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Background: Deterioration rates after enhanced cognitive behavioral therapy (CBT-E) for patients with bulimia-spectrum eating disorders (BN-EDs) remain high, and decreased posttreatment skill use might be a particularly relevant contributor. Digital interventions could be an ideal option to improve skill use after treatment ends but they have yet to be investigated for BN-EDs., Objective: This study used a user-centered design approach to explore patients' interest in a digital intervention to prevent deterioration after CBT-E and their desired features., Methods: A total of 12 participants who previously received CBT-E for BN-EDs and experienced at least a partial response to treatment completed a qualitative interview asking about their interests and needs for an app designed to prevent deterioration after treatment ended. Participants were also presented with features commonly used in digital interventions for EDs and were asked to provide feedback., Results: All 12 participants expressed interest in using an app to prevent deterioration after treatment ended. In total, 11 participants thought the proposed feature of setting a goal focusing on skill use weekly would help improve self-accountability for skill use, and 6 participants supported the idea of setting goals related to specific triggers because they would know what skills to use in high-risk situations. A total of 10 participants supported the self-monitoring ED behaviors feature because it could increase their awareness levels. Participants also reported wanting to track mood (n=6) and food intake (n=5) besides the proposed tracking feature. A total of 10 participants reported wanting knowledge-based content in the app, including instructions on skill practice (n=6), general mental health strategies outside of EDs (n=4), guided mindfulness exercises (n=3), and nutrition recommendations (n=3). Eight participants reported a desire for the app to send targeted push notifications, including reminders of skill use (n=7) and inspirational quotes for encouragement (n=3). Finally, 8 participants reported wanting a human connection in the app, 6 participants wishing to interact with other users to support and learn from each other, and 4 participants wanting to connect with professionals as needed. Overall, participants thought that having an app targeting skill use could provide continued support and improve self-accountability, thus lowering the risk of decreased skill use after treatment ended., Conclusions: Insights from participants highlighted the perceived importance of continued support for continued skill use after treatment ended. This study also provided valuable design implications regarding potential features focusing on facilitating posttreatment skill use to include in digital deterioration prevention programs. Future research should examine the optimal approaches to deliver the core features identified in this study that could lead to higher continued skill use and a lower risk of deterioration in the long term., (©Jianyi Liu, Alyssa Giannone, Hailing Wang, Lucy Wetherall, Adrienne Juarascio. Originally published in JMIR Formative Research (https://formative.jmir.org), 18.11.2024.)

Bulimia nervosa (BN) is characterized by recurrent loss of control over eating (LOC) and inappropriate compensatory behaviors. Although cognitive-behavioral therapy (CBT) is efficacious for BN, many patients continue to experience symptoms at posttreatment. One potential driver of this low treatment response may be low mood, which maintains BN symptoms through negative reinforcement. Thus, it is important to understand how mood changes over enhanced cognitive-behavioral therapy (CBT-E) and whether these changes are associated with improved treatment outcomes. Participants (N = 56) with BN-spectrum eating disorders (EDs) received 16 sessions of the focused version of CBT-E. The Eating Disorder Examination (EDE) was used to measure ED symptoms (global ED pathology, frequency of binge episodes, and compensatory behaviors) at pre- and posttreatment. Latent growth mixture modeling (LGMM) of affective ratings via digital self-monitoring identified latent growth classes. Kruskal-Wallis H tests examined the effect of trajectory of change in mood on pre- to posttreatment symptom change. LGMM yielded a four-class model that best fit the data representing distinct mood trajectories over the course of treatment: (a) highest baseline mood, linear improving; (b) moderate baseline mood, stable; (c) moderate baseline mood, quadratic worsening; and (d) lowest baseline mood, quadratic improving. Participants who demonstrated worsening mood over treatment (i.e., individuals in the "moderate baseline mood, quadratic worsening" class) had significantly higher EDE global scores at posttreatment and follow-up compared to participants with stable mood across treatment. Change in LOC eating frequency and compensatory behaviors across treatment did not significantly differ by mood class. The main effect of mood class or interaction effect between time and mood class on objective binge episodes, subjective binge episodes, and compensatory behaviors was not significant. There were no significant differences in global ED pathology at either posttreatment or follow-up for any other class comparisons. These results suggest that certain trajectories of change in mood during treatment are particularly associated with change in pre- to posttreatment EDE global score. If replicated, our findings could suggest that future iterations of CBT-E should target mood early in treatment in order to maximize reductions in global eating pathology., (Copyright © 2024 Association for Behavioral and Cognitive Therapies. Published by Elsevier Ltd. All rights reserved.)

Objective: Anxiety sensitivity (AS), the trait-like fear of symptoms of anxiety, has been associated with eating disorder (ED) pathology broadly, bulimia nervosa (BN) symptoms specifically, and the anxiety disorders that are commonly comorbid with BN. AS, especially for physical symptoms specifically, maybe a risk and maintenance factor for BN and comorbid anxiety., Method: Adult participants with BN (n = 44) in a clinical trial comparing CBT to mindfulness and acceptance-based treatment (MABT) reported ED symptoms, trait anxiety, and AS through treatment and follow-up. We predicted that greater early reduction (i.e., within the first month of treatment) in AS would predict greater reductions in ED symptoms and trait anxiety at post-treatment and follow-up., Results: Early reductions in AS for physical concerns predicted lower ED symptoms and trait anxiety at post-treatment but not follow-up. Exploratory analyses indicated that treatment groups did not differ in either early or total change in AS, controlling for baseline AS., Discussion: Early reductions in AS may be an important treatment target for BN, and may additionally support reductions in anxiety. Future research should identify which components of CBT and MABT best target AS, to deliver these components early in treatment, when they can have maximum effect., Public Significance: Anxiety sensitivity, the fear of symptoms of anxiety, is associated with eating disorders (ED). In this study, participants in treatment for bulimia nervosa reported ED symptoms, trait anxiety, and anxiety sensitivity through treatment and follow-up. Greater early reductions in anxiety sensitivity predicted lower ED symptoms and trait anxiety at post-treatment. Future research should identify which elements of treatment best target anxiety sensitivity, to deliver them early in treatment., (© 2024 Wiley Periodicals LLC.)

Objective: Deterioration rate among patients with bulimia-spectrum eating disorders (BN-EDs) after receiving enhanced cognitive-behavioral therapy (CBT-E) remains high. Previous studies identified body image concerns, environmental triggers, lack of social support, lack of resources, comorbidity, and discontinued skill use as predictors of deterioration. However, no studies have qualitatively explored patients' perceptions of how these factors influenced their skill use and led to deterioration after receiving outpatient CBT., Methods: This study aimed to qualitatively explore (1) what post-treatment factors patients believe contributed to deterioration, and (2) whether patients continued to practice the CBT skills they learned from treatment and identify motivators and barriers to post-treatment skill use. Twelve participants who had previously completed 16 sessions of CBT for their BN-EDs and experienced at least modest treatment responses participated in the qualitative interviews., Results: Four themes were identified from the qualitative interviews. Post-treatment deterioration was primarily driven by decreased skill use due to a perceived sudden loss of accountability and continued body dissatisfaction after treatment ended. Discontinued practice of binge analysis led to decreased awareness of the relationship between poor skill use and ED behaviors. Difficulty accessing resources impeded participants from receiving external help to address challenges in skill practice, thus also contributing to deterioration., Discussion: Findings suggested that outpatient treatment for BN-EDs patients should emphasize more on body image concern, and deterioration prevention for outpatient CBT-E should focus on building self-accountability to keep practicing skills after treatment ends., Public Significance: This study was the first to qualitatively explore post-treatment factors influencing skill use and deterioration in patients with bulimia-spectrum eating disorders after they completed outpatient CBT. Findings indicated that decreased skill use was a primary driver of post-treatment deterioration, and that relapse prevention for outpatient CBT for BN-EDs should focus on enhancing patients' self-accountability to continue practicing therapeutic skills independently after treatment ended., (© 2024 Wiley Periodicals LLC.)

