An exploration of homework completion in cognitive behavioral treatments for bulimia-spectrum eating disorders.

The impact of homework completion on outcome from cognitive behavioral therapies (CBTs) for eating disorders (EDs) is unknown. We examined homework completion during two CBTs for bulimia-spectrum EDs and tested the associations among homework and treatment outcomes. After each session, therapists rated the quantity of self-monitoring completed (e.g. tracking food intake and ED symptoms), and degree of completion of the previous week's written (e.g. completing a worksheet) and behavioral (e.g. completing an at-home food exposure, regularly eating) homework on a Likert scale. On average, patients (N = 42) completed 50-100% of self-monitoring homework, moderate completion of written homework, and below-moderate completion of behavioral homework. Average behavioral homework completion, but not self- monitoring or written homework, was related to end-of-treatment symptom cessation. Improving homework completion might enhance the efficacy of CBTs for EDs.

A closer look at homework compliance in behavior therapy for bulimia nervosa: does homework compliance in between-session period prospectively predict session-by-session change in bulimia symptoms?

INTRODUCTION: Homework assignments are considered key components of behavioral treatments for bulimia nervosa (BN), but little is known about whether homework compliance predicts BN symptom improvement. The present study is the first to examine whether session-by-session change in homework compliance predicts session-by-session changes in BN symptoms during behavioral treatment. METHOD: Patients with BN-spectrum eating disorders (n = 42) received 20 sessions of behavioral treatment. Each session, their clinicians completed surveys assessing compliance with self-monitoring, behavioral, and written homework assignments and BN symptom frequency during the previous week. RESULTS: Significant between-persons effects of self-monitoring and behavioral homework compliance were identified, such that patients with greater compliance in the past week experienced greater reductions in binge eating and purging the following week. There were significant within-persons effects of self-monitoring compliance on binge eating and behavioral homework compliance on restrictive eating, binge eating, and purging, such that greater than one's usual compliance predicted greater improvements in BN symptoms the following week. No significant effects of written homework compliance were identified. CONCLUSION: Compliance with self-monitoring and behavioral homework predict improvements in BN symptoms during behavioral treatment. These findings reinforce the importance of self-monitoring and behavioral homework compliance as drivers of change during treatment for BN.

Weight status is associated with clinical characteristics among individuals with bulimia nervosa.

Recent studies have found increasing rates of overweight and obesity in bulimia nervosa (BN). However, the relationships between body mass index (BMI) and BN symptoms and other clinically relevant constructs are unknown. Participants (N = 152 adults with BN) were assigned to three groups by BMI: group with no overweight or obesity (NOW-BN; BMI <25; N = 32), group with overweight (OW-BN; BMI ≥25 and <30; N = 66), and group with obesity (O-BN; BMI ≥30; N = 54). We compared the groups on demographics, diet and weight histories, body esteem, BN symptoms, and depression using chi square, analysis of variance, analysis of covariance, and Poisson regression models. The O-BN group was older (d = 0.57) and OW-BN and O-BN groups had greater proportions of race/ethnic minorities than NOW-BN group. The O-BN group was significantly younger at first diet (d = 0.41) and demonstrated significantly higher cognitive dietary restraint (d = 0.31). Compared to NOW-BN, O-BN participants had lower incidence of objective binge eating (incidence rate ratio [IRR] = 4.86) and driven exercise (IRR = 7.13), and greater incidence of vomiting (IRR = 9.30), laxative misuse (IRR = 4.01), and diuretic misuse (d = 2.08). O-BN participants also experienced higher shape (d = 0.41) and weight (d = 0.42) concerns than NOW-BN and OW-BN, although NOW-BN experienced higher shape (d = 0.44) and weight (d = 0.39) concerns than OW-BN. Groups did not differ on depression scores. These results were replicated when examining BMI as a continuous predictor across the full sample, with the exception of objective binge eating and driven exercise, which were not significantly associated with BMI. Individuals with BN and comorbid obesity have distinct clinical characteristics. Existing interventions may need to be adapted to meet clinical needs of these individuals.

An empirical examination of appetite hormones and cognitive and behavioral bulimic symptomatology.

PURPOSE: Existing literature has demonstrated that appetite hormones are frequently dysregulated in individuals with bulimic-spectrum eating disorders (BN-EDs). Although dysregulations in appetite hormones may maintain BN-EDs, very limited research has examined the association between dysregulated appetite hormones and cognitive and behavioral bulimic symptoms. We hypothesized that greater frequency of behavioral symptoms and severity of cognitive symptoms of BN-EDs would correlate with greater dysregulation in appetite hormones. METHODS: The association between ghrelin, cortisol, leptin, GLP-1, and amylin levels and eating pathology was examined in treatment-seeking adults with BN-EDs (N = 33). Participants completed bloodwork to assess fasting blood hormone levels and bulimic symptoms were measured by the Eating Disorder Examination. Pearson partial correlations were run to examine the association between hormone levels and eating pathology, controlling for BMI. RESULTS: Contrary to hypotheses, none of the appetite hormones tested were significantly associated with frequency of behavioral ED symptoms (p range = 0.13-0.97, negligible to small effect sizes). Global eating pathology was positively associated with leptin (p = 0.03) and negatively associated with GLP-1 (p = 0.03) and amylin (p = 0.04), with medium effect sizes. Post hoc analyses indicated significantly stronger associations between appetite hormones and cognitive eating pathology than between appetite hormones and frequency of binge eating [GLP-1 (p = 0.02) and amylin (p = 0.02)] or compensatory behaviors [leptin (p = 0.03), GLP-1 (p = 0.02), and amylin (p = 0.04)]. CONCLUSION: In individuals with BN-EDs, appetite hormones may be more strongly associated with cognitive symptoms than behavioral symptoms. LEVEL OF EVIDENCE: Level V, cross-sectional descriptive study.

