Granger, D. N., Gavins, F. N. E. A critical role for both CD40 and VLA5 in angiotensin II-mediated thrombosis and inflammation.

Harm minimization in severe and enduring anorexia nervosa.

For many sufferers of anorexia nervosa, the time course is long, and the prospect of disability and family burden great. This is all too often the case, even with early diagnosis and treatment. The term severe and enduring anorexia nervosa has been applied to these survivors. Yet, a majority of patients do eventually recover and, even where this is not the case, adaptive medical stability and function can be maintained despite alarming dilapidation. Managing the years of illness so as to have the best outcome physically and psychologically, even where full weight recovery does not occur, or has not yet occurred, is the topic of this article. Literature pertaining to harm minimization in chronic, severe, enduring, and long-standing anorexia nervosa was selectively reviewed using an Ovid data base and Google Scholar. The authors' own clinical experience over almost four decades in public and private hospital and community settings has also informed much of what has been written. The authors would like to think that it is possible to do better than the familiar injunction (variously attributed to Hippocrates, Galen, and others) of 'primum non nocere'-although this is a good place to start.

Depression and cardiac dysautonomia in eating disorders.

PURPOSE: Individuals with eating disorder (ED) are at an increased risk of cardiac arrhythmias due to cardiac dysautonomia, which may be exacerbated if depression is also present. The aim of the study was to use heart rate analysis as a marker for cardiac dysautonomia in patients with eating disorders and depression as a comorbidity. METHODS: Clinical data, including presence of depression, was obtained from all participants. A three-lead ECG was used to determine interbeat intervals, and these were analyzed using time domain, frequency domain, and nonlinear heart rate variability measures. RESULTS: Thirty ED patients and 44 healthy controls participated in the research. The presence of depression was associated with additional decreased time domain (RMSSD 36.8 ± 26 vs. 22.9 ± 12.3; p < 0.05), frequency domain (HF power 788 ± 1075 vs. 279 ± 261; p < 0.05), and nonlinear domain (DFAα2 0.82 ± 0.1 vs. 0.97 ± 0.1; p < 0.01) which results in the ED group compared to patients with no depression. CONCLUSIONS: The presence of depression in ED patients decreased HRV even further compared to the non-depressed patient group and controls, suggesting that higher vigilance and a holistic treatment approach may be required for these patients to avoid cardiac arrhythmia complications.

Formyl-Peptide Receptor 2/3/Lipoxin A4 Receptor Regulates Neutrophil-Platelet Aggregation and Attenuates Cerebral Inflammation: Impact for Therapy in Cardiovascular Disease.

BACKGROUND: Platelet activation at sites of vascular injury is essential for hemostasis, but it is also a major pathomechanism underlying ischemic injury. Because anti-inflammatory therapies limit thrombosis and antithrombotic therapies reduce vascular inflammation, we tested the therapeutic potential of 2 proresolving endogenous mediators, annexin A1 N-terminal derived peptide (AnxA1Ac2-26) and aspirin-triggered lipoxin A4 (15-epi-lipoxin A4), on the cerebral microcirculation after ischemia/reperfusion injury. Furthermore, we tested whether the lipoxin A4 receptor formyl-peptide receptor 2/3 (Fpr2/3; ortholog to human FPR2/lipoxin A4 receptor) evoked neuroprotective functions after cerebral ischemia/reperfusion injury. METHODS AND RESULTS: Using intravital microscopy, we found that cerebral ischemia/reperfusion injury was accompanied by neutrophil and platelet activation and neutrophil-platelet aggregate formation within cerebral microvessels. Moreover, aspirin-triggered lipoxin A4 activation of neutrophil Fpr2/3 regulated neutrophil-platelet aggregate formation in the brain and inhibited the reactivity of the cerebral microvasculature. The same results were obtained with AnxA1Ac2-26 administration. Blocking Fpr2/lipoxin A4 receptor with the antagonist Boc2 reversed this effect, and treatments were ineffective in Fpr2/3 knockout mice, which displayed an exacerbated disease severity, evidenced by increased infarct area, blood-brain barrier dysfunction, increased neurological score, and elevated levels of cytokines. Furthermore, aspirin treatment significantly reduced cerebral leukocyte recruitment and increased endogenous levels of aspirin-triggered lipoxin A4, effects again mediated by Fpr2/3. CONCLUSION: Fpr2/lipoxin A4 receptor is a therapeutic target for initiating endogenous proresolving, anti-inflammatory pathways after cerebral ischemia/reperfusion injury.

