Recent advances in therapies for the eating disorders

In the first part of this decade, many reviews of the impact of treatments for the eating disorders were conducted, with broadly similar conclusions. This review provides an update on progress (or otherwise) in the field over the past three years

The role of exposure in treatment of anxiety disorders: a meta-analysis

OBJECTIVE: This meta-analysis aimed to determine the overall effect that psychotherapy has on anxiety disorders and to determine what moderates that effect. Studies were grouped by type (efficacy or effectiveness) and grouped by analysis type (completer or intent-to-treat). METHOD: Medline was searched for articles published between 2011 and 2014 that related to the treatment of anxiety disorders. An initial search revealed 8056 articles. Of these, 99 articles met inclusion criteria and were included in the final analyses. RESULTS: Overall, manualised psychotherapy outperformed control conditions. In general, psychotherapy for anxiety disorders had a large effect. This effect appeared to be moderated by the use or lack of use of exposure techniques, with greater effects if exposure was used. This finding held particularly true for the treatment of post-traumatic stress disorder. CONCLUSION: Psychotherapies for anxiety disorders are both efficacious and effective. Exposure techniques enhance the effect of therapies. Future research work is required to determine what else moderates the effect of such therapies

Changes in internal states across the binge–vomit cycle in bulimia nervosa

While there is considerable evidence that bulimic behaviors serve the function of modifying internal states (e.g., satiety, mood), there is less clarity over the roles of the different behaviors across the binge-purge cycle. The present study examines the impact of bingeing and vomiting upon these internal states at different time points, and evaluates the potential reinforcement of those behaviors by the changes in internal states. Twenty-three women with diagnoses of bulimia nervosa completed a diary of all binge-vomit episodes over the course of 7 days, rating their internal states (satiety, negative mood, positive mood) at four time points during each episode. There were substantial changes across the cycle in levels of hunger, fullness, guilt/shame, anxiety/worry, and happiness/relief, but not in other states. The changes indicate that the binge-vomit cycle is maintained by the effects of both behaviors, but that the vomiting behavior evokes the strongest pattern of reinforcement. Further research is needed to determine the levels of internal states during the binge itself

Evidence for feasibility of implementing online brief cognitive‐behavioral therapy for eating disorder pathology in the workplace

Objective: CBT-T is a brief (10-week) cognitive-behavioral therapy for non-underweight eating disorders. This report describes the findings from a single center, single group, feasibility trial of online CBT-T in the workplace as an alternative to health service settings. Method: This trial was approved by the Biomedical and Scientific Research Ethics committee, University of Warwick, UK (reference 125/20-21) and was registered with ISRCTN (reference number: ISRCTN45943700). Recruitment was based on self-reported eating and weight concerns rather than diagnosis, potentially enabling access to treatment for employees who have not previously sought help and for those with sub-threshold eating disorder symptoms. Assessments took place at baseline, mid-treatment (week 4), post-treatment (week 10), and follow-up (1 and 3 months post-treatment). Participant experiences following treatment were assessed using quantitative and qualitative approaches. Results: For the primary outcomes, pre-determined benchmarks of high feasibility and acceptability were met, based on recruiting >40 participants (N = 47), low attrition (38%), and a high attendance rate (98%) over the course of the therapy. Participant experiences revealed low previous help-seeking for eating disorder concerns (21%). Qualitative findings indicated a wide range of positive impacts of the therapy and the workplace as the therapeutic setting. Analysis of secondary outcomes for participants with clinical and sub-threshold eating disorder symptoms showed strong effect sizes for eating pathology, anxiety and depression, and moderate effect sizes for work outcomes. Discussion: These pilot findings provide a strong rationale for a fully powered randomized controlled trial to determine the effectiveness of CBT-T in the workplace. Public Significance: This study demonstrates the feasibility of implementing an eating disorders intervention (online CBT-T) in the workplace as an alternative to traditional healthcare settings. Recruitment was based on self-reported eating and weight concerns rather than diagnosis, potentially enabling access to treatment for employees who had not previously sought help. The data also provide insights into recruitment, acceptability, effectiveness, and future viability of CBT-T in the workplace

A feasibility study of the delivery of online brief cognitive-behavioral therapy (CBT-T) for eating disorder pathology in the workplace

Objective CBT-T is a brief (10 sessions) version of cognitive behavioral therapy for non-underweight eating disorders. This report describes the protocol for a single center, single group, feasibility trial of online CBT-T in the workplace as an alternative to the health-service setting. By offering mental health services for eating disorders in the workplace, greater accessibility and increased help-seeking behaviors could be achieved. Method Treatment will be delivered online over 10 weeks and offered to employees based on self-referral rather than meeting diagnostic criteria, making treatment available to employees with sub-threshold eating disorder symptoms. Results Assessments will be conducted at baseline, mid-treatment (week 4), posttreatment (week 10) and at follow-up (1 month and 3 months posttreatment). For the primary outcome, measures will include recruitment, attrition and attendance data using pre-set benchmarks to determine high, medium or low feasibility and acceptability. Qualitative participant experiences data will be analyzed using thematic analysis. Impact on work engagement and effect sizes will be determined from secondary outcome measures; the latter enabling sample size calculations for future study. Discussion These pilot data will provide insights to recruitment, acceptability, effectiveness and viability of a future fully powered clinical trial of online CBT-T in the workplace. Public Significance Statement This study will present feasibility data from an eating disorders intervention (online CBT-T) using the workplace as an alternative to the healthcare setting to recruit and treat workers. Recruitment will be based on self-reported eating and weight concerns rather than diagnosis potentially enabling treatment to employees who have not previously sought help. The data will also provide insights to recruitment, acceptability, effectiveness, and future viability of CBT-T in the workplace