Longitudinal trajectories of behavior change in a national sample of patients seeking eating-disorder treatment.

OBJECTIVE: Rapid response to treatment, indicated by substantial decreases in eating-disorder (ED) symptoms within the first 4-6 weeks of treatment, is the most reliable predictor of treatment outcomes for EDs. However, there is limited research evaluating short-term longitudinal trajectories of ED symptoms during treatment. Thus, it is difficult to know which aspects of ED psychopathology are slow or fast to change. The purpose of this study was to elucidate three-month trajectories of ED psychopathology during treatment and test whether ED diagnosis influenced the direction and rate of change. METHOD: Participants were Recovery Record users seeking treatment for an ED (N = 4,568; 86.8% female). Participants completed the Eating Pathology Symptoms Inventory once per month for 3 months. RESULTS: Latent growth curve models indicated that ED diagnosis influenced the rate of ED behavior change. Anorexia nervosa was associated with faster reductions in cognitive restraint, excessive exercise, restricting, yet slower reductions in body dissatisfaction, and binge eating. Bulimia nervosa was associated with faster reductions in binge eating, cognitive restraint, excessive exercise, and purging. Binge-eating disorder was associated with faster reductions in body dissatisfaction and binge eating, yet slower reductions in restricting. CONCLUSIONS: Our results have implications for future research by providing initial information about the direction and rate of ED change over the course of treatment. If clinicians and researchers know which ED symptoms are slow to change, on average, across diagnostic groups, treatment protocols could be adjusted to target slow changing symptoms more quickly, and therefore improve ED treatment outcomes.

Developing more efficient, effective, and disseminable treatments for eating disorders: an overview of the multiphase optimization strategy.

The present manuscript describes the multiphase optimization strategy (MOST) and its potential applications to treatments for eating disorders (EDs). The manuscript describes the three phases of MOST, discusses a hypothetical case example of how MOST could be applied to developing a disseminable ED treatment, and reviews the pros and cons of the MOST approach. Outcomes from treatments for EDs leave room for improvement. However, traditional methods of treatment development and evaluation (i.e., the treatment package approach) make it challenging to determine how best to improve ED treatments. For example, testing full treatment packages in open trials and RCTs without systematic testing of each component is inefficient (as it is unknown which components are effective), and often does not provide concrete future directions for optimization of the treatment. Much stands to be gained by optimizing treatments in the early stages before testing them in open trials or RCTs. MOST is an alternative, engineering-inspired research framework that is well-suited to address the issues of inefficiency associated with the treatment package approach. MOST entails identifying the most promising treatment components for inclusion in interventions, then eliminating or deemphasizing less efficacious/inert components. This strategy results in a treatment comprised of only effective components that can then be tested via RCT. Though the MOST approach has limitations, it has the potential to greatly benefit ED treatment research and is worthy of application in the field.

New Horizons in Measurement: a Review of Novel and Innovative Approaches to Eating-Disorder Assessment.

PURPOSE OF REVIEW: Eating disorders are serious mental-health concerns that will affect over 30 million individuals in the USA at some point in their lives. Eating disorders occur across the lifespan, in a variety of ethnicities and races, in both men and women, and across the socioeconomic spectrum. Given the prevalence and severity of eating disorders, it is important that clinicians and researchers have access to appropriate assessment tools to aid in the early identification and treatment referral, differential diagnosis, treatment planning, and progress monitoring, and to ensure valid research findings. In this review, we describe novel and innovative assessment tools that were developed within the past 5 years for utilization in research and/or clinical practice with individuals with eating disorders. RECENT FINDINGS: We identified six multidimensional assessments for eating disorders, all of which can be administered online (with some also offering paper-and-pencil versions). Strengths of the measures included good internal consistency, test-retest reliability, and convergent validity. However, in part, due to problematic scale construction methods, certain scales had poor discriminant validity and most were developed and validated in mostly female samples. There are promising new eating disorder measures from which to choose; however, many measures continue to be limited by poor discriminant validity and need additional validation prior to incorporation into routine research and clinical practice.

Incremental validity of weight suppression in predicting clinical impairment in bulimic syndromes.

Research has shown that weight suppression (WS; the difference between a person's highest and current body weight in pounds) is a robust predictor of weight gain and eating-disorder (ED) symptoms among individuals with bulimic syndromes. Given the important prognostic role that WS plays in ED course and outcome, we hypothesized that WS would represent a clinically useful indicator of impairment for bulimic syndromes. We further posited that WS would demonstrate incremental validity above-and-beyond other proposed indicators in explaining clinical impairment in bulimic syndromes. Participants were community-recruited adults (N = 101; 80.2% female) with full-threshold (n = 51) or subthreshold (n = 50) bulimia nervosa. Other indicators of impairment included body mass index, frequency of inappropriate compensatory behaviors, lifetime history of any internalizing disorder, and multiple purging. Clinical impairment was assessed with the clinical impairment assessment (CIA). Hierarchical linear regression tested whether WS added to the explanation of CIA score variance above-and-beyond other indicators of bulimic-syndrome impairment. WS was significantly associated with clinical impairment (p = .011), but did not demonstrate incremental validity over other independent variables in predicting CIA scores. WS explained an additional 1.7% of the variance in CIA scores above-and-beyond other variables and the independent effect of WS on CIA scores represented a medium-sized effect (Cohen's d = 0.521). Results suggested that WS may be an indicator of ED-related clinical impairment. Inquiring about WS could be an informative component of routine bulimic-syndrome assessment, given that WS explains some of the variance in clinical impairment in bulimic syndromes.