Importance: Despite the existence of effective treatments, many individuals with bulimia nervosa (BN) do not receive evidence-based therapies. Integrating digital interventions into routine care might reach more patients and reduce the clinical burden of BN., Objective: To evaluate the effectiveness of a web-based cognitive behavioral self-help intervention for individuals with BN., Design, Setting, and Participants: A 2-group randomized clinical trial without follow-up was conducted between February 2, 2021, and July 9, 2022, in Germany. Participants aged between 18 and 65 years who met the diagnostic criteria for BN were enrolled online via self-referral. Data analyses were conducted from October 24, 2022, to December 23, 2023., Interventions: A web-based cognitive behavioral self-help intervention including 12 weekly modules was compared with a waiting-list control group only having access to routine care., Main Outcomes and Measures: The primary outcome was the change in the number of bulimic episodes between baseline and posttreatment. Secondary outcomes included changes in global eating disorder symptoms, clinical impairment, well-being, work capacity, comorbid symptoms, self-esteem, and emotion regulation complemented by weekly measures and ecological momentary assessment. Intention-to-treat analyses were performed., Results: Participants (N = 154; mean [SD] age, 29.6 [8.6] years; 149 [96.8%] female) receiving the web-based intervention demonstrated a significantly greater decrease in bulimic episodes compared with the control group (Cohen d = -0.48; 95% CI, -0.75 to -0.20; P < .001), representing a significant change in binge-eating episodes (Cohen d = -0.61; 95% CI, -0.89 to -0.33; P < .001), but not in compensatory behaviors (Cohen d = -0.25; 95% CI, -0.51 to 0.02; P = .21). The intervention was superior in improving global eating disorder symptoms (Cohen d = -0.61; 95% CI, -0.89 to -0.32; P < .001) and clinical impairment (Cohen d = -0.62; 95% CI, -0.92 to -0.33; P < .001). No significant effects were found for well-being (Cohen d = -0.08; 95% CI, -0.37 to 0.22; P > .99) and work capacity (Cohen d = -0.01; 95% CI, -0.68 to 0.66; P = .99). Exploratory analyses indicated significant changes in self-esteem and emotion regulation difficulties, but not in comorbid symptoms., Conclusions and Relevance: In this randomized clinical trial, a web-based cognitive behavioral self-help intervention effectively decreased eating disorder symptoms and illness-related burden in individuals with BN, underlining the potential of digital interventions to complement established treatments., Trial Registration: ClinicalTrials.gov Identifier: NCT04876196.

Background: Timely intervention is beneficial to the effectiveness of eating disorder (ED) treatment, but limited capacity within ED services means that these disorders are often not treated with sufficient speed. This service evaluation extends previous research into guided self-help (GSH) for adults with bulimic spectrum EDs by assessing the feasibility, acceptability, and preliminary effectiveness of virtually delivered GSH using videoconferencing., Method: Patients with bulimia nervosa (BN), binge eating disorder (BED) and other specified feeding and eating disorders (OSFED) waiting for treatment in a large specialist adult ED out-patient service were offered virtually delivered GSH. The programme used an evidence-based cognitive behavioural self-help book. Individuals were supported by non-expert coaches, who delivered the eight-session programme via videoconferencing., Results: One hundred and thirty patients were allocated to a GSH coach between 1 September 2020 and 30 September 2022; 106 (82%) started treatment and 78 (60%) completed treatment. Amongst completers, there were large reductions in ED behaviours and attitudinal symptoms, measured by the ED-15. The largest effect sizes for change between pre- and post-treatment were seen for binge eating episode frequency ( d = -0.89) and concerns around eating ( d = -1.72). Patients from minoritised ethnic groups were over-represented in the non-completer group., Conclusions: Virtually delivered GSH is feasible, acceptable and effective in reducing ED symptoms amongst those with bulimic spectrum disorders. Implementing virtually delivered GSH reduced waiting times, offering a potential solution for long waiting times for ED treatment. Further research is needed to compare GSH to other brief therapies and investigate barriers for patients from culturally diverse groups.

Objective: To examine trajectories of therapeutic skills use and weekly relations between skills use and symptom change during the enhanced version of cognitive-behavioral therapy (CBT-E) for bulimia nervosa (BN)., Method: Fifty-five adults (M age: 39.0 ± 14.1; 83.9% female; 64.3% White, 93.6% non-Hispanic/Latino) receiving CBT-E for BN-spectrum eating disorders (EDs) self-monitored their use of five therapeutic skills (i.e., regular eating, eating enough to prevent excessive hunger and eating a range of macronutrients, breaking dietary rules, urge management strategies, and mood management strategies) several times per day during treatment. Patients also self-reported their ED symptoms (i.e., frequency of binge eating, compensatory behaviors, and dietary restraint) weekly. We examined trajectories of use of each CBT-E skill and temporal relations between skills use and ED symptoms from week-to-week during treatment., Results: Participants showed significant increases in eating enough to prevent excessive hunger and eating a range of macronutrients from week-to-week (p < .05). Regular eating, eating enough to prevent excessive hunger, and eating a range of macronutrients 1 week predicted lower binge eating and compensatory behaviors the same week and the following week, and urge management strategy use predicted greater binge eating the same week and the following week (p < .05)., Conclusions: Results showed temporal relationships between therapeutic skills use and symptom change on a weekly level, with evidence that using skills targeting dietary restraint was associated with lower BN symptoms. Findings highlight the promise of future work to elucidate the most potent CBT-E skills for symptom improvement and inform more targeted interventions., Public Significance: Findings showed weekly relationships between therapeutic skills use and symptom change during treatment, with evidence that using CBT-E skills aimed to reduce dietary restraint (i.e., regular eating, eating enough to prevent excessive hunger, and eating a range of macronutrients) was associated with lower BN symptoms. Future work has the potential to identify the most potent CBT-E skills for symptom improvement and inform more targeted interventions., (© 2023 Wiley Periodicals LLC.)

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., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023. Published by Elsevier B.V.)

Objective: Brief cognitive-behavioral therapy for non-underweight eating disorders (CBT-T) has been shown to be clinically useful in non-underweight samples, when delivered one-to-one. This pilot study assessed the acceptance, compliance and feasibility levels of a group version of CBT-T, which has the potential to enhance patient access., Method: A group CBT-T protocol was developed and piloted in two therapy groups (N = 8). Eating disorder attitudes and behaviors, depression and anxiety were assessed at the beginning and end of treatment., Results: A third of all patients approached accepted the offer of group CBT-T, and entered treatment. Among that group of treatment starters, none were lost to treatment. The therapy was feasible in practical terms, including online delivery. Finally, mean scores on measures suggested improvement in clinical profiles., Discussion: This pilot study demonstrated that a group CBT-T is a feasible intervention for non-underweight eating disorders in adults, with low acceptance but high compliance. Group CBT-T has the potential to reduce demand on services and in turn increase availability of treatment to those with eating disorders., Public Significance: The present research contributes to the treatment of non-underweight adults with eating disorders. Group CBT-T was shown to be feasible in this pilot study. It was associated with low acceptance but strong compliance. If supported by further research, group CBT-T has the potential to reduce waitlists, ensure throughput in services, and ultimately improve the lives of many who are affected by eating disorders., (© 2023 The Authors. International Journal of Eating Disorders published by Wiley Periodicals LLC.)

