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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. [ABSTRACT FROM AUTHOR]

Less help-seeking for an eating disorder is predicted by higher levels of denial of, and failure to perceive, illness severity. This research evaluates a "backdoor" approach to early intervention by investigating whether internet cognitive behaviour therapy for perfectionism can significantly improve disordered eating. Additionally, we investigated whether a more interactive intervention impacted outcomes. Participants were recruited worldwide online; 368 were screened, 172 (46.7%) met inclusion criteria (endorsed high shape, weight, or eating concerns) and randomised to an interactive (Focused Minds Program; FMP) or static PDF intervention (Centre for Clinical Intervention; CCI-P) or waitlisted (control condition). Participants completed assessments on disordered eating, perfectionism, and a range of secondary variables at the end of treatment, and 1- and 3-month follow-up. Intent-to-treat analyses indicated that, compared to control, FMP resulted in significantly lower levels of disordered eating at each assessment and CCI-P at the 1- and 3-month follow-up (respective 3-month follow-up between group effect sizes of 0.78 and 0.54). There were no significant differences between the two active interventions on any measure except depression and hated self. Results suggest an alternative approach to directly tackling disordered eating that is low-cost is effective, with a more interactive intervention producing a more rapid effect. Trials Registration: Australian New Zealand Clinical Trials Registry (ANZCTR) Trial Number: ACTRN12621001448831 [ABSTRACT FROM AUTHOR]

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

Many studies have sought to identify predictors of outcome in eating disorder treatment. However, despite extensive investigation, the only consistent predictor is early change in eating disorder symptoms. Identifying predictors is an important research endeavour as doing so may assist with developing new treatments, improving existing interventions, and matching patients to treatments based on their characteristics at baseline. We conducted logistic regression analyses to examine potential predictors of good outcome, abstinence, and remission. Participants were treatment completers (N = 37) who were referred for 10-session cognitive behavioural therapy (CBT-T) for non-underweight patients with eating disorders. The only unique predictor was early change in eating disorder psychopathology. Specifically, greater early change was associated with higher likelihoods of being abstinent and in remission at 1-month follow-up. The present study highlights the importance of pushing for early change in eating disorder treatment. Future studies are required to identify other consistent predictors. What is already known about this topic: In eating disorders, many variables have been examined as predictors. Early change in eating disorder symptoms is the only consistent predictor that has been identified. What this topic adds: We examined whether baseline variables predicted outcome when early change was included as a predictor. In line with previous research, early change was the only unique predictor. Clinicians are advised to push for early change to help patients do better in treatment. [ABSTRACT FROM AUTHOR]

Suicide and self-harm have significant health, economic and social costs. Group-based interventions can be an effective and advantageous treatment approach; however, there is little evidence on the application of these groups in youth community mental health settings in Australia. Using the RE-AIM framework, we explore the feasibility and implementation of two group programmes in a youth-focussed community-based mental health service: dialectical behaviour therapy-adolescent (DBT-A) and cognitive behavioural Self and Strength (S&S). Data were collected from an Australian community mental health service that implemented two group therapy treatments over 12 months. RE-AIM implementation framework outcomes included programme reach (patient flow, group uptake, treatment completion), effectiveness (youth and care clinical outcomes), adoption (staff perception), implementation (barriers), and maintenance (service commitment and acceptability). Groups were considered for all eligible clients (61% of referrals), of these 36% accepted treatment and of those who commenced, 71% completed DBT-A and 82% completed S&S. DBT-A participants reported improved suicidality, emotion dysregulation, self-harm and quality of life (QoL). S&S participants reported improved QoL. Despite small sample size, treatment was acceptable to participants, with high retention and adherence across both groups. Clinicians involved in facilitation noted positive clinical impacts. Group-based interventions have the potential to reduce emotion dysregulation difficulties for youth. Understanding barriers to uptake of group programmes in community-based mental health settings is essential to improve the reach and implementation of group programmes. What is already known about this topic: Self-harm and suicide are major public health concerns for youth, with self-harm linked to suicide completion. High rates of self-harm and emotion dysregulation occur in youth presenting to community-based mental health services. Clinicians need to be able to offer evidence-based interventions to support these individuals. Group-based interventions for emotion dysregulation present an opportunity to improve health outcomes, facilitate skill development and encourage social help-seeking behaviour. What this topic adds: Group-based interventions for emotion dysregulation have positive clinical outcomes for young people who engage in these programmes and offer potentially cost-effective solutions to addressing youth mental health; however, reach was low. Staff facilitators and group participants reported high acceptability and provided positive feedback on the group programmes. Further investigation into the barriers for group therapy is required to develop and implement strategies to increase uptake of group therapy. [ABSTRACT FROM AUTHOR]

Evidence-based cognitive-behaviour therapy for eating disorders (CBT-ED) differs from other forms of CBT for psychological disorders, making existing generic CBT measures of therapist competence inadequate for evaluating CBT-ED. This study developed and piloted the reliability of a novel measure of therapist competence in this domain—the Cognitive Behaviour Therapy Scale for Eating Disorders (CBTS-ED). Initially, a team of CBT-ED experts developed a 26-item measure, with general (i.e. present in every session) and specific (context- or case-dependent) items. To determine statistical properties of the measure, nine CBT-ED experts and eight non-experts independently observed six role-played mock CBT-ED therapy sessions, rating the therapists' performance using the CBTS-ED. The inter-item consistency (Cronbach's alpha and McDonald's omega) and inter-rater reliability (ICC) were assessed, as appropriate to the clustering of the items. The CBTS-ED demonstrated good internal consistency and moderate/good inter-rater reliability for the general items, at least comparable to existing generic CBT scales in other domains. An updated version is proposed, where five of the 16 "specific" items are reallocated to the general group. These preliminary results suggest that the CBTS-ED can be used effectively across both expert and non-expert raters, though less experienced raters might benefit from additional training in its use. [ABSTRACT FROM AUTHOR]

Objective: This pilot study investigated the feasibility and preliminary efficacy of the metacognitive training for eating disorders (MCT‐ED) program in adolescents with anorexia nervosa (AN). We report attrition and subjective evaluation as well as changes to cognitive flexibility, perfectionism and eating disorder pathology relative to waitlist controls. Method: Female (n = 35, aged 13–17 years) outpatients with a diagnosis of AN (n = 20) or atypical AN (n = 15) completed baseline measures of cognitive flexibility, perfectionism, and eating disorder pathology (May 2020–May 2022). Participants were randomly allocated to either treatment‐as‐usual (TAU) plus MCT‐ED or TAU waitlist condition. All participants completed post‐intervention and 3‐month follow‐up questionnaires. Results: The MCT‐ED condition had a treatment attrition rate <15%. Participants provided positive evaluation of the program. There were large between groups differences favoring MCT‐ED at post‐intervention and 3‐month follow‐up for concern over mistakes perfectionism (respective ds = −1.25, 95% CI [−2.06, −.45]; −.83, 95% CI [−1.60,.06]) with a significant group difference post‐intervention but not 3‐month follow‐up. Discussion: Findings provide tentative support for the feasibility of MCT‐ED as an adjunct intervention for young people with AN, however replication is needed with a larger sample size to further explore its efficacy. Public significance: Metacognitive training for eating disorders (MCT‐ED) is a feasible adjunct intervention for adolescents with anorexia nervosa. The intervention, which targets thinking styles and is delivered online by a therapist, received positive feedback, had high treatment retention, and led to reductions in perfectionism by the end of treatment compared to wait‐list controls. Although these gains were not sustained long‐term, the program is suitable adjunct intervention for young people with eating disorders. [ABSTRACT FROM AUTHOR]

Background: Perfectionism is significantly associated with symptoms of eating disorders in adolescents. Studies to date have not examined parent-supported CBT for perfectionism in eating disorders (CBT-P-ED). We co-designed the treatment and conducted a feasibility trial. Methods: Eight parents of adolescents with eating disorders (M age = 48.75 years, 100% female) engaged in three co-design workshops to create a parent-supported CBT-P-ED self-help intervention. A further 10 parents (M age 41.8 years, 50% female) and their adolescent offspring (n = 10, M age 15.4 years, 60% female, 50% with self-reported diagnosis of anorexia nervosa) participated in a feasibility trial and provided feedback on the intervention. Results: The parents who engaged in the co-design workshops suggested several areas to optimise the perfectionism intervention, including using plain language, the impact of parental perfectionism, how to engage with their adolescent in treatment and the importance of increasing eating disorder specific material. Feedback from the feasibility trial suggested that the intervention was acceptable and feasible with 100% of parents and adolescents saying it was useful, and no attrition. Conclusions: Parent-supported CBT-P-ED appears to be feasible. Future research is now required in a randomised controlled trial. Plain English Summary: It has been repeatedly demonstrated that perfectionism can contribute to a variety of health issues. Perfectionism is a process centered on intense self-pressure to meet high standards, which has a significant impact on how an individual views themselves. Perfectionism is more prevalent in individuals with eating disorders than in those without it. There is a strong link between perfectionism and the onset of eating disorders, as well as an increase in disordered eating symptoms and a lower rate of recovery. There is currently no treatment available that addresses perfectionism in both parents and young people. The aim of the project was to work with parents and carers to co-design a parent-supported self-help program for young people that addresses perfectionism in eating disorders. We conducted three co-design workshops, followed by a four-week feasibility study to determine suitability and feedback on the intervention. The goal was to develop an intervention which can offer caregivers and young people easily available support that may aid in their understanding of perfectionism. It is hoped that by addressing perfectionism in young people with eating disorders, this approach will help them recover and thrive. [ABSTRACT FROM AUTHOR]

Perinatal borderline personality disorder (BPD) and complex post-traumatic stress disorder (cPTSD) are associated with significant impairment to interpersonal functioning, and risk of intergenerational transmission of psychopathology. Evaluation of interventions, however, is scarce. To date, no systematic review has addressed interventions for perinatal BPD, cPTSD, and associated symptomatology. Given the modest evidence to support informed clinical guidelines, the objective of this systematic review is to synthesise the literature on interventions for perinatal BPD and cPTSD, and to generate future directions for research. A comprehensive literature search following PRISMA guidelines was conducted in PsycInfo, MEDLINE, Emcare, Scopus, and ProQuest Dissertations and Theses Global databases. Seven original studies were included, of which only two were randomised controlled trials, using less intensive comparison conditions. Results suggest an association between Dialectical Behavioural Therapy (DBT) group skills training, a multimodal therapeutic approach at a Mother-Baby Unit (MBU), and Child-Parent Psychotherapy with improved perinatal mental health outcomes and remission of symptoms. MBU admission and home-visiting programs were associated with healthy postpartum attachment relationships. Home-visiting programs and DBT group skills were additionally associated with improved maternal parenting capabilities. Conclusions to inform clinical guidelines are limited by a lack of credible comparison conditions, and low quantity and quality of evidence. The feasibility of implementing intensive interventions in real-world settings is dubious. Hence, it is suggested that future research considers utilising antenatal screening to identify at-risk mothers, and the implementation of early intervention, using robust designs that can inform robust conclusions. [ABSTRACT FROM AUTHOR]

Copyright of Clinical Psychologist is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Objective: Evaluate the feasibility, acceptability, and preliminary efficacy of a self‐criticism intervention addressing the link between appearance‐motivated social media use and eating disorder risk. Another condition, designed to help users curate their social media feed to reduce negative impacts on wellbeing, was also trialed as an active and credible comparison. Method: University students aged 17–25 (N = 170) were screened and randomized (n = 130) to the self‐criticism intervention, social media curation, or waitlist control group. The intervention comprised self‐guided cognitive behavior therapy delivered in four modules over 1 week. Primary outcomes were feasibility and acceptability. Secondary outcomes were appearance motivations for social media use, appearance comparison, self‐criticism, body image flexibility, and disordered eating (at baseline, one‐week postrandomization, and two‐weeks postrandomization). Trial registration: ACTRN12621000353897. Results: Participants completed an average of 82% of the intervention modules and 77% of the homework exercises within the week allocated. The intervention was well‐accepted; participants reported a range of positive aspects, alongside suggested modifications to the intervention and study design to improve acceptability. Group by time interactions suggested groups changed at a different rate on three secondary outcomes; between‐groups effect sizes suggested this was due to greater improvements in the self‐criticism group than waitlist control. Discussion: This was the first study to evaluate an intervention for the link between appearance‐related social media use and eating disorder risk for young adults. Positive findings relating to feasibility, acceptability, and preliminary efficacy suggest a larger randomized controlled trial, with modifications to the intervention and study design, is warranted. Public significance: Appearance‐related social media use has been linked to poorer body image and disordered eating, necessitating treatments that can disrupt this relationship. The self‐criticism intervention evaluated in this study shows promise as a strategy to address this need. It is the first intervention focused on appearance‐related social media use to be designed for and tested in young adults, who are at heightened risk of developing an eating disorder. [ABSTRACT FROM AUTHOR]

Copyright of Clinical Psychologist is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

The current study investigated the impact of an 8-module internet-based cognitive behaviour therapy for perfectionism (ICBT-P) across a variety of perfectionism subscales. Undergraduate students who identified as having a problem with perfectionism were randomized to receive the intervention (n = 41), and were free to choose the number of treatment modules they completed over a 4-week period, while the control group (N = 48) received access to treatment 8 weeks post-randomisation. Secondary measures included depression, anxiety, stress, body image and self-compassion. Assessments occurred at baseline, 2-, 4- and 8-week time points. A mean of 3.12 (SD = 2.67) modules were completed; 7 participants (17%) completed none and 6 (15%) completed all. Linear mixed modelling (with baseline observation included as a covariate) showed significant Bonferroni-adjusted post-hoc between-group differences for 5 of the 6 perfectionism measures, favouring the intervention group; the most robust between group effect sizes were for the Concern over Mistakes (d = −0.82), High Standards (d = −0.69), and Perfectionistic Standards (d = −0.47) subscales. There were no between-group differences for our secondary measures. ICBT-P was found to be an effective intervention for reducing different components of perfectionism compared to a control group. The relatively low use of modules may have contributed to a lack of effect on secondary measures. Australian New Zealand Clinical Trials Registry (ANZCTR) Trial Number: ACTRN12620000562976 [ABSTRACT FROM AUTHOR]

Background: Meta-analyses show an association between perfectionism and depression and anxiety (negative affect), and that therapy for perfectionism impacts positively on negative affect. No systematic reviews have focused on qualitative studies of perfectionism. Aims: Our aim was to perform a systematic, meta-synthesis of qualitative literature to (i) help inform our understanding of how perfectionism is associated with negative affect, so that we can (ii) inform future development of treatment for perfectionism in young people and to make it more effective. Method: Included in the meta-synthesis were 37 qualitative studies. Results: Six themes related to perfectionism were found: (1) the association with negative affect, (2) self-worth dependent on achievement, (3) cognitive and behavioural maintaining factors, (4) the expectations of others, (5) effective elements of interventions, and (6) barriers to treatment. Conclusions: The qualitative literature supports the notion of perfectionism as an important construct to consider in reducing negative affect. While cognitive behavioural therapy for perfectionism holds promise as a treatment to target negative affect, there was a paucity of qualitative research, particularly related to young people. A greater understanding of the views of young people are required to help tailor more effective interventions for perfectionism that can impact negative affect in this group. [ABSTRACT FROM AUTHOR]

The article discusses the clinical perfectionism, where self-worth is based on striving to achieve demanding standards despite negative impacts. Topics include the evidence-based online or remote treatments or supports; CBT for perfectionism works to reduce perfectionism and is trans diagnostic in reducing symptoms of anxiety, depression and eating disorders, and new developments include a focus on co-designing internet delivered CBT-P with young people.

Objective: The coronavirus pandemic has led to a dramatically different way of working for many therapists working with eating disorders, where telehealth has suddenly become the norm. However, many clinicians feel ill equipped to deliver therapy via telehealth, while adhering to evidence‐based interventions. This article draws together clinician experiences of the issues that should be attended to, and how to address them within a telehealth framework. Method: Seventy clinical colleagues of the authors were emailed and invited to share their concerns online about how to deliver cognitive‐behavioral therapy for eating disorders (CBT‐ED) via telehealth, and how to adapt clinical practice to deal with the problems that they and others had encountered. After 96 hr, all the suggestions that had been shared by 22 clinicians were collated to provide timely advice for other clinicians. Results: A range of themes emerged from the online discussion. A large proportion were general clinical and practical domains (patient and therapist concerns about telehealth; technical issues in implementing telehealth; changes in the environment), but there were also specific considerations and clinical recommendations about the delivery of CBT‐ED methods. Discussion: Through interaction and sharing of ideas, clinicians across the world produced a substantial number of recommendations about how to use telehealth to work with people with eating disorders while remaining on track with evidence‐based practice. These are shared to assist clinicians over the period of changed practice. [ABSTRACT FROM AUTHOR]

Background: The current study explored whether higher‐ (up to 8 modules) versus lower‐dose (3 or less modules) unguided internet Cognitive Behaviour Therapy for perfectionism (ICBT‐P) was more effective, and the best method to promote higher dosage. Methods: Two sequential randomised ICBT‐P studies were conducted with participants who self‐identified as having difficulties with perfectionism; in the first participants (N= 51) received 3‐module ICBT‐P or wait‐list, and in the second participants (N = 55) received fixed (asked to complete all 8 modules two per week over 4‐weeks) or flexible format (after completing the first psychoeducational module, participants decided how many/in what order they completed the modules). We examined impact on our primary variables, perfectionistic concerns and standards, and secondary outcomes of negative affect, body image flexibility, and self‐efficacy. Results: More modules were completed in the higher‐ (M modules = 4.36, SD = 3.29) versus lower‐dose (M = 1.96, SD = 1.23) ICBT‐P, d = 0.86 (95% confidence interval: 0.39, 1.34). The latter impacted perfectionism but not secondary outcomes; the former impacted all outcomes (except for self‐efficacy), and within‐group effect size improvements were double in the high‐ compared to low‐dose ICBT‐P. There was no difference between the fixed and flexible formats in terms of the number of modules completed or impact. Conclusions: We can offer a patient‐centred approach to ICBT‐P that is effective, while suggesting completion of more modules can result in larger, more pervasive improvements. ANZCTR Trial Number: ACTRN12619000147189. [ABSTRACT FROM AUTHOR]

Objective: Ten‐session cognitive behavioural therapy (CBT‐T) for transdiagnostic eating disorders targets several barriers to treatment, including cost, therapist expertise, and lengthy wait lists. Method: We used a case series design to investigate the effectiveness of CBT‐T delivered by trainee psychologists in a postgraduate training clinic. Participants were randomly allocated to commence treatment either immediately or after a 4‐week waitlist period. CBT‐T was delivered to 52 patients, by six different trainees under supervision. Measures of eating disorder cognitions and behaviours, quality of life, and general psychopathology were examined in completer and intention‐to‐treat analyses using multilevel modelling. Last observation carried forward was applied for abstinence, remission, and good outcome analyses to aid comparison with prior studies. Results: Significant improvements, associated with medium to large effect sizes, were found for eating disorder cognitions, behaviours quality of life, and negative affect from baseline to posttreatment, and at 1‐ and 3‐month follow‐up. Attrition (38.5%) was comparable with other treatment studies. Conclusion: Results provide evidence for the effectiveness of CBT‐T delivered by trainee psychologists for transdiagnostic eating disorder patients, thus tackling some important barriers for treatment. Longer follow‐up, randomised controlled trial designs, and moderator analyses will provide more robust evidence about which patients do best with a shorter therapy. [ABSTRACT FROM AUTHOR]

Background: Ten‐session cognitive‐behavioural therapy (CBT‐T) for eating disorders is designed to reduce barriers to treatment, including cost, therapist expertise, and lengthy wait lists. The current study aimed to replicate the first case series, evaluating the effectiveness of CBT‐T in a sample of non‐underweight clients, delivered by trainee psychologists under expert supervision. Methods: CBT‐T was delivered to 26 clients in an outpatient setting. Outcomes included eating disorder cognitions and behaviours, quality of life, and general psychopathology. Analyses adopted a completer and intention‐to‐treat approach to data analysis, using multi‐level modelling. Results: Significant improvements were found for the majority of outcomes from baseline to post‐treatment and at one‐ and three‐month follow‐up. Effect sizes at post‐treatment and follow‐up from baseline were typically medium to large. Conclusion: Results support the effectiveness of CBT‐T as a treatment for non‐underweight eating disorder clients. Results were also comparable to longer versions of CBT for eating disorders and to outcomes delivered by experienced therapists. Longer follow‐ups and the use of randomised controlled trial designs are required to confirm the efficacy of CBT‐T. [ABSTRACT FROM AUTHOR]

Objective: This case report describes the psychological treatment for bulimia nervosa of a 16‐year old with co‐occurring gender dysphoria. He reported restricting his food intake and purging for approximately 1 year prior to therapy commencing. Method: Ten sessions of cognitive behavioral therapy for eating disorders (CBT‐T) were conducted with accommodations for gender‐specific body dissatisfaction. Results: The client eliminated binging and purging from the second treatment session and had maintained this at the 3‐month follow‐up. The quantity and variety of foods he was eating had increased and he no longer reported subjective binges. Improvements were also evident in his depression, anxiety and stress symptoms. Discussion: This suggests that bulimia nervosa may be effectively treated with CBT‐T in the context of gender dysphoria. Further research that investigates the generalizability of these outcomes would be beneficial. [ABSTRACT FROM AUTHOR]

Objective: Eating disorder psychopathology is associated with a propensity to interpret ambiguous stimuli to be negatively related to one's appearance and self‐worth. The relative impact of modifying interpretation bias for these respective stimuli is unknown. Hence the main aim of the current study was to compare two cognitive bias modification protocols targeting interpretation bias (CBM‐I), one focused on appearance and the other on self‐worth, in terms of impacting interpretation bias, body dissatisfaction and negative affect. The appearance‐based CBM‐I protocol was developed for the current study. Method: Female university students (N = 123) were randomized into one of three CBM‐I conditions: appearance, self‐worth or control. Immediately following a negative induction that significantly increased body dissatisfaction and negative affect, participants underwent their respective CBM‐I training. Results: The CBM‐I for appearance produced significant changes in the targeted bias, as well as significant improvements (moderate effect sizes) in appearance satisfaction, relative to the CBM‐I for self‐worth and control conditions. Discussion The results support the usefulness of the CBM‐I for appearance protocol, and suggests that this technique warrants further investigation with respect to modifying interpretation bias and risk factors associated with eating disorder psychopathology. Null effects of CBM‐I for self‐worth should be interpreted in light of study limitations, including the potential unsuitability of training material for young women. CBM‐I for both types of interpretation bias should be evaluated in future research. [ABSTRACT FROM AUTHOR]

Background: While randomized controlled trials (RCTs) inform the efficacy and effectiveness of treatments, we need to understand that even RCTs can be associated with sub‐optimal execution. This is of special pertinence to eating disorders given the majority of treatment studies involving cognitive behaviour therapy are of poor quality with respect to managing risk of bias adequately. Methods: The current paper outlines the components of a good RCT for psychotherapy, and examines ways to improve the conduct, interpretation, and usefulness of RCTs. Results: This includes managing reporting bias, recognizing the limits of randomization, applicability, and ethical considerations. Conclusions: We highlight a number of strategies for future research, including issues related to utilizing a variety of designs to examine treatment outcomes, integrity, openness and reproducibility. [ABSTRACT FROM AUTHOR]

Abstract: Objective: This case report details the presentation and treatment of a 42‐year‐old male self‐presenting for treatment who reported having been a restrictive eater since childhood; since adolescence he had failed to meet appropriate nutritional intake with one meal at night followed by around 10–20 standard alcoholic drinks. Method: Ten sessions of cognitive behavioral therapy were offered emphasizing the need to adhere to regular eating patterns in conjunction with significant reduction of binge drinking. Results: At the end of treatment, and 1‐month follow‐up, improvements in nutritional intake and alcohol intake were observed, accompanied by improvements in depression, anxiety, and stress. Discussion: However, excessive alcohol intake had reoccurred at 3‐month follow‐up, accompanied by increases in negative affect and impairment due to eating, indicating that longer‐term therapy may be required for this group of people. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Predictors of attrition and predictors and moderators of outcome were explored in a transdiagnostic sample of patients who received ten‐session cognitive behavioral therapy (CBT‐T) for nonunderweight eating disorders. Body image flexibility, a protective positive body image construct, was hypothesized to be a significant moderator. Method: Data from two case series were combined to form a sample of 78 participants who received CBT‐T. Baseline measures of body image, negative affect, personality, and motivation (readiness to change and self‐efficacy) were included as potential predictors. Global eating disorder psychopathology at each assessment point (baseline, mid‐ and post‐treatment, 1‐ and 3‐month follow‐up) was the outcome variable. Predictors of attrition were assessed using logistic regression, and multilevel modeling was applied for predictors and moderators of outcome. Results: Body image flexibility emerged as the strongest predictor and moderator of global eating disorder psychopathology, followed by body image avoidance. Body checking, negative affect, personality beliefs, and self‐efficacy were significant predictors of global eating disorder psychopathology. Discussion: Higher body image flexibility predicted lower global eating disorder psychopathology at every assessment point. Further research is required to replicate findings and explore the benefit of focusing on positive body image in treatment. [ABSTRACT FROM AUTHOR]

Objective: This meta-analysis examined the efficacy of cognitive-behavioral therapy (CBT) for eating disorders. Method: Randomized controlled trials of CBT were searched. Seventy-nine trials were included. Results: Therapist-led CBT was more efficacious than inactive (wait-lists) and active (any psychotherapy) comparisons in individuals with bulimia nervosa and binge eating disorder. Therapist-led CBT was most efficacious when manualized CBT-BN or its enhanced version was delivered. No significant differences were observed between therapist-led CBT for bulimia nervosa and binge eating disorder and antidepressants at posttreatment. CBT was also directly compared to other specific psychological interventions, and therapist-led CBT resulted in greater reductions in behavioral and cognitive symptoms than interpersonal psychotherapy at posttreatment. At follow-up, CBT outperformed interpersonal psychotherapy only on cognitive symptoms. CBT for binge eating disorder also resulted in greater reductions in behavioral symptoms than behavioral weight loss interventions. There was no evidence that CBT was more efficacious than behavior therapy or nonspecific supportive therapies. Conclusions: CBT is efficacious for eating disorders. Although CBT was equally efficacious to certain psychological treatments, the fact that CBT outperformed all active psychological comparisons and interpersonal psychotherapy specifically, offers some support for the specificity of psychological treatments for eating disorders. Conclusions from this study are hampered by the fact that many trials were of poor quality. Higher quality RCTs are essential. [ABSTRACT FROM AUTHOR]

An internet guided self-help cognitive-behavioural treatment (ICBT) for perfectionism was recently found to be effective (see this issue). Such studies stand in need of replication. The aim of this study was to report the outcomes and predictors of change when the treatment is delivered in a UK setting. A total of 120 people (Mean = 28.9 years; 79% female) were randomised to receive ICBT or wait-list control over 12 weeks (trial registration: NCT02756871). While there were strong similarities between the current study and its Swedish counterpart, there were also important differences in procedural details. There was a significant impact of the intervention on the primary outcome measure (Frost Multidimensional Perfectionism Scale, Concern over Mistakes subscale) and also on the Clinical Perfectionism Questionnaire (between group effect sizes d = 0.98 (95% CI: 0.60–1.36) and d = 1.04 (95% CI: 0.66–1.43) respectively using intent-to-treat analyses). Unlike the Swedish study, there was significant non-engagement and non-completion of modules with 71% of participants completing fewer than half the modules. The number of modules completed moderated the rate of change in clinical perfectionism over time. In conclusion, the study indicates the intervention is effective in a UK setting but highlighted the importance of procedural details to optimise retention. [ABSTRACT FROM AUTHOR]

Objective: To develop a psychotherapy rating scale to measure therapist adherence in the Strong Without Anorexia Nervosa (SWAN) study, a multi-center randomized controlled trial comparing three different psychological treatments for adults with anorexia nervosa. The three treatments under investigation were Enhanced Cognitive Behavioural Therapy (CBT-E), the Maudsley Anorexia Nervosa Treatment for Adults (MANTRA), and Specialist Supportive Clinical Management (SSCM). Method: The SWAN Psychotherapy Rating Scale (SWAN-PRS) was developed, after consultation with the developers of the treatments, and refined. Using the SWANPRS, two independent raters initially rated 48 audiotapes of treatment sessions to yield inter-rater reliability data. One rater proceeded to rate a total of 98 audiotapes from 64 trial participants. Results: The SWAN-PRS demonstrated sound psychometric properties, and was considered a reliable measure of therapist adherence. The three treatments were highly distinguishable by independent raters, with therapists demonstrating significantly more behaviors consistent with the actual allocated treatment compared to the other two treatment modalities. There were no significant site differences in therapist adherence observed. Discussion: The findings provide support for the internal validity of the SWAN study. The SWAN-PRS was deemed suitable for use in other trials involving CBT-E, MANTRA, or SSCM. VC 2015 The Authors. International Journal of Eating Disorders Published by Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To investigate if baseline depression moderated response to Media Smart, an 8-lesson school-based program previously found to achieve a long-term risk reduction effect in young adolescents. Method: 540 Grade 8 students (M age = 13.62 years, SD = .37) from 4 schools participated with 11 classes receiving the Media Smart program (126 girls; 107 boys) and 13 comparison classes receiving their normal lessons (147 girls; 160 boys). Shape and weight concern, media internalization, body dissatisfaction, dieting, ineffectiveness, and perceived pressure were the outcome variables. Results: Moderation was indicated by significant interaction effects for group (Media Smart; Control) × moderator (high depression; low depression) × time (post-program; 6-month follow-up; 2.5-year follow-up), with baseline entered as a covariate. Such effects were found for shape and weight concern, media internalization, body dissatisfaction, ineffectiveness and perceived pressure. Post-hoc testing found high depression Media Smart participants scored significantly lower than their control counterparts at post-program on shape and weight concern, media internalization and dieting, whereas low depression Media Smart participants scored significantly lower on shape and weight concern at 2.5-year follow-up. Discussion: Media Smart achieved a reduction in eating disorder risk factors for high-depression participants and a reduced rate of growth in risk factor scores for low-depression participants. Trial registry name: Australian New Zealand Clinical Trials Registry. URL: http://www.anzctr.org.au. Registration identification number: ACTRN12608000545369. [Copyright &y& Elsevier]

Background: Research indicates that psycho-education and cognitive behavioural interventions can reduce perfectionism but to date no group treatments have been examined. Aims: The current study utilized a case series design to compare psycho-education materials and subsequent eight-week group cognitive behaviour therapy (CBT) to a baseline waitlist in an outpatient community psychiatry sample (n = 21). Method: Participants were assessed on five occasions: baseline, 4 weeks later (waitlist), 4 weeks after receiving psycho-education material, post-treatment (8 weeks after receiving the group intervention), and 3-month follow-up. Results: There was a main effect of time for perfectionism and negative affect from baseline to post-group (effect sizes ranging from 1.46 to 1.91) that were maintained at 3-month follow-up. Conclusions: These results suggested that group CBT for clinical perfectionism may be beneficial, but that psycho-education alone is not effective for reducing perