Fulfilling the promise: Commentary on Schleider et al. (2023)

In their paper on "Realizing the Untapped Promise of Single-Session Interventions for Eating Disorders" Schleider and colleagues suggest an innovative approach to addressing a much- discussed critical issue in the treatment of eating disorders-how we help more people quickly and with greater efficiency. While building on the feasibility and success of program-led approaches, they make a potentially transformative proposal for the use of single-session, "one-at-a-time" interventions freely accessible to those in need. We suggest that not only does this proposal have the potential to narrow the treatment gap, but its ability to generate informative data at scale may also contribute to improving treatment outcomes overall. We also note the need for further independent support for the claim that single sessions produce meaningful benefit especially in the field of the prevention and treatment of eating disorders. While Schleider and colleagues' proposal is potentially transformative and has heuristic value, some caution needs to be exercised. In our view, single-session interventions should not be regarded as displacing existing treatment provision. Rather they should be seen as complementary and a potential way of improving provision overall

CBT for a fear of morphing: a case illustration

Describes the theoretical background to the treatment of a case of morphing fear in an adult and how evidence based practice was used to treat them

Developing a protocol to address co-occurring mental health conditions in the treatment of eating disorders

OBJECTIVE: While co-occurring mental health conditions are the norm in eating disorders, no testable protocol addresses management of these in psychotherapy. METHOD: The literature on managing mental health conditions that co-occur with eating disorders is outlined and reviewed. RESULTS: In the absence of clear evidence to inform managing co-occurring mental health conditions, we advocate for use of an iterative, session-by-session measurement to guide practice and research. We identify three data-driven treatment approaches (focus solely on the eating disorder; multiple sequential interventions either before or after the eating disorder is addressed; integrated interventions), and the indications for their use. Where a co-occurring mental health condition/s impede effective treatment of the eating disorder, and an integrated intervention is required, we outline a four-step protocol for three broad intervention approaches (alternate, modular, transdiagnostic). A research program is suggested to test the usefulness of the protocol. DISCUSSION: Guidelines that provide a starting point to improving outcomes for people with eating disorders that can be evaluated/researched are offered in the current paper. These guidelines require further elaboration with reference to: (1) whether any difference in approach is required where the co-occurring mental health condition is a comorbid symptom or condition; (2) the place of biological treatments within these guidelines; (3) precise guidelines for selecting among the three broad intervention approaches when adapting care for co-occurring conditions; (4) optimal approaches to involving consumer input into identifying the most relevant co-occurring conditions; (5) detailed specification on how to determine which adjuncts to add. PUBLIC SIGNIFICANCE: Most people with an eating disorder also have another diagnosis or an underlying trait (e.g., perfectionism). Currently no clear guidelines exist to guide treatment in this situation, which often results in a drift away from evidence-based techniques. This paper outlines data-driven strategies for treating eating disorders and the accompanying comorbid conditions and a research program that can test the usefulness of the different approaches suggested

Biased interpretation in perfectionism and its modification

Perfectionism is a transdiagnostic construct associated with a range of diagnoses, including depression, eating disorders and obsessive compulsive disorder. Treatments that directly target perfectionist cognitions have been shown to successfully reduce associated pathologies. However, the way in which they do this is not clear. We set out to assess the role of one candidate mechanism of action, namely the cognitive process of interpretation of ambiguity. In one experiment we looked for associations between biased interpretation and perfectionism. In a second, we manipulated interpretations, thereby providing a strong test of their aetiological significance. Results from the first experiment confirmed the presence of biased interpretation in perfectionism and demonstrated that these are highly specific to perfection relevant information, rather than reflecting general negativity. The second experiment succeeded in manipulating these perfection relevant interpretations and demonstrated that one consequence of doing so is a change in perfectionist behaviour. Together, these data experimentally demonstrate that biased interpretation of perfection relevant ambiguity contributes to the maintenance of perfectionism, but that it is also possible to reverse this. Clinical implications include the identification of one likely mechanism of therapeutic change within existing treatments, as well as identification of an appropriate evidence based focus for future treatment development. Targeting underlying functional mechanisms, such as biased interpretation, has the potential to offer transdiagnostic benefits

El proceso transdiagnóstico del perfeccionismo

The transdiagnostic approach to theory and treatment of psychological disorders is gainingincreasing interest. A transdiagnostic process is one that occurs across disorders and explainstheir onset or maintenance. The purpose of this review is to provide evidence that perfectionism isa transdiagnostic process that it is elevated in anxiety disorders, eating disorders, depression, obsessivecompulsive personality disorder and somatoform disorders. Data are also reviewed to showthat perfectionism can explain aetiology as it is a prospective predictor of depression and eatingdisorders. Perfectionism is also demonstrated to predict poorer outcome to treatment for anxietydisorders, eating disorders and depression, suggesting the need for specific treatment of perfectionism.Evidence is provided to demonstrate that perfectionism can be successfully treated with cognitivebehavioural therapy which results in reduction in psychopathologies. Clinical guidelines areoutlined to assist in treatment planning for individuals with elevated perfectionism.Abstract: The transdiagnostic approach to theory and treatment of psychological disorders is gainingincreasing interest. A transdiagnostic process is one that occurs across disorders and explainstheir onset or maintenance. The purpose of this review is to provide evidence that perfectionism isa transdiagnostic process that it is elevated in anxiety disorders, eating disorders, depression, obsessivecompulsive personality disorder and somatoform disorders. Data are also reviewed to showthat perfectionism can explain aetiology as it is a prospective predictor of depression and eatingdisorders. Perfectionism is also demonstrated to predict poorer outcome to treatment for anxietydisorders, eating disorders and depression, suggesting the need for specific treatment of perfectionism.Evidence is provided to demonstrate that perfectionism can be successfully treated with cognitivebehavioural therapy which results in reduction in psychopathologies. Clinical guidelines areoutlined to assist in treatment planning for individuals with elevated perfectionism.Resumen: El enfoque transdiagnóstico sobre la teoría y el tratamiento de los trastornos psicológicosestá generando un interés creciente en la literatura. Un proceso transdiagnóstico es aquel quese da a través de los trastornos y explica su inicio o mantenimiento. El objetivo de esta revisiónconsiste en aportar evidencia sobre el perfeccionismo como un proceso transdiagnóstico que seencuentra elevado en los trastornos de ansiedad, los trastornos alimentarios, la depresión, el trastornode personalidad obsesivo-compulsivo y los trastornos somatoformes. Revisamos la evidenciaempírica para mostrar que el perfeccionismo puede explicar la etiología como predictor prospectivode la depresión y los trastornos alimentarios. También se ha demostrado que el perfeccionismopredice un peor resultado terapéutico del tratamiento de los trastornos de ansiedad, los trastornosalimentarios y la depresión, sugiriendo la necesidad de un tratamiento específico del perfeccionismo.Proporcionamos evidencia para demostrar que el perfeccionismo puede ser tratado con éxitomediante terapia cognitivo conductual y que el tratamiento del perfeccionismo produce reduccionesen un rango amplio de psicopatologías. Se describen directrices clínicas para asistir en la planificacióndel tratamiento en individuos con elevados niveles de perfeccionismo

Reducing contamination by exposure plus safety behaviour

Background and objectives: It has been proposed that the judicious use of safety behaviour can facilitate improvements in the acceptability of cognitive behaviour therapy (CBT). It was decided to explore the possibility of facilitating CBT by introducing a form of safety behaviour.We sought to assess the degree to which Exposure plus Safety Behaviour (E þ SB) is an effective intervention for contamination fears. Methods: A comparison was made between the effects of a control condition (Exposure and Response Prevention; ERP) and an experimental condition (Exposure plus Safety Behaviour; E þ SB) in which each exposure to a contaminant was followed by the use of a hygienic wipe in a sample of (n ¼ 80) undergraduate students. In session one, each participant touched a confirmed contaminant 20 times. After each exposure participants were asked to report their feelings of contamination, fear, disgust, and danger. In the second session, two weeks later, the same procedure was carried out for a further 16 trials. Results: The ERP and the E þ SB conditions both produced large, significant and stable reductions in contamination. Significant reductions in fear, danger and disgust were also reported in both conditions. Limitations: The treatment was provided to an analogue sample and over two sessions. Conclusions: The use of hygienic wipes, the safety behaviour used in this experiment, did not preclude significant reductions in contamination, disgust, fear and danger. If it is replicated and extended over a longer time-frame, this finding may enable practitioners to enhance the acceptability of cognitive behavioural treatments and boost their effectiveness

Coming of age: A reflection of the first 21 years of cognitive behaviour therapy for perfectionism

It has been 21 years since the publication of the cognitive behavioural model of clinical perfectionism that underpins cognitive behaviour therapy (CBT) for perfectionism. The notion of clinical perfectionism and CBT for perfectionism has been controversial. Despite 15 randomised controlled trials which have demonstrated the efficacy of CBT for perfectionism in reducing perfectionism and symptoms of anxiety, depression and eating disorders, strong responses to this work continue to appear in the literature. In this article, we examine the evolution and controversy surrounding clinical perfectionism, the efficacy of CBT for perfectionism, and future directions for the concept of perfectionism and its treatment. Future research should aim to provide independent evaluations of treatment efficacy, compare CBT for perfectionism to active treatments, conduct dismantling trials to examine the effective components of treatment, and examine the causal processes involved in perfectionism. We provide recommendations for future pathways to support innovation in theory, understanding, and treatment of perfectionism with a view towards improving clinical outcomes

Development and validation of the Morphing Fear Questionnaire (MFQ)

Morphing fears (also called transformation obsessions) involve concerns that a person may become contaminated by and acquire undesirable characteristics of others. These symptoms are found in patients with OCD and are thought to be related to mental contamination. Given the high levels of distress and interference morphing fears can cause, a reliable and valid assessment measure is needed. This article describes the development and evaluation of the Morphing Fear Questionnaire (MFQ), a 13-item measure designed to assess for the presence and severity of morphing fears. A sample of 900 participants took part in the research. Of these, 140 reported having a current diagnosis of OCD (SR-OCD) and 760 reported never having had OCD (N-OCD; of whom 24 reported a diagnosis of an anxiety disorder and 23 reported a diagnosis of depression). Factor structure, reliability, and construct and criterion related validity were investigated. Exploratory and confirmatory factor analyses supported a one-factor structure replicable across the N-OCD and SR-OCD group. The MFQ was found to have high internal consistency and good temporal stability, and showed significantly greater associations with convergent measures (assessing obsessive-compulsive symptoms, mental contamination, thought-action fusion and magical thinking) than with divergent measures (assessing depression and anxiety). Moreover, the MFQ successfully discriminated between the SR-OCD sample and the N-OCD group, anxiety disorder sample, and depression sample. These findings suggest that the MFQ has sound psychometric properties and that it can be used to assess morphing fear. Clinical implications are discussed

Case-series Evaluating a Transdiagnostic Cognitive-behavioral Treatment For Co-occurring Anxiety Disorders.

Background. Patients with anxiety disorder diagnoses commonly have more than one anxiety diagnosis. While cognitive-behavioral interventions have proven efficacy in treating single anxiety disorder diagnoses, there has been little investigation of their efficacy in treating cooccurring anxiety disorders. Aims. To evaluate the efficacy of a transdiagnostic cognitive-behavioral intervention for treating co-occurring anxiety disorders. Methods. An A-B single case study design (N = 6) was used to evaluate the efficacy of a 12 to 13 session modular transdiagnostic cognitive-behavioral intervention for treating co-occurring anxiety disorders across patients with at least two of the following diagnoses: GAD, Social Phobia, Panic Disorder and/or OCD. Results. Five of the six participants completed treatment. At post-treatment assessment the five treatment completers achieved diagnostic and symptomatic change with three participants being diagnosis free. All participants who completed treatment no longer met criteria for any DSM-IV-TR Axis-I diagnosis at the three-month follow-up assessment, and demonstrated reliable and clinically-significant improvements in symptoms. Across the participants, statistically significant improvements from pre- to post-intervention were found on measures of anxiety, depression and general well-being, and all improvements were maintained at three-month follow-up. Conclusions. Results suggest that transdiagnostic cognitive behavioral interventions can be of benefit to patients with co-occurring anxiety disorders