Cognitive Behavior Therapy (CBT) for bulimia nervosa (BN) requires patient skill utilization (use of treatment skills) and skill acquisition (successful skill use) for symptom improvement. Treatment outcomes are unsatisfactory, possibly due to poor skill acquisition and utilization by post-treatment. Just-in-time adaptive interventions (JITAIs), momentary interventions delivered at opportunities for skill practice, may improve skill acquisition and utilization. Participants ( N  = 56 individuals with bulimia-spectrum eating disorders) completed electronic self-monitoring in CBT+ and received JITAIs or no JITAIs alongside 16 sessions of CBT. Feasibility, acceptability, target engagement, and treatment outcomes were evaluated. JITAIs demonstrated feasibility and acceptability. Treatment outcomes and target engagement did not differ between conditions. The lack of group differences in target engagement and treatment outcomes may be explained by skill use self-monitoring promoting skill utilization and acquisition or low statistical power. Our findings suggest that JITAIs are feasible and acceptable during CBT for BN and warrant additional study.

Recent advances in developing and screening candidate pharmacotherapies for psychiatric disorders have depended on rodent models. Eating disorders are a set of psychiatric disorders that have traditionally relied on behavioral therapies for effective long-term treatment. However, the clinical use of Lisdexamfatamine for binge eating disorder (BED) has furthered the notion of using pharmacotherapies for treating binge eating pathologies. While there are several binge eating rodent models, there is not a consensus on how to define pharmacological effectiveness within these models. Our purpose is to provide an overview of the potential pharmacotherapies or compounds tested in established rodent models of binge eating behavior. These findings will help provide guidance for determining pharmacological effectiveness for potential novel or repurposed pharmacotherapies.

Purpose: Fear of weight gain may play a central role in maintaining eating disorders (EDs), but research on the role of fear of weight gain during cognitive behavioral therapy (CBT-E) for binge-spectrum EDs is sparse. We examined changes in fear of weight gain during CBT-E for binge-spectrum EDs. We investigated whether fear of weight gain predicted loss of control (LOC) eating or weight change., Methods: Participants (N = 63) were adults of any gender recruited as part of a larger trial. Participants received 12 sessions of CBT-E, completed diagnostic assessments at pre-, mid-, and post-treatment, and completed brief surveys before sessions., Results: Fear of weight gain decreased across treatment, moderated by diagnosis. Those with bulimia nervosa spectrum EDs (BN-spectrum), compared to binge eating disorder, reported higher fear of weight gain at baseline and experienced a larger decrease in fear across treatment. Those reporting higher fear of weight gain at a given session experienced more frequent LOC episodes the following week. Fear of weight gain was not associated with session-by-session changes in BMI., Conclusion: CBT-E results in decreases in fear of weight gain, but levels remain high at post-treatment, especially for those with BN-spectrum EDs. Future interventions should consider targeting fear of weight gain as a maintaining factor for LOC episodes TRIAL REGISTRATION: NCT04076553., Level of Evidence: Level II controlled trial without randomization., (© 2023. The Author(s).)

A broad array of important and diverse studies surrounding the treatment of eating disorders were published in Eating Disorders: The Journal of Treatment & Prevention in 2022. Novel interventions such as neurosurgical and neuromodulatory treatments were discussed, as evidence continues to mount around their potential utility in treating eating disorders, in particular namely anorexia nervosa. Important pragmatic and theoretical developments around feeding and refeeding approaches emerged, and are also discussed. In this review, we carefully review evidence alluding to the potential efficacy of exercise in partially ameliorating binge eating disorder symptomatology, while examining broader evidence underscoring the importance of therapeutically ameliorating compulsive exercise in anorexia nervosa and bulimia nervosa. In addition, we overview evidence relating to the risk and sequelae associated with premature discharge from intensive eating disorder treatment, as well as the efficacy of CBT versus group therapy-based maintenance treatments. Finally, important developments around the use of open versus blind weighing in treatment are assessed. Overall, the articles published in Eating Disorders: The Journal of Treatment & Prevention in 2022 evidence the promise of treatment advances in the field and requires further work to address the development of efficacious treatments to achieve greater outcomes for those with eating disorders.

Bulimia nervosa is an eating disorder characterised by marked impairment to one's physical health and social functioning, as well as high rates of chronicity and comorbidity. This literature review aims to summarise existing academic research related to the symptom profile of BN, the costs and burden imposed by the illness, barriers to the receipt of care, and the evidence base for available psychological treatments. As a consequence of well-documented difficulties in accessing evidence-based treatments for eating disorders, efforts have been made towards developing innovative, diverse channels to deliver treatment, with several of these attempting to harness the potential of digital platforms. In response to the increasing number of trials investigating the utility of online treatments, this paper provides a critical review of previous attempts to examine digital interventions in the treatment of eating disorders. The results of a focused literature review are presented, including a detailed synthesis of a knowledgeable selection of high-quality articles with the aim of providing an update on the current state of research in the field. The results of the review highlight the potential for online self-help treatments to produce moderately sized reductions in core behavioural and cognitive symptoms of eating disorders. However, concern is raised regarding the methodological limitations of previous research in the field, as well as the high rates of dropout and poor adherence reported across most studies. The review suggests directions for future research, including the need to replicate previous findings using rigorous study design and methodology, as well as further investigation regarding the utility of clinician support and interactive digital features as potential mechanisms for offsetting low rates of engagement with online treatments.

Objective: Data suggest that obsessive-compulsive (OC) symptoms are commonly observed in adolescents with eating disorders and predict poorer treatment response. Further, emerging data among adults suggest that changes in OC symptoms relate to changes in eating disorder symptoms across treatment. Given evidence that early invention decreases risk for protracted illness, evaluating processes that may relate to treatment response will be useful in increasing the effectiveness of existing interventions. Therefore, the current investigation explored changes in general and eating disorder-specific OC symptoms throughout family-based treatment (FBT) and cognitive behavioral therapy (CBT) for bulimia nervosa (BN), as well as associations among these changes and eating disorder outcomes at follow-up., Method: Participants (N = 110) received 18 sessions of FBT or CBT and completed measurements of general and eating disorder-specific OC symptoms at baseline, end-of-treatment, and 6- and 12-month follow-up., Results: Multilevel models indicated that across both treatments, there was no change in general OC symptoms, whereas all eating disorder-related OC symptoms decreased over treatment and follow-up. Exploratory analyses indicated that lower severity in discharge eating-disorder-specific OC symptoms contributed to lower eating pathology at follow-up., Discussion: Together, findings support the efficacy of both FBT and CBT in helping to reduce eating disorder-specific OC symptoms and suggest that adjunctive intervention may be required for ameliorating general OC symptoms in this population., Public Significance: BN is associated with significant increases in mortality and societal cost, and there is a pressing need for innovations within available treatments for young people with this disorder. In the current study, we explore the extent to which existing evidence-based treatments for adolescent BN are effective in targeting obsessive-compulsive symptoms, a known predictor of treatment response and common co-morbidity in this population., (© 2022 Wiley Periodicals LLC.)

