The role of readiness and confidence to change in the treatment of atypical anorexia nervosa and bulimia nervosa.

OBJECTIVE: Atypical anorexia nervosa (AN) is a serious eating disorder that is more common in the population than AN. Despite this, people with atypical AN are less likely to be referred or admitted for eating disorder treatment and there is evidence that they are less likely to complete or benefit from existing interventions. This study examined whether baseline readiness and/or confidence moderated outcomes from 10-session cognitive behavioral therapy among people with atypical AN and bulimia nervosa (BN), and whether the impact of these variables differed between diagnoses. METHODS: Participants (n = 67; 33 with atypical AN) were a subset from an outpatient treatment study. Linear mixed model analyses were conducted to examine whether baseline readiness and/or confidence moderated outcomes. RESULTS: People with BN who had higher levels of readiness or confidence at baseline had steeper decreases in eating disorder psychopathology over time. There was no evidence that readiness or confidence moderated outcomes for people with atypical AN. DISCUSSION: This study suggests that the moderators that have been identified for other eating disorders may not apply for people with atypical AN and highlights a need for future work to routinely investigate whether theoretically or empirically driven variables moderate outcomes in this little-understood population. PUBLIC SIGNIFICANCE STATEMENT: People with bulimia nervosa with higher readiness and confidence experienced greater decreases in eating disorder symptoms than people with lower readiness and confidence when treated with cognitive behavioral therapy. These findings did not apply to people with atypical anorexia nervosa. Results demonstrate that future work is urgently required to identify helpful treatments for people with atypical anorexia nervosa as well as the variables that have a positive impact on outcomes in treatment for these individuals.

Factor Structure and Psychometric Properties of the ED-15 in People With an Eating Disorder.

OBJECTIVE: This study examines the factorial structure and psychometric properties of the Eating Disorder-15 questionnaire (ED-15) in a large clinical sample, as well as the instrument's sensitivity to early clinical change in therapy and ability to measure remission. METHOD: Participants with eating disorders (N = 278) referred to the Flinders University Services for Eating Disorders in South Australia completed the ED-15 as well as other measures of eating disorder symptoms and co-occurring psychopathology, including depression, anxiety, and stress. RESULTS: Confirmatory factor analysis (CFA) revealed a two-factor model for the ED-15. The ED-15 had good internal consistency. It showed satisfactory concurrent validity with moderate correlations with the EDE-Q global score and contribution of unique variance to that score. Correlations indicated good convergent validity with clinical impairment and good divergent validity from depression, anxiety, and stress. The ED-15 showed a significant medium effect size change within the first four sessions of therapy. Good discriminant validity was indicated by cut-off scores used for remission, with significantly different levels of ED psychopathology and other impairments between the two groups. DISCUSSION: This study adds to the four previous psychometric studies of the ED-15, confirming robustness of the English version in a clinical sample. The brevity and psychometric robustness of the ED-15 makes it a preferable measure to the Eating Disorder Examination for sessional assessment of progress in treatment.

Developing Solutions to the Waitlist Problem for Eating Disorder Treatments.

OBJECTIVE: We examine the small amount of research to date that describes and/or evaluates waitlist interventions as a precursor to treatment for an eating disorder (ED) with the intent to provide recommendations for future research that can further test the efficacy and effectiveness of waitlist interventions. METHOD: A review of published studies showed the standard of proof about the usefulness of waitlist interventions to be slight, with important gaps in our knowledge. One such gap was whether recovered people with lived experience could provide support to adults waiting for treatment. We briefly present new research evaluating this approach (N = 40), where people waiting for treatment were randomized to waitlist as usual or guided self-help with a trainee psychologist or a person with lived experience. RESULTS: Eight published studies across 10 different programs are described; N = 7 addressed waitlists for children and adolescents, and only three were randomized controlled trials. Our new research did not support the involvement of people with lived experience at this stage of the treatment journey. DISCUSSION: The results suggest some promise of waitlist interventions. Parents waiting for family-based treatment were able to improve weight and nutritional health in their children and experienced improved self-efficacy with respect to managing the ED. Provision of a waitlist intervention to adults may increase the probability of later engagement in treatment. It is still not possible to conclude whether waitlist interventions improve outcomes over treatment compared to those who did not receive such an intervention. We make five recommendations for future research.

The potential value of brief waitlist interventions in enhancing treatment retention and outcomes: a randomised controlled trial.

People with eating disorders are often placed on lengthy waitlists for treatment. This is problematic, as increased time spent on waitlists has been shown to predict dropout. We examined whether providing brief interventions to people on a waitlist improved retention or outcomes in treatment. Participants (N = 85) were referred to a university training clinic for 10-session cognitive behavioural therapy for non-underweight patients with eating disorders (CBT-T). While waitlisted for CBT-T, participants were randomised to one of two waitlist interventions or a control condition. In one waitlist intervention (CRT-Brief), participants received a cognitive remediation therapy session at the start of the waitlist period. In the other waitlist intervention (brief contact), participants were sent a short supportive email and psychoeducation halfway through the waitlist period. The control condition was waitlist as usual. There was no evidence to suggest that the waitlist interventions improved symptoms during the waitlist period or CBT-T. However, participants who received a waitlist intervention were three times more likely to complete treatment. The present study suggests that providing even brief contact while people are waitlisted for eating disorder treatment significantly improves retention. However, replication in a more adequately powered study is required.

Central coherence and set-shifting between nonunderweight eating disorders and anorexia nervosa: A systematic review and meta-analysis.

OBJECTIVE: This systematic review and meta-analysis compared previously documented inefficiencies in central coherence and set-shifting between people with nonunderweight eating disorders (bulimia nervosa and binge-eating disorder) and people with anorexia nervosa. METHOD: We performed random-effects meta-analyses on 16 studies (1,112 participants) for central coherence and 38 studies (3,505 participants) for set-shifting. Random effects meta-regressions were used to test whether the effect sizes for people with nonunderweight eating disorders were significantly different from the effect sizes for people with anorexia nervosa. RESULTS: People with anorexia nervosa (Hedge's g = -0.53, 95% CIs: -0.80, -0.27, p < .001) and bulimia nervosa (Hedge's g = -0.70, 95% CIs: -1.14, -0.25, p = .002), but not binge-eating disorder, had significantly poorer central coherence than healthy controls. Similarly, people with anorexia nervosa (Hedge's g = -0.38, 95% CIs: -0.50, -0.26, p < .001) and bulimia nervosa (Hedge's g = -0.55, 95% CIs: -0.81, -0.29, p < .001), but not binge-eating disorder, had significantly poorer set-shifting than healthy controls. The effect sizes for people with nonunderweight eating disorders did not significantly differ from those for people with anorexia nervosa. DISCUSSION: Our meta-analysis was underpowered to make definitive judgments about people with binge-eating disorder. However, we found that people with bulimia nervosa clearly have central coherence and set-shifting inefficiencies which do not significantly differ from those observed in people with anorexia nervosa. Clinically, this suggests that people with bulimia nervosa might benefit from adjunctive approaches to address these inefficiencies, such as cognitive remediation therapy.

OBJECTIVO: Esta revisión sistemática y metanálisis comparó las ineficiencias documentadas previamente en la coherencia central y el cambio de tareas entre personas con trastornos de la conducta alimentaria sin bajo peso (bulimia nervosa y trastorno por atracón) y personas con anorexia nerviosa. MÉTODO: Realizamos metanálisis de efectos aleatorios en 16 estudios (1112 participantes) para la coherencia central y 38 estudios (3505 participantes) para el cambio de tareas. Se utilizaron metarregresiones de efectos aleatorios para probar si los tamaños del efecto para las personas con trastornos alimentarios sin bajo peso eran significativamente diferentes de los tamaños del efecto para las personas con anorexia nerviosa. RESULTADOS: Las personas con anorexia nervosa (g de Hedge = −.53, IC del 95%: −.80, −.27, p <.001) y bulimia nervosa (g de Hedge = −.70, IC del 95%: −1.14, − 0,25, p = 0,002), pero no el trastorno por atracón, tenían una coherencia central significativamente más pobre que los controles sanos. De manera similar, las personas con anorexia nervosa (g de Hedge = −.38, IC del 95%: −.50, −.26, p <.001) y bulimia nervosa (g de Hedge = −.55, IC del 95%: −.81, −.29, p <.001), pero no el trastorno por atracón, tuvieron cambios de tareas significativamente más pobres que los controles sanos. Los tamaños del efecto para las personas con trastornos de la conducta alimentaria sin bajo peso no difirieron significativamente de los de las personas con anorexia nervosa. DISCUSIÓN: Nuestro metanálisis no tuvo el poder estadístico suficiente para emitir juicios definitivos sobre las personas con trastorno por atracón. Sin embargo, encontramos que las personas con bulimia nervosa claramente tienen coherencia central e ineficiencias de cambio de tareas que no difieren significativamente de las observadas en personas con anorexia nerviosa. Clínicamente, esto sugiere que las personas con bulimia nervosa podrían beneficiarse de enfoques complementarios para abordar estas ineficiencias, como la terapia de remediación cognitiva.

Relationship between eating disorder duration and treatment outcome: Systematic review and meta-analysis.

OBJECTIVE: This systematic review and meta-analysis examine the contribution of duration to treatment outcome for eating disorders. METHOD: Studies (n = 31) were identified that examined associations (r) between duration and 45 different outcomes. We were unable to extract r for seven studies (9 outcomes) and extracted r for 36 outcomes across 24 studies (2,349 participants). Indicators of treatment outcome were heterogeneous and thus a series of different meta-analyses, aimed at increasing homogeneity, were conducted. RESULTS: First, we examined the average effect size for one primary eating disorder related outcome from each of the 24 studies. There was no association between duration and treatment outcome (r = .05, 95% CI: -.03:.13), with high heterogeneity. Second, we conducted three sub-group analyses to explore possible sources of heterogeneity (diagnosis: anorexia nervosa versus bulimia nervosa; nature of the outcome: binary versus continuous; or type of outcome: binary indicator of recovery, eating disorder psychopathology, weight gain). There was no significant moderation or associations between duration and outcome (ranging from .02-.08), with low to medium heterogeneity. Third, two stand-alone analyses examined outcomes related to weight gain (n = 8) and eating disorder psychopathology (n = 5), with nonsignificant rs of .23/-.06, respectively. High levels of heterogeneity were present. DISCUSSION: Duration did not influence treatment outcome across any of our meta-analyses. Increasing homogeneity and power will allow more stable estimates of the impact of duration on outcome to be calculated; to this end, future treatment studies should include outcome related to weight gain (anorexia nervosa) and improvements in eating disorder psychopathology.

ANTECEDENTES: Esta revisión sistemática y metaanálisis examinan la contribución de la duración al resultado del tratamiento para los trastornos de la conducta alimentaria. MÉTODOS: Se identificaron estudios (n = 31) que examinaron las asociaciones (r) entre la duración y 45 diferentes resultados. No fue posible extraer r para siete estudios (nueve resultados) y se extrajo r para 36 resultados en 24 estudios (2349 participantes). Los indicadores del resultado del tratamiento fueron heterogéneos y, por lo tanto, se realizaron una serie de diferentes metaanálisis, destinados a aumentar la homogeneidad. RESULTADOS: Primero, examinamos el tamaño del efecto promedio para un resultado primario relacionado con el trastorno de la conducta alimentaria de cada uno de los 24 estudios. No hubo asociación entre la duración y el resultado del tratamiento (r = .05, IC del 95%: −.03: .13), con alta heterogeneidad. En segundo lugar, realizamos tres análisis de subgrupos para explorar posibles fuentes de heterogeneidad (diagnóstico: anorexia nerviosa versus bulimia nerviosa; naturaleza del resultado: binario versus continuo; o tipo de resultado: indicador binario de recuperación, psicopatología del trastorno alimentario, aumento de peso). No hubo moderación significativa o asociaciones entre la duración y el resultado (rango de .02−.08), con heterogeneidad baja a media. En tercer lugar, dos análisis independientes examinaron los resultados relacionados con el aumento de peso (n = 8) y la psicopatología del trastorno de la conducta alimentaria (n = 5), con una rs no significativa de 0,23/−0,06 respectivamente. Se presentaron altos niveles de heterogeneidad. CONCLUSIONES: La duración no influyó en el resultado del tratamiento en ninguno de nuestros metaanálisis. El aumento de la homogeneidad y el poder permitirá calcular estimaciones más estables del impacto de la duración en el resultado; con este fin, los estudios de tratamiento futuros deben incluir resultados relacionados con el aumento de peso (anorexia nerviosa) y mejoras en la psicopatología de los trastornos de la conducta alimentaria.