The Anorexia Nervosa Genetics Initiative: Study description and sample characteristics of the Australian and New Zealand arm.

OBJECTIVES: Anorexia nervosa is a severe psychiatric disorder with high mortality rates. While its aetiology is poorly understood, there is evidence of a significant genetic component. The Anorexia Nervosa Genetics Initiative is an international collaboration which aims to understand the genetic basis of the disorder. This paper describes the recruitment and characteristics of the Australasian Anorexia Nervosa Genetics Initiative sample, the largest sample of individuals with anorexia nervosa ever assembled across Australia and New Zealand. METHODS: Participants completed an online questionnaire based on the Structured Clinical Interview Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) eating disorders section. Participants who met specified case criteria for lifetime anorexia nervosa were requested to provide a DNA sample for genetic analysis. RESULTS: Overall, the study recruited 3414 Australians and 543 New Zealanders meeting the lifetime anorexia nervosa case criteria by using a variety of conventional and social media recruitment methods. At the time of questionnaire completion, 28% had a body mass index ⩽ 18.5 kg/m2. Fasting and exercise were the most commonly employed methods of weight control, and were associated with the youngest reported ages of onset. At the time of the study, 32% of participants meeting lifetime anorexia nervosa case criteria were under the care of a medical practitioner; those with current body mass index < 18.5 kg/m2 were more likely to be currently receiving medical care (56%) than those with current body mass index ⩾ 18.5 kg/m2 (23%). Professional treatment for eating disorders was most likely to have been received from general practitioners (45% of study participants), dietitians (42%) and outpatient programmes (42%). CONCLUSIONS: This study was effective in assembling the largest community sample of people with lifetime anorexia nervosa in Australia and New Zealand to date. The proportion of people with anorexia nervosa currently receiving medical care, and the most common sources of treatment accessed, indicates the importance of training for general practitioners and dietitians in treating anorexia nervosa.

Roles of Coagulation and fibrinolysis in angiotensin II-enhanced microvascular thrombosis.

OBJECTIVE: AngII-induced HTN is associated with accelerated thrombus development in arterioles. This study assessed the contributions of different components of the coagulation cascade and fibrinolysis to AngII-mediated microvascular thrombosis. METHODS: Light/dye-induced thrombus formation (the time of onset and flow cessation) was quantified in cremaster muscle arterioles of AngII infused (two weeks) WT/AngII mice, EPCR-TgN, and mice deficient in PAI-1. WT/AngII mice were also treated with either tissue factor antibody, antithrombin III, heparin, hirudin, or murine APC. RESULTS: TF immunoblockade or hirudin treatment did not prevent the AngII-induced acceleration of thrombosis. While antithrombin III treatment prevented the acceleration in both thrombus onset and flow cessation, heparin only improved the time for blood flow cessation. Neither WT mice treated with murine APC nor EPCR-TgN were protected against AngII-induced thrombus development. A similar lack of protection was noted in PAI-1deficient mice. CONCLUSION: These findings implicate a role for thrombin generation pathway in the accelerated thrombosis induced by AngII and suggest that an impaired protein C pathway and increased PAI-1 do not make a significant contribution to this model of microvascular thrombosis.

Interleukin-6 mediates the platelet abnormalities and thrombogenesis associated with experimental colitis.