Objective: Cognitive-behavioural therapy (CBT) delivered face-to-face and via the internet reduces bulimia nervosa (BN) symptoms. However, our empirical understanding of factors affecting patient outcomes is limited., Method: Using data from a randomised, controlled trial comparing internet-based (CBT4BN, n = 78) with face-to-face (CBTF2F, n = 71) group CBT (97% female, M = 28 years), we examined general treatment (across conditions) and modality-specific predictors of end-treatment and 1-year outcomes (abstinence, binge-eating frequency, purging frequency)., Results: Improved eating disorder-related quality of life (EDQOL) during treatment and follow-up predicted abstinence at end-treatment and 1-year assessments. Improved EDQOL, disordered eating cognitions, and anxiety symptoms predicted less frequent binge eating and purging. Previous CBT and being employed predicted more frequent binge eating and purging at both assessments. Higher self-transcendence and self-directedness predicted less frequent binge eating. More severe binge eating and purging at baseline and end-treatment predicted more frequent binge eating and purging at subsequent assessments. Improved EDQOL was more strongly associated with positive outcome in CBT4BN; improved depressive symptoms and health-related QOL predicted positive outcome in CBT4BN but not CBTF2F., Discussion: Symptom improvement and certain character traits predicted positive outcome, whereas more severe presentation and prior CBT experience predicted poorer outcome. Consideration of intreatment symptom improvement may facilitate care recommendations, particularly for internet-based modalities., (© 2022 Eating Disorders Association and John Wiley & Sons Ltd.)

Purpose: Recent studies demonstrated that the embodiment disorder represents a core feature of eating disorders (EDs). The aim of this study was to evaluate the role of its variation as a possible mediator of the efficacy of enhanced cognitive behavioural therapy (CBT-E) on classic ED symptomatology, including body uneasiness., Methods: 73 patients with anorexia nervosa and 68 with bulimia nervosa were treated with a multidisciplinary approach including CBT-E. Psychometric questionnaires were administered at baseline (T0) and after one (T1) and 2 years (T2) to evaluate general and ED-specific psychopathology, body uneasiness and the embodiment disorder. Data regarding diagnostic crossover and remission were also collected., Results: Longitudinal analysis showed an improvement of all psychopathological dimensions at T1, which remained stable at T2 (p < 0.05). Remission rate at T2 was 44.7%, and diagnostic crossover occurred in 17.0% of patients. Higher levels of embodiment disorder predicted increased diagnostic instability (OR: 1.80 [1.01-3.20], p = 0.045). The amelioration of the embodiment disorder mediated the decrease in both ED-specific psychopathology (indirect effect: 0.67 [0.46-0.92]) and body uneasiness (indirect effect: 0.43 [0.28-0.59])., Conclusion: For the first time, these findings highlighted the role of the embodiment disorder as a maintaining factor of ED symptomatology, supporting the importance of integrating CBT-E with a phenomenological model of EDs., Level of Evidence: Level IV, longitudinal observational study (case series)., (© 2021. The Author(s).)

Background: This study aimed to investigate the effectiveness of mindfulness-based cognitive therapy (MBCT) as a complementary approach in patients with bulimia nervosa (BN) or binge eating disorder (BED), and to assess how the reduction of the cognitive load of words related to eating disorders (ED) could constitute an intermediate factor explaining its global efficacy., Methods: Eighty-eight women and men participated in clinical assessments upon inscription, prior to and following 8-week group MBCT. Mindfulness skills were assessed using the five facet mindfulness questionnaire; eating behaviors were assessed using the Three Factor Eating Questionnaire (TFEQ); comorbid pathologies were assessed using the beck depression index and the state-trait anxiety inventory. The cognitive load of words associated with ED was assessed through a modified version of the Stroop color naming task., Results: Mindfulness skills improved significantly (p < .05) after group MBCT. The improvement of TFEQ scores was accompanied by reduced levels of depressive mood and trait anxiety. The positive impact of MBCT on TFEQ score was directly related to an improvement of the performance in the Stroop task., Conclusions: MBCT represents an interesting complementary therapy for patients with either BN or BED, at least when cognitive and behavioral domains are concerned. Such efficacy seems to be mediated by the reduction of the cognitive load associated with ED stimuli, which offers a possible explanation of how MBCT could reduce binge-eating behaviors. Other studies are needed, in independent centers, to focus more directly on core symptoms and long-term outcome.

Purpose: This study tests the value of a measure of eating disorder (ED) psychopathology in predicting outcome following guided self-help in a non-underweight sample with regular binge eating. It examines whether early reductions in ED psychopathology are associated with remission status at post-treatment., Methods: Seventy-two adults with bulimia nervosa, binge-eating disorder, or an atypical form of these illnesses received up to ten sessions of cognitive behaviour therapy-based guided self-help. Using a session-by-session measure of eating pathology and associated reliable change indices, response was analysed using receiver operating characteristic analysis to predict outcomes at post-treatment., Results: In this routine care setting, nearly one-quarter of the sample achieved remission following GSH, approximately two-thirds of whom showed early change in ED psychopathology. Early change prior to session 6 was accurate in predicting later remission. Individuals showing early change did not differ from others on baseline characteristics or rates of attrition., Conclusion: Data suggest that a majority of those who respond to treatment will do so before the second half of treatment, information that could be used to ensure that evidence-based treatments are used as effectively as possible., Level of Evidence: Level III., (© 2020. The Author(s).)

Background: About half of Swedish eating disorder patients report exercising compulsively and compulsive exercise (CE) is prevalent in all diagnoses and both genders. Yet there are no systematic treatments targeting CE in specialist care. This study aims to evaluate the effects of The CompuLsive Exercise Activity TheraPy (LEAP) - a promising group treatment targeting compulsive exercise, in Swedish eating disorder patients., Method: One hundred twenty-eight adult females and males suffering from anorexia nervosa, bulimia nervosa or other specified feeding and eating disorders (type 1, 2, or 4) with CE will be recruited via four specialist eating disorder treatment units. Participants will be randomized to receive treatment as usual (control group) or treatment as usual plus LEAP (intervention group). The groups will be assessed on key variables (e.g., BMI, eating disorder symptoms, exercise cognitions and behaviors) at three occasions: initially, after 3 months and after 6 months., Discussion: The project takes place in a clinical setting, including both male and female patients with different eating disorder diagnoses with CE, enabling a good indication of the efficacy of LEAP. If our results are positive, LEAP has the potential of benefiting about half of the eating disorder population, with remission and recovery hopefully improving as a result., Trial Registration: The trial is registered with the ISRCTN registry (registration date 2020-03-25), trial ID: ISRCTN80711391 ., (© 2021. The Author(s).)

Multi-family therapy for Bulimia Nervosa (MFT-BN) was developed in response to the modest outcomes following both Family Therapy and Cognitive Behavior Therapy for adolescents with BN. BN impacts individuals and their family members with high levels of carer stress. MFT-BN targets barriers to treatment including low motivation to change, hostility and criticism, negative affect alongside emotion dysregulation and common comorbidities. MFT-BN enhances treatment, providing a community of support and acquisition of emotional regulation and interpersonal skills. The study describes the clinical characteristics of the group of participants to whom MFT-BN is offered and presents the outcomes of families who have participated in it. Prior to MFT-BN, adolescents who received it were more likely to have self-harmed and had elevated levels of eating disordered cognitions than those who did not receive MFT-BN. Following MFT-BN, parents report decreases in the negative experiences of caregiving and in their own symptoms of anxiety. Adolescents report reductions in anxiety and depression alongside improvement in emotion regulation. Improvements in symptoms of eating disorders include reductions in eating disorder cognitions and modest reductions in binge and purge symptoms after 14 weeks of treatment. Adolescents who participated in MFT-BN were less likely to drop out of outpatient treatment.