Impairments among DSM-5 eating disorders: A systematic review and multilevel meta-analysis.

Previous research revealed that people who did not meet full DSM-IV criteria for anorexia nervosa (AN), bulimia nervosa (BN), or binge-eating disorder (BED) but met criteria for eating disorder not otherwise specified (EDNOS) display high levels of psychiatric and physical morbidity commensurate with full criteria eating disorders. The DSM-5 introduced significant changes to eating disorder diagnostic criteria, so the present study aimed to determine whether the revised diagnostic criteria better distinguish between full criteria eating disorders, and other specified feeding or eating disorder (OSFED) and unspecified feeding or eating disorder (UFED). We present a series of meta-analyses comparing eating pathology, general psychopathology, and physical health impairments among those with AN, BN, and BED, compared to those with OSFED or UFED (n = 69 eligible studies). Results showed significantly more eating pathology in OSFED compared to AN, no difference in general psychopathology, and greater physical health impairments in AN. BN had greater eating pathology and general psychopathology than OSFED, but OSFED showed more physical health impairments. No differences were found between BN and purging disorder or low-frequency BN, or between BED and OSFED. Findings highlight the clinical severity of OSFED and suggest the DSM-5 criteria may not appropriately account for these presentations.

An exploratory examination of executive functioning as an outcome, moderator, and predictor in outpatient treatment for adults with anorexia nervosa.

OBJECTIVE: People with anorexia nervosa often exhibit inefficiencies in executive functioning (central coherence and set shifting) that may negatively impact on treatment outcomes. It is unclear from previous research whether these inefficiencies can change over treatment. We aimed to (1) investigate whether executive functioning can improve over treatment, (2) determine whether baseline executive functioning moderates treatment outcome, and (3) examine whether baseline executive functioning predicts early change (i.e., increase in body mass index over the first 13 weeks of treatment) or remission. METHOD: We conducted linear mixed model and logistic regression analyses on data from the Strong Without Anorexia Nervosa trial (Byrne et al. in Psychol Med 47:2823-2833, 2017). This study was a randomised controlled trial of three outpatient treatments for people with anorexia nervosa: Enhanced Cognitive Behavioural Therapy, Maudsley Model Anorexia Nervosa Treatment for Adults, and Specialist Supportive Clinical Management. RESULTS: While set shifting clearly improved from baseline to end of treatment, the results for central coherence were less clear cut. People with low baseline central coherence had more rapid reductions in eating disorder psychopathology and clinical impairment than those with high baseline central coherence. Baseline executive functioning did not predict early change or remission. DISCUSSION: The detail-focused thinking style commonly observed among people with anorexia nervosa may aid treatment outcomes. Future research that is more adequately powered should replicate this study and examine whether the same pattern of results is observed among people with non-underweight eating disorders.

People with anorexia nervosa often have difficulty thinking flexibly and in terms of the big picture. We investigated whether these thinking styles (1) change over treatment, (2) influence response to treatment, or (3) predict whether people gain weight or overcome the eating disorder. We found that people were able to think more flexibly after treatment. We also found that people who had more difficulty seeing the big picture prior to treatment had a more rapid decrease in eating disorder symptoms and clinical impairment in treatment. Thinking styles did not predict whether people gained weight early in treatment or overcame the eating disorder. Our findings suggest that the detail-focused thinking style commonly observed among people with anorexia nervosa can be both a vulnerability and a strength.

The effect of the spatial positioning of a healthy food cue on food choice from a pictorial-style menu.

The present study aimed to investigate the effect of the spatial positioning of a healthy food cue in the context of unhealthy food cues on subsequent food choice. Undergraduate women (N = 143) were asked to choose a food from a pictorial-style menu that presented a salad and three unhealthier food options in a horizontal line. The position of the salad was manipulated to be presented either (a) in the middle, (b) at the end, or (c) separated by 5 cm to the right of the line of unhealthier food options. Participants also completed a questionnaire measure of dietary restraint. Participants were significantly more likely to choose the salad when it was presented separately rather than in the middle of the unhealthier food options. This effect was not moderated by dietary restraint. The findings point to the possibility of designing pictorial menus in fast-food outlets in such a way as to subtly nudge people towards making healthier food choices.