Clinical studies and animal experimentation have shown that colonic inflammation is associated with an increased number and reactivity of platelets, coagulation abnormalities, and enhanced thrombus formation. The objective of this study was to define the contribution of IL-6 to the thrombocytosis, exaggerated agonist-induced platelet aggregation, and enhanced extra-intestinal thrombosis that occur during experimental colitis. The number of mature and immature platelets, platelet life span, thrombin-induced platelet aggregation response, and light/dye-induced thrombus formation in cremaster muscle arterioles were measured in wild-type (WT) and IL-6-deficient (IL-6(-/-)) mice with dextran sodium sulfate (DSS)-induced colitis. DSS colitis in WT mice was associated with thrombocytosis with an elevated number of both mature and immature platelets and no change in platelet life span. The thrombocytosis response was absent in IL-6(-/-) mice. DSS treatment also enhanced the platelet aggregation response to thrombin and accelerated thrombus development in WT mice, but not in IL-6(-/-) mice. Exogenous IL-6 administered to WT mice elicited a dose-dependent enhancement of thrombus formation. These findings indicate that IL-6 mediates the thrombocytosis, platelet hyperreactivity, and accelerated thrombus development associated with experimental colitis. The IL-6-dependent colitis-induced thrombocytosis appears to result from an enhancement of thrombopoiesis because platelet life span is unchanged.

The household economic burden of eating disorders and adherence to treatment in Australia.

BACKGROUND: This study investigated the household economic burden of eating disorders and cost-related non-adherence to treatment in Australia. METHODS: Multi-centre prospective observational study using a structured questionnaire. Ninety participants were recruited from two clinic settings in New South Wales, Australia and from the community using social media. The primary outcome measures were household economic burden of illness measured in terms of out-of-pocket expenditure, household economic hardship and cost-related non-adherence. RESULTS: The pattern of out-of-pocket expenditure varied by diagnosis, with Bulimia Nervosa associated with the highest total mean expenditure (per three months). Economic hardship was reported in 96.7% of participants and 17.8% reported cost-related non-adherence. Those most likely to report cost-related non-adherence had a longer time since diagnosis. Cost-related non-adherence and higher out-of-pocket expenditure were associated with poorer quality of life, a more threatening perception of the impact of the illness and poor self-reported health. CONCLUSIONS: This study is the first to empirically and quantitatively examine the household economic burden of eating disorders from the patient perspective. Results indicate that households experience a substantial burden associated with the treatment and management of an eating disorder. This burden may contribute to maintaining the illness for those who experience cost-related non-adherence and by negatively influencing health outcomes. Current initiatives to implement sustainable and integrated models of care for eating disorders should strive to minimise the economic impact of treatment on families.

A phase II randomised controlled trial of intranasal oxytocin in anorexia nervosa.

BACKGROUND: Anorexia nervosa (AN) is an eating disorder (ED) with high mortality rates and limited response to existing treatments, prompting the need to identify effective agents and adjuncts. There is evidence for an emerging role for the neuropeptide oxytocin (OT) in the pathophysiology of AN, with studies showing a perturbed oxytocinergic system in patients with AN. Preliminary evidence has demonstrated that intranasal OT (IN-OT) can produce anxiolytic effects in AN, as well as reducing concern about eating, and dysfunctional attentional biases related to the disorder. IN-OT is a non-invasive treatment option for AN that requires investigation as an adjunct to nutritional rehabilitation. METHODS: This multi-site study (Trial Registration:ACTRN1261000897460) sought to replicate and extend a previous randomised placebo-controlled pilot trial of repeated dose IN-OT in patients with AN hospitalised for nutritional rehabilitation. Patients with AN (N=61) received daily IN-OT (18 IU twice per day) or placebo for four weeks, whilst undergoing inpatient hospital treatment. Outcome measures included ED psychopathology (primary) as measured by the Eating Disorder Examination (EDE) and Body Mass Index (BMI; secondary). Participants were assessed pre- and post-treatment, and at six months following the intervention. The effects of the first and last doses of IN-OT on responses (anxiety ratings and salivary cortisol) to a high-energy snack were also examined. RESULTS: Sixty-one female inpatients (Mage=24.36,SD=7.87) with an average BMI of 16.24 (range: 11.43-18.55), were recruited into the study. No significant differences were found between placebo and OT groups at any of the time points on the outcomes of interest, but significant improvements in almost all psychological parameters in both groups were evident over time. IN-OT did not significantly reduce anxiety nor salivary cortisol in response to a high-calorie snack. CONCLUSION: This is the largest randomised placebo-controlled trial of repeated dose intranasal OT in people with AN, during refeeding. The therapeutically promising findings of the pilot study were not replicated. Limitations and reasons for the non-replication included relatively large variance, baseline psychopathology scores being higher in this patient group, potential ceiling effects in BMI and ED psychopathology as well as differing comorbidities.