Introduction: Anorexia nervosa is a refractory psychiatric disorder with a mortality rate of 5.9% and standardised mortality ratio of 5.35, which is much higher than other psychiatric disorders. The standardised mortality ratio of bulimia nervosa is 1.49; however, it is characterised by suicidality resulting in a shorter time to death. While there is no current validated drug treatment for eating disorders in Japan, cognitive-behavioural therapy (CBT) is a well-established and commonly used treatment. CBT is also recommended in the Japanese Guidelines for the Treatment of Eating Disorders (2012) and has been covered by insurance since 2018. However, the neural mechanisms responsible for the effect of CBT have not been elucidated, and the use of biomarkers such as neuroimaging data would be beneficial., Methods and Analysis: The Eating Disorder Neuroimaging Initiative is a multisite prospective cohort study. We will longitudinally collect data from 72 patients with eating disorders (anorexia nervosa and bulimia nervosa) and 70 controls. Data will be collected at baseline, after 21-41 sessions of CBT and 12 months later. We will assess longitudinal changes in neural circuit function, clinical data, gene expression and psychological measures by therapeutic intervention and analyse the relationship among them using machine learning methods., Ethics and Dissemination: The study was approved by The Ethical Committee of the National Center of Neurology and Psychiatry (A2019-072). We will obtain written informed consent from all patients who participate in the study after they had been fully informed about the study protocol. All imaging, demographic and clinical data are shared between the participating sites and will be made publicly available in 2024., Trial Registration Number: UMIN000039841., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Mentalization is a developmental achievement defined as the capacity to understand behavior in terms of mental states. This study investigated mentalization in psychoanalytic psychotherapy (PPT) and cognitive behavior therapy (CBT) through a secondary data analysis of findings from a randomized controlled trial for bulimia nervosa. It was hypothesized that mentalization would predict alliance and outcome in both treatments, whereas increase in mentalization was only expected after PPT. Furthermore, it was investigated whether change in mentalization predicted symptom change. A total of 70 participants with bulimia nervosa were randomized to PPT or CBT. Participants were assessed at 3 time points with the Eating Disorder Examination and the Adult Attachment Interview (rated for reflective functioning [RF]). Therapy sessions were rated with the Vanderbilt Therapeutic Alliance Scale. Higher intake RF significantly predicted better alliance, whereas no association was observed between RF and outcome. A significant interaction between time, therapy type, and RF found RF improving more in PPT than in CBT. There was a significant association between RF change and symptom change in the PPT group. The study suggests a relation between RF and psychotherapy process, whereas the relation between RF and outcome is more complex. Furthermore, PPT seems to enhance mentalization, which seems related to symptomatic improvement, suggesting that mentalization might serve as a specific mechanism of change in PPT. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Objective: The aim of this study was to determine whether posttraumatic stress disorder (PTSD) predicts non-completion of CBT-based day hospital treatment for bulimia nervosa (BN) and other specified feeding and eating disorder (OSFED)., Method: Participants were 151 day hospital patients with BN or OSFED. Participants were assessed at pretreatment via interview and self-report measures. Cox regression was used to model the rate and timing of treatment termination; pretreatment binge and vomit frequencies, eating disorder-related clinical impairment, depression, and ED psychopathology were entered as covariates., Results: Participants who screened positive for PTSD (n = 64) had more severe ED psychopathology, ED-related impairment, negative schemas, and depression relative to those who did not screen positive. Cox regression indicated that PTSD significantly predicted premature termination and was associated with a 2.32 times greater risk. Individuals with BN or OSFED and co-occurring PTSD were particularly likely to terminate in the early phase of treatment compared with later in treatment., Conclusion: PTSD appears to affect some individuals' ability to complete intensive ED treatment. Future research should examine whether PTSD predicts premature termination from less intensive ED treatments, as well as in other intensive treatment settings, and whether PTSD predicts poorer outcomes from ED treatment., (© 2020 John Wiley & Sons, Ltd and Eating Disorders Association.)

Background: Day treatment programs for individuals with eating disorders (ED) have been the subject of research and are promoted as an alternative to inpatient treatment due to their therapeutic and economic advantages, but have not regularly been implemented in regular care., Purpose: We investigated the long-term effectiveness of a transdiagnostic combined eating disorder treatment program which consisted of an 8-week day treatment phase followed by an average of 19 sessions of outpatient treatment over an average of 39 weeks in a naturalistic setting., Methods: We accepted 148 patients with different diagnoses of eating disorders into our combined treatment program. We assessed weight, behavioral eating disorder symptoms and eating disorder related cognitions and attitudes at the beginning and the end of the day treatment phase and after 6, 12 and 26 months., Results: Over the course of the 8-week day treatment phase, patients with initial binge eating, purging and/or fasting behavior reduced these symptoms by 91%, 90% and, 86%. Patients who were underweight at baseline gained on average 1.05 BMI points (d = 0.76). In addition, eating disorder related cognitions and attitudes of all patients significantly improved with large effect sizes (d = 1.12). On average, all improvements remained stable during the follow-up period., Conclusions: Our findings add to the existing studies on day treatment and support previously found encouraging effects of treatment programs that combine day treatment and consecutive outpatient treatment for eating disorders., Level of Evidence: Level III, longitudinal cohort study.

Eating disorders (ED's) are the deadliest of all mental disorders, yet there is a paucity of research examining the clinical presentation of eating disorders in Hispanic populations and limited guidelines for culturally sensitive treatment. Given the rapid growth of Hispanic communities in the U.S., it is important to acknowledge the unique clinical profile of patients within this demographic and examine eating pathology within this socio-cultural context. This case study aims to illustrate the utility, relevance, and effectiveness of cognitive behavioral therapy (CBT) on alleviating eating disorder symptoms in an adult Latina patient with bulimia nervosa to understand the broader implications of applying manualized treatments to diverse populations. We outline the strengths of CBT in quickly modifying problematic thought patterns and decreasing pathological behaviors while raising questions about cultural generalizability. In addition, we explore CBT's limitations in addressing certain underlying ED pathology-driving and maintaining factors for minority individuals., (© 2019 Wiley Periodicals, Inc.)

Objective: We tested an aptitude by treatment interaction; namely, whether patients' baseline interpersonal problems moderated the comparative efficacy of cognitive-behavioral therapy (CBT) vs. interpersonal psychotherapy (IPT) for bulimia nervosa (BN). Method: Data derived from a randomized-controlled trial. Patients reported on their interpersonal problems at baseline; purge frequency at baseline, midtreatment, and posttreatment; and global eating disorder severity at baseline and posttreatment. We estimated the rate of change in purge frequency across therapy, and the likelihood of attaining clinically meaningful improvement (recovery) in global eating disorder severity by posttreatment. We then tested the interpersonal problem by treatment interactions as predictors of both outcomes. Results: Patients with more baseline overly communal/friendly problems showed steeper reduction in likelihood of purging when treated with CBT vs. IPT. Patients with more problems of being under communal/cold had similar reductions in likelihood of purging across both treatments. Patients with more baseline problems of being overly agentic were more likely to recover when treated with IPT vs. CBT, whereas patients with more problems of being under agentic were more likely to recover when treated with CBT vs. IPT. Conclusions: Interpersonal problems related to communion and agency may inform treatment fit among two empirically supported therapies for BN.

Objective: We previously demonstrated that early improvements in access to emotion regulation strategies during the first 4 weeks of intensive cognitive behavior therapy (CBT)-based eating disorder (ED) treatment predicted a range of post-treatment outcomes. This follow-up article examines whether early improvements in access to emotion regulation strategies continue to predict good treatment outcomes at 6 months post-treatment., Method: Participants were 76 patients with bulimia nervosa or purging disorder who participated in the original study and the 6-month follow-up assessment. Hierarchical regression models were used to examine whether early improvements in emotion regulation strategies predicted 6-month follow-up outcomes., Results: After controlling relevant covariates and rapid and substantial behavior change, greater early improvements in access to emotion regulation strategies during the first 4 weeks of intensive treatment predicted lower overall ED psychopathology and ED-related functional impairment 6 months after treatment. They did not predict abstinence from binge, vomit, and laxative use behaviors during the follow-up period., Discussion: Individuals who learn early in treatment that they can use skills to more effectively regulate emotions have better treatment outcomes on some variables 6 months after treatment. Teaching emotion regulation skills in the first phase of CBT for ED may be beneficial, particularly for individuals with baseline difficulties., (© 2019 Wiley Periodicals, Inc.)

Cognitive behavioral therapy (CBT) is an evidence-based treatment for bulimia nervosa and binge-eating disorder and is regarded as the first-line treatment for both eating disorders. An enhanced version of the treatment (CBT-E) appears more effective in treating patients with severe comorbidity. There is less evidence that CBT is effective for the treatment of anorexia nervosa. Evidence suggests that CBT-E is no more effective than specialist care involving regular medical follow-up and supportive psychotherapy in the persistent adult form of anorexia nervosa (AN). Early studies suggest that CBT-E may be useful in treating the adolescent form of AN., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The etiopathogenesis of eating disorders (EDs) is complex and still not well understood. Biological, psychological and environmental factors (e.g. childhood abuse) have all been considered to be involved in the onset and the persistence of EDs. The hypothalamic-pituitary-adrenal (HPA) axis is a relevant biological factor capable of influencing the onset and the course of EDs and not many information are available about the impact of a Cognitive Behavioral Therapy (CBT) on cortisol changes in EDs. The HPA-axis functioning has been evaluated before and after CBT in a group of patients with Anorexia Nervosa (n = 34) and Bulimia Nervosa (n = 35) according to the presence/absence of a history of sexual/physical abuse. At baseline, only patients reporting childhood abuse showed lower morning cortisol levels as compared with other patients of the same diagnostic group and Healthy Controls. After CBT, a variation of cortisol levels has been found only in patients without abuse, suggesting a role of childhood adversities in the persistence of HPA-axis alterations in Eating Disorders., (Copyright © 2019. Published by Elsevier B.V.)

Estimates of lifetime bulimia nervosa (BN) range from 4% to 6.7% across studies. There has been a decrease in the presentation of BN in primary care but an increase in disordered eating not meeting full diagnostic criteria. Regardless of diagnostic status, disordered eating is associated with long-term significant impairment to both physical and mental quality of life, and BN is associated with a significantly higher likelihood of self-harm, suicide, and death. Assessment should adopt a motivationally enhancing stance given the high level of ambivalence associated with BN. Cognitive behavior therapy specific to eating disorders outperforms other active psychological comparisons., (Copyright © 2018 Elsevier Inc. All rights reserved.)

This article reviews the 6-month followup data of a randomized, multicenter, parallel-group study conducted at five clinical sites in three European cities, which compared two second-level treatments for bulimia nervosa (BN) and binge eating disorder (BED): virtual reality-based cue exposure therapy (VR-CET) versus additional cognitive behavioral therapy (A-CBT). Post-treatment outcomes of this study were previously published and details of its design can be found at clinicaltrials.gov (identifier: NCT02237300). This article focuses on the evolution of symptoms assessed after 6 months of followup in a subgroup of 58 patients from the original study. In this study 64 patients with eating disorders (EDs) (35 with BN and 29 with BED), who still showed active episodes of binge eating by the end of a structured CBT program (first-level treatment), were randomly assigned to one of two second-level treatments (A-CBT or VR-CET). Frequency of binge and purge episodes, and attitudinal features of binge-related EDs (bulimia, drive for thinness, and body dissatisfaction) were assessed before starting the second-level treatment (n = 64), at the end (n = 64), and at 6-month followup (n = 58). Mixed between-within subject analyses of variance were used to compare outcomes of both second-level treatments over time. Although both treatment conditions showed statistically significant improvements at the end and after 6-month followup, obtained reductions were greater after VR-CET, regarding binge and purge episodes, as well as the decrease of self-reported tendency to engage in overeating episodes. Accordingly, abstinence from binge episodes were higher in VR-CET than A-CBT at followup (70 percent vs. 26 percent, respectively; χ 2  = 11.711, p = 0.001). These results provide further support for the use of VR-CET as an effective second-level intervention for BN and BED treatment-resistant patients.

Cognitive Behavioral Therapy for Bulimia Nervosa Abstract. Abstract:: Cognitive behavioural therapy for eating disorders is an evidence-based effective method for the treatment of bulimia nervosa. It is based on a multifactorial and behavioal disorder model in which causes, triggering and maintaining conditions are considered and summarized in a behavioral analysis. Symptom-oriented standard procedures are used in the therapy process. Skills such as emotion regulation, interpersonal competence and cognitive techniques are taught. The low self-esteem and body dissatisfaction are of particular importance. Finally, personal goals are worked on with the patient, taking into account individual needs.

In the complex pathomechanism of eating disorders (especially that of bulimia nervosa and binge eating disorder) the traumatic experiences (sexual, physical, emotional abuse, neglect) often play an important role. The consequence of traumas can be the borderline personality disorder, or different disorders of the emotional regulation. These occur mainly in the multiimpulsive subtype of eating disorders with impulse control disorders. In relation to the trauma dissociative phenomena are frequent. In the diagnostics of eating disorders the history of traumatization is essential. Among the therapeutical possibilities the psychodynamic approach is important. Moreover, the newer methods based on cognitive behavioral therapy are effective, e.g., dialectic behavior therapy, integrative cognitive-analytic therapy, and other complex programs of trauma processing, such as the trauma-informed care.

Background: Bulimia nervosa (BN) is a severe eating disorder that can be managed using a variety of treatments including pharmacological, psychological, and combination treatments. We aimed to compare their effectiveness and to identify the most effective for the treatment of BN in adults., Methods: A search was conducted in Embase, Medline, PsycINFO, and Central from their inception to July 2016. Studies were included if they reported on treatments for adults who fulfilled diagnostic criteria for BN. Only randomised controlled trials (RCTs) that examined available psychological, pharmacological, or combination therapies licensed in the UK were included. We conducted a network meta-analysis (NMA) of RCTs. The outcome analysed was full remission at the end of treatment., Results: We identified 21 eligible trials with 1828 participants involving 12 treatments, including wait list. The results of the NMA suggested that individual cognitive behavioural therapy (CBT) (specific to eating disorders) was most effective in achieving remission at the end of treatment compared with wait list (OR 3.89, 95% CrI 1.19-14.02), followed by guided cognitive behavioural self-help (OR 3.81, 95% CrI 1.51-10.90). Inconsistency checks did not identify any significant inconsistency between the direct and indirect evidence., Conclusions: The analysis suggested that the treatments that are most likely to achieve full remission are individual CBT (specific to eating disorders) and guided cognitive behavioural self-help, although no firm conclusions could be drawn due to the limited evidence base. There is a need for further research on the maintenance of treatment effects and the mediators of treatment outcome.

Background: Previous research suggests that computerized interpretation bias modification (IBM) techniques may be useful for modifying thoughts and behaviours relevant to eating pathology; however, little is known about the utility of IBM for decreasing specific eating disorder (ED) symptoms (e.g. bulimia, drive for thinness)., Aims: The current study sought to further examine the utility of IBM for ED symptoms via secondary analyses of an examination of IBM for individuals with elevated body dysmorphic disorder (BDD) symptoms (see Summers and Cougle, 2016), as these disorders are both characterized by threat interpretation biases of ambiguous appearance-related information., Method: We recruited 41 participants for a randomized trial comparing four sessions of IBM aimed at modifying problematic social and appearance-related threat interpretation biases with a placebo control training (PC)., Results: At 1-week post-treatment, and relative to the PC, the IBM group reported greater reductions in negative/threat interpretations of ambiguous information in favour of positive/benign biases. Furthermore, among individuals with high pre-treatment bulimia symptoms, IBM yielded greater reductions in bulimia symptoms compared with PC at post-treatment. No treatment effects were observed on drive for thinness symptoms., Conclusions: The current study suggests that cognitive interventions for individuals with primary BDD symptoms may improve co-occurring ED symptoms such as bulimia.

Objective: This review looked at internet-delivered cognitive behavioural therapy (iCBT) as a possible treatment for patients with bulimic symptoms. CBT has been established as an effective treatment; however, waiting lists lead to delayed initiation of treatment. iCBT is a possible delivery method to combat this. Medline, EMBASE and PsycInfo were searched for controlled trials using iCBT as a treatment for patients with bulimia nervosa (BN), subthreshold BN or 'eating disorders not otherwise specified' with bulimic characteristics (EDNOS-BN). The literature search returned 482 papers. 5 met the review criteria and were compared in characteristics, methodological quality and outcomes. Outcomes were analysed by calculation of effect sizes; iCBT was evaluated on reduction in binge eating and purging post treatment and at follow-up., Results: Participants were mostly female with an average age range of 23.7-31 years. 4 studies demonstrated good methodological quality. 1 did not report all of the outcome data, increasing the likelihood of bias. Only 1 study showed widespread benefit over waiting list controls. iCBT was shown to reduce behaviours but was not found to be superior to bibliotherapy or waiting list. Further large-scale studies are required to make conclusive recommendations.

Objective: Provision of eating disorder (ED) treatment in practice is often guided by national health service structures rather than evidence-based treatment recommendations. Especially for more severely or chronically ill patients, clinicians seem to advocate a "the more the better" strategy of treatment provision. Exploring the dose-response relationship in ED treatment may shed light on both beneficial and detrimental effects of prolonged treatment provision., Method: We utilized data from 64 women from the treatment-as-usual (TAU) group of a randomized controlled trial on Internet-based aftercare for women with bulimia nervosa who had received inpatient treatment. We examined the relationship between treatment duration and dose and (1) baseline patient characteristics and (2) treatment outcomes (abstinence from binge eating and compensatory behaviors, frequency of binge eating and vomiting, thin ideal internalization, and general psychopathology) at 18-month follow up., Results: On average, the women in our study were hospitalized for 9 weeks and most received high doses of subsequent outpatient psychotherapy (median: 45 sessions). The severity of symptoms that a patient experienced at hospital admission or discharge was largely unrelated to the amount of outpatient treatment she subsequently received. Longer inpatient treatments or higher doses of subsequent outpatient treatment did not result in more favorable outcomes., Discussion: Our findings suggest that, instead of providing costly long treatment without evidenced benefit to patients, there is a need for further exploration of and discussion about the risks and benefits of providing high doses of treatment for both individuals and the health care system., (© 2018 Wiley Periodicals, Inc.)

Objective: The most widely researched treatment for bulimia nervosa (BN) and binge-eating disorder (BED) is cognitive behavioral therapy (CBT), a present-focused, active, skill-oriented treatment. However, despite the success of CBT, many patients fail to achieve sufficient rates of skill utilization (i.e., the frequency with which a patient practices or uses therapeutic skills) or adequate skill acquisition (i.e., the ability to successfully perform a skill learned in treatment) by the end of treatment and outcomes suffer as a result. One method for improving skill acquisition and utilization in patients with BN or BED could be the augmentation of in-person treatment with just-in-time adaptive interventions (JITAIs), which use smartphone technology to deliver real-time interventions during app-identified moments of need. The current article discusses how novel JITAI systems that utilize machine learning or other predictive algorithms could be used to detect momentary risk for eating disordered behavior and provide tailored interventions to enhance outcomes. We will consider technologies that may help reduce patient burden and suggest avenues for future research on developing acceptable and effective JITAIs that can be used as an adjunct to CBT protocols., (© 2018 Wiley Periodicals, Inc.)

This study examined the effect of family-based treatment for bulimia nervosa (FBT-BN) and cognitive behavioral therapy for adolescents (CBT-A) on depressive symptoms and self-esteem in adolescents with BN. Data were collected from 110 adolescents, ages 12-18, who met Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition, text revision criteria for BN or partial BN. Participants were randomly assigned to FBT-BN or CBT-A and completed measures of depressive symptoms and self-esteem before and after treatment and at 6- and 12-month follow-up assessments. Depressive symptoms and self-esteem significantly improved in both treatments, and neither treatment appeared superior on these clinical outcomes. Parents often worry whether FBT-BN addresses comorbid depressive symptoms and low self-esteem. Our findings address this concern, as they demonstrate that FBT-BN does not differ from CBT-A in improving depressive symptoms and self-esteem, and both treatments result in symptom improvement. These findings can help clinicians guide families to choose a treatment that addresses BN and depressive symptoms and low self-esteem., (Copyright © 2018 John Wiley & Sons, Ltd and Eating Disorders Association.)

Objective: Guided self-help treatments based on cognitive behavioral therapy (CBT-GSH) are regarded as a first-line effective treatment for bulimia nervosa (BN). With limited application for CBT-GSH in Japanese clinical settings, we conducted a single arm pilot study in order to confirm the acceptability and availability of CBT-GSH in Japan., Results: 25 women with BN received 16-20 sessions of face-to-face CBT-GSH. Primary outcomes were the completion rate of intervention and abstinence rates from objective bingeing and purging as assessed by the Eating Disorder Examination. Secondary outcomes were other self-report measurements of the frequency of bingeing and purging, and characteristic psychopathologies of eating disorders. Assessments were conducted before CBT as baseline as well as after CBT. 92% (23/25) of the participants completed the CBT sessions. After CBT-GSH, 40% (10/25) of the participants (intention-to-treat) achieved symptom abstinence. The mean binge and purge episodes during the previous 28 days improved from 21.88 to 10.96 (50% reduction) and from 22.44 to 10.88 (52% reduction), each (before CBT-GSH to after CBT-GSH), and the within-group effect sizes were medium (Cohen's d = 0.67, 0.65, each). Our study provided a preliminary evidence about the feasibility of CBT-GSH in Japanese clinical settings for the future. Trial registration This study was registered retrospectively in the national UMIN Clinical Trials Registry on July 10, 2013 (registration ID: UMIN000011120).

The original and enhanced cognitive model of eating disorders proposes that cognitive-behavioral therapy (CBT) "works" through modifying dietary restraint and dysfunctional attitudes towards shape and weight. However, evidence supporting the validity of this model is limited. This meta-analysis examined whether CBT can effectively modify these proposed maintaining mechanisms. Randomized controlled trials that compared CBT to control conditions or non-CBT interventions, and reported dietary restraint and shape and weight concern outcomes were searched. Twenty-nine trials were included. CBT was superior to control conditions in reducing shape (g=0.53) and weight (g=0.63) concerns, and dietary restraint (g=0.36). These effects occurred across all diagnoses and treatment formats. Improvements in shape and weight concerns and restraint were also greater in CBT than non-CBT interventions (g's=0.25, 0.24, 0.31, respectively) at post-treatment and follow-up. The magnitude of improvement in binge/purge symptoms was related to the magnitude of improvement in these maintaining mechanisms. Findings demonstrate that CBT has a specific effect in targeting the eating disorder maintaining mechanisms, and offers support to the underlying cognitive model. If changes in these variables during treatment are shown to be causal mechanisms, then these findings show that CBT, relative to non-CBT interventions, is better able to modify these mechanisms.

Explanatory models for eating disorders have changed over time to account for changing clinical presentations. The transdiagnostic model evolved from the maintenance model, which provided the framework for cognitive behavioural therapy for bulimia nervosa. However, for many individuals (especially those at the extreme ends of the weight spectrum), this account does not fully fit. New evidence generated from research framed within the food addiction hypothesis is synthesized here into a model that can explain recurrent binge eating behaviour. New interventions that target core maintenance elements identified within the model may be useful additions to a complex model of treatment for eating disorders., (Copyright © 2018 John Wiley & Sons, Ltd and Eating Disorders Association.)

Objective: This study examines the statistical and clinical significance of symptom changes during an intensive inpatient treatment program with a strong psychotherapeutic focus for individuals with severe bulimia nervosa., Method: 295 consecutively admitted bulimic patients were administered the Structured Interview for Anorexic and Bulimic Syndromes-Self-Rating (SIAB-S), the Eating Disorder Inventory-2 (EDI-2), the Brief Symptom Inventory (BSI), and the Beck Depression Inventory-II (BDI-II) at treatment intake and discharge., Results: Results indicated statistically significant symptom reductions with large effect sizes regarding severity of binge eating and compensatory behavior (SIAB-S), overall eating disorder symptom severity (EDI-2), overall psychopathology (BSI), and depressive symptom severity (BDI-II) even when controlling for antidepressant medication. The majority of patients showed either reliable (EDI-2: 33.7%, BSI: 34.8%, BDI-II: 18.1%) or even clinically significant symptom changes (EDI-2: 43.2%, BSI: 33.9%, BDI-II: 56.9%). Patients with clinically significant improvement were less distressed at intake and less likely to suffer from a comorbid borderline personality disorder when compared with those who did not improve to a clinically significant extent., Conclusions: Findings indicate that intensive psychotherapeutic inpatient treatment may be effective in about 75% of severely affected bulimic patients. For the remaining non-responding patients, inpatient treatment might be improved through an even stronger focus on the reduction of comorbid borderline personality traits.

Introduction: Women with bulimia nervosa and binge eating disorder often suffer for many years before they seek professional help. Evidence-based treatments like cognitive-behavioural therapy (CBT) might be poorly accessible, and about 50% of those who receive CBT respond to it. Such outcome may reflect the heterogeneous nature of eating disorders, and addressing this heterogeneity calls for expanding the portfolio of treatment options. In particular, it is important to explore such options' acceptability, tolerability and affordability expressed through experiences with the treatment. This protocol outlines the rationale and design of a qualitative study. It captures experiences from patients and therapists who were involved in a randomised controlled trial (RCT) exploring the efficacy of a new group-based treatment programme combining physical exercise and dietary therapy., Methods and Analysis: 15 patients with bulimia nervosa or binge eating disorder, 10 therapists (physical trainers and dietitians) and 6-10 patients who dropped out of the RCT will be semistructurally interviewed. All interviews will be analysed using a systematic text condensation approach., Ethics and Dissemination: Results will be presented in peer-reviewed international journals, and at relevant international conferences. Key findings will be available to study participants as well as to patient organisations and health authorities. The overall study meets the intent and requirements of the Health Research Act and the Declaration of Helsinki. It is approved by the regional committee for medical research ethics (2013/1871)., Trial Registration Number: NCT02079935; Pre-results., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objective: To evaluate the cost-effectiveness of Internet-based cognitive-behavioral therapy for bulimia nervosa (CBT-BN) compared to face-to-face delivery of CBT-BN., Methods: This study is a planned secondary analysis of data from a randomized clinical trial. Participants were 179 adults (98% female, mean age = 28 years) meeting DSM-IV criteria for bulimia nervosa who were randomized to group face-to-face or group Internet-based CBT-BN for 16 sessions during 20 weeks. The cost-effectiveness analysis was conducted from a third-party payor perspective, and a partial societal perspective analysis was conducted to investigate cost-utility (ie, cost per gain in quality-adjusted life-years) and patient out-of-pocket travel-related costs. Net health care costs were calculated from protocol and nonprotocol health care services using third-party payor cost estimates. The primary outcome measure in the clinical trial was abstinence from binge eating and purging, and the trial start and end dates were 2008 and 2016., Results: The mean cost per abstinent patient at posttreatment was $7,757 (95% confidence limit [CL], $4,515, $13,361) for face-to-face and $11,870 (95% CL, $6,486, $22,188) for Internet-based CBT-BN, and at 1-year follow-up was $16,777 (95% CL, $10,298, $27,042) for face-to-face and $14,561 (95% CL, $10,165, $21,028) for Internet-based CBT-BN. There were no statistically significant differences between treatment arms in cost-effectiveness or cost-utility at posttreatment or 1-year follow-up. Out-of-pocket patient costs were significantly higher for face-to-face (mean [95% CL] = $178 [$127, $140]) than Internet-based ($50 [$50, $50]) therapy., Conclusions: Third-party payor cost-effectiveness of Internet-based CBT-BN is comparable with that of an accepted standard. Internet-based dissemination of CBT-BN may be a viable alternative for patients geographically distant from specialist eating disorder services who have an unmet need for treatment., Trial Registration: ClinicalTrials.gov identifier: NCT00877786​., (© Copyright 2017 Physicians Postgraduate Press, Inc.)

Objective: This study was to model the cost-effectiveness of specialist-delivered cognitive behavioral therapy for bulimia nervosa (CBT-BN) compared to no intervention within the Australian context., Method: An illness-death model was developed to estimate the cost per disability-adjusted life-year (DALY) averted of CBT-BN over 2 years from the healthcare perspective. Target population was adults aged 18-65 years with BN. Results are reported as incremental cost-effectiveness ratios (ICER) in 2013 Australian dollars per DALY averted. Uncertainty and sensitivity analyses were conducted to test the robustness of results., Results: Primary analysis indicated that CBT-BN was associated with greater DALY averted (0.10 DALY per person) and higher costs ($1,435 per person) than no intervention, resulting the mean ICER of $14,451 per DALY averted (95% uncertainty interval [UI]: $8,762 to $35,650). Uncertainty analysis indicated CBT-BN is 99% likely to be cost-effective at a threshold of $50,000 per DALY averted. Including the patients' time and travel costs resulted in the mean ICER of $18,858 per DALY averted (95% UI: $11,235 to $46,026). Sensitivity analysis indicated the intervention was not cost-effective if over 80% people discontinued treatment. Other analyses including a reduced time horizon, increased remission rates, and 4-month effect size of CBT-BN increases the ICERs but these ICERs remained well below under a threshold of $50,000 per DALY averted., Conclusion: This study has demonstrated that CBT-BN for adults with BN is a cost-effective treatment intervention. Further research is required to investigate the practicability of CBT-ED and the cost-effectiveness of other formats of CBT-BN delivery., (© 2017 Wiley Periodicals, Inc.)