Development and validation of the Negative Attitudes towards CBT Scale

Background: Clinicians commonly fail to use cognitive-behavioural therapy (CBT) adequately, but the reasons for such omissions are not well understood. Aims: The objective of this study was to create and validate a measure to assess clinicians’ attitudes towards CBT - the Negative Attitudes towards CBT Scale (NACS). Method: The participants were 204 clinicians from various mental healthcare fields. Each completed the NACS, measures of anxiety and self-esteem, and a measure of therapists’ use of CBT and non-CBT techniques and their confidence in using those techniques. Exploratory factor analysis was used to determine the factor structure of the NACS, and scale internal consistency was tested. Results: A single, 16-item scale emerged from the factor analysis of the NACS, and that scale had good internal consistency. Clinicians’ negative attitudes and their anxiety had different patterns of association with the use of CBT and other therapeutic techniques. Conclusions: The findings suggest that clinicians’ attitudes and emotions each need to be considered when understanding why many clinicians fail to deliver the optimum version of evidence-based CBT. They also suggest that training effective CBT clinicians might depend on understanding and targeting such internal states

Effectiveness of Group Behavioural Activation for Depression: A Pilot Study.

BACKGROUND: The evidence base for behavioural activation (BA) is mainly grounded in the individual delivery method, with much less known about the impact of group delivery. AIMS: To conduct a pilot study of behavioural activation in groups (BAG) for depression delivered in a routine service setting, in order to explore acceptability, effectiveness and predictors of outcome. METHODS: The manualized group treatment format was delivered in a Primary Care mental health setting, at step three of an Improving Access to Psychological Therapies (IAPT) service. BAG was facilitated by cognitive behavioural psychotherapists, and outcome measures (depression, anxiety and functional impairment) were taken at each session. Seventy-three participants were referred and treated within nine groups. RESULTS: BAG was an acceptable treatment generating a low drop-out rate (7%). Significant pre-post differences were found across all measures. There was a moderate to large depression effect size (d + = 0.74), and 20% met the criteria for a reliable recovery in depression. Greater severity of initial depression and attendance of at least four BAG sessions predicted better outcomes. CONCLUSIONS: BAG appears to be an effective depression treatment option that shows some clinical promise. Further larger and more controlled studies are nevertheless required

Are we really delivering evidence-based treatments for eating disorders? How eating disordered patients describe their experience of cognitive behavioral therapy

Psychotherapists report routinely not practising evidence-based treatments. However, there is little research examining the content of therapy from the patient perspective. This study examined the self-reported treatment experiences of individuals who had been told that they had received cognitive-behavior therapy (CBT) for their eating disorder. One hundred and fifty-seven such sufferers (mean age = 25.69 years) were recruited from self-help organisations. Participants completed an online survey assessing demographics, clinical characteristics, and therapy components. The use of evidence-based CBT techniques varied widely, with core elements for the eating disorders (e.g., weighing and food monitoring) used at well below the optimum level, while a number of unevidenced techniques were reported as being used commonly. Cluster analysis showed that participants received different patterns of intervention under the therapist label of ‘CBT’, with evidence-based CBT being the least common. Therapist age and patient diagnosis were related to the pattern of intervention delivered. It appears that clinicians are not subscribing to a transdiagnostic approach to the treatment of eating disorders. Patient recollections in this study support the conclusion that evidence-based practice is not routinely undertaken with this client group, even when the therapy offered is described as such

To Deliver or Not to Deliver Cognitive Behavioral Therapy for Eating Disorders: Replication and Extension of Our Understanding of Why Therapists Fail to Do What They Should Do

Objective: This study investigated the extent to which therapists fail to apply empirically supported treatments in a sample of clinicians in The Netherlands, delivering cognitive behavioral therapy for eating disorders (CBT-ED). It aimed to replicate previous findings, and to extend them by examining other potential intra-individual factors associated with the level of (non-)use of core CBT-ED techniques. Method: Participants were 139 clinicians (127 women; mean age 41.4 years, range = 24-64) who completed an online survey about the level of use of specific techniques, their beliefs (e.g., about the importance of the alliance and use of pretreatment motivational techniques), anxiety (Intolerance of Uncertainty Scale), and personality (Ten Item Personality Inventory). Results: Despite some differences with Waller’s (2012) findings, the present results continue to indicate that therapists are not reliably delivering the CBT-ED techniques that would be expected to provide the best treatment to their patients. This ‘non-use’ appears to be related to clinician anxiety, temporal factors, and clinicians’ beliefs about the role of the therapeutic alliance in driving therapy outcomes. Discussion: Improving treatment delivery will involve working with clinicians’ levels of anxiety, clarifying the lack of benefit of pre-therapy motivational enhancement work, and reminding clinicians that the therapeutic alliance is enhanced by behavioral change in CBT-ED, rather than the other way around