Tissue factor: a mediator of inflammatory cell recruitment, tissue injury, and thrombus formation in experimental colitis.

There is growing evidence for an interplay between inflammatory and coagulation pathways in acute and chronic inflammatory diseases. However, it remains unclear whether components of the coagulation pathway, such as tissue factor (TF), contribute to intestinal inflammation, and whether targeting TF will blunt the inflammatory cell recruitment, tissue injury, and enhanced thrombus formation that occur in experimental colitis. Mice were fed 3% dextran sodium sulfate (DSS) to induce colonic inflammation, with some mice receiving a mouse TF-blocking antibody (muTF-Ab). The adhesion of leukocytes and platelets in colonic venules, light/dye-induced thrombus formation in cremaster muscle microvessels, as well as disease activity index, thrombin-antithrombin (TAT) complexes in plasma, and histopathologic changes in the colonic mucosa were monitored in untreated and muTF-Ab-treated colitic mice. In untreated mice, DSS elicited the recruitment of adherent leukocytes and platelets in colonic venules, caused gross and histologic injury, increased plasma TAT complexes, and enhanced thrombus formation in muscle arterioles. muTF-Ab prevented elevation in TAT complexes, reduced blood cell recruitment and tissue injury, and blunted thrombus formation in DSS colitic mice. These findings implicate TF in intestinal inflammation and support an interaction between inflammation and coagulation in experimental colitis.

Mechanisms of enhanced thrombus formation in cerebral microvessels of mice expressing hemoglobin-S.

The microvasculature assumes an inflammatory and procoagulant state in a variety of different diseases, including sickle cell disease (SCD), which may contribute to the high incidence of ischemic stroke in these patients. This study provides evidence for accelerated thrombus formation in arterioles and venules in the cerebral vasculature of mice that express hemoglobin-S (ß(s) mice). Enhanced microvascular thrombosis in ß(s) mice was blunted by immunologic or genetic interventions that target tissue factor, endothelial protein C receptor, activated protein C, or thrombin. Platelets from ß(s) mice also exhibited enhanced aggregation velocity after stimulation with thrombin but not ADP. Neutropenia also protected against the enhanced thrombosis response in ß(s) mice. These results indicate that the cerebral microvasculature is rendered vulnerable to thrombus formation in ß(s) mice via a neutrophil-dependent mechanism that is associated with an increased formation of and enhanced platelet sensitivity to thrombin.

An open trial of self-help behaviours of clients with eating disorders in an online programme.

AIM: The aim of this study was to evaluate the self-help behaviour of individuals with eating disorders in an Internet-based self-help programme developed in the Asia-Pacific region and to determine their compliance with the programme. BACKGROUND: Eating disorders represent a growing health problem affecting both Western and Asian countries. Without timely and adequate treatment, individuals with eating disorders are at risk of premature death. Self-help approaches for treating eating disorders offer therapeutic promise. DESIGN: An open trial design was used. METHOD: This study, conducted from August 2006-July 2011, included 280 participants recruited from outpatient eating disorder clinics and treatment units and through a university student newspaper and Internet websites. This open trial evaluated an Internet-based self-help programme, which included components on healthy eating, family education, health assessment, motivation enhancement, self-help strategies, and psychological health promotion. The progress of participants was followed up via monthly e-mails. A tracking system was implemented to determine their compliance with the programme. FINDINGS: A small majority of the participants (56·9%) were already undergoing treatment for their eating disorders. About 63% (n = 176) demonstrated self-help behaviour, as manifested by their completion of health assessment questionnaires, involvement in motivation enhancement exercises, or the use of self-help strategies such as monitoring, normalizing eating behaviour, and stress management. Improvements were observed in their eating disorder psychopathology, motivational stage of change and psychological health from baseline to the 1-month follow up. CONCLUSION: Internet-based self-help programmes for eating disorders are helpful adjuncts to professional treatment.

Oxytocin and anorexia nervosa: a review of the emerging literature.

Anorexia nervosa (AN) is an intractable illness that is difficult to treat. The identification of neural correlates and novel agents to transform treatment has become priority avenues for research. Oxytocin (OT) is a neuropeptide whose emerging sphere of influence on mammalian behaviour and demonstrated impact on psychiatric illness suggest it may have potential in AN. In this paper, we undertake a targeted summary of the existing literature on OT research as it pertains to brain based behaviour and psychiatric dysfunction. Then, we conduct a systematic review of OT in AN. Papers that addressed any aspect of the OT system in AN were examined. The existing literature, although limited and based on small sample sizes, suggests a derangement of the OT system in AN that may normalise upon recovery. Preliminary pilot data from unpublished studies suggest a potential effect of OT administration on eating-related indices.

Oxytocin and eating disorders: Knowledge gaps and future directions.

Eating disorders continue to be a major public health issue and important cause of morbidity and premature mortality, particularly for young people. Yet in a concerning dialectic, this occurs in the context of an epidemic of obesity which, with its medical complications, constitutes another vexing public health challenge. While it is not an eating disorder per se obesity is often comorbid with eating disorders. Effective treatment for both eating disorders and obesity has proven to be elusive and in the search for novel therapeutic interventions, the prosocial, anxiolytic, brain plasticity and metabolic effects of oxytocin (OT) have been examined from this perspective. The availability of intranasal oxytocin (IN-OT) has led to a number of interventional treatment studies in anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), their atypical and subclinical forms and in medical and psychiatric conditions co-occurring or comorbid with these, obesity with BED would be included here. The aim of this mini review is to collate recent findings on OT as a novel therapeutic intervention in eating disorders and obesity and to identify and address some of the knowledge gaps in the use of IN-OT. The wider clinical perspective utilised here might better address some of the gaps and identify future directions of research. Clearly much remains to be done for OT to fulfil its therapeutic promise in eating disorders. OT might yet be of therapeutic promise and will be appreciated where treatment advances have been hard to come by and prevention challenging for these disorders.

A randomised controlled trial of clinician supported vs self-help delivery of online cognitive behaviour therapy for Bulimia Nervosa.

High dropout rates and poor adherence associated with digital interventions have prompted research into modifications of these treatments to improve engagement and completion rates. This trial aimed to investigate the added benefit of clinician support when paired alongside a ten-session, online cognitive behaviour therapy (CBT) self-help intervention for bulimia nervosa (BN). As part of a three-arm, phase II randomised controlled trial, 114 participants (16 years or over) with full or subthreshold BN were randomly assigned to complete the intervention in a self-help mode (with administrative researcher contact; n = 38), with adjunct clinician support (weekly 30-minute videoconferencing sessions; n = 37), or a no-treatment waitlist control (WLC; n = 39). Baseline to post-treatment (12-weeks) decreases in objective binge episode frequency were significantly greater for clinician-supported participants as compared to WLC, but not for self-help when compared to WLC. However, due to continued improvements for self-help across follow-up (24-weeks), both arms outperformed WLC when analysed as an overall rate of change across three timepoints. Clinician-supported participants outperformed self-help in regards to laxative use and dietary restraint. Our results demonstrate that good clinical outcomes can be achieved with a relatively brief online CBT-based program even in the absence of structured clinical support, indicating a possible overreliance upon clinician support as a primary adherence-facilitating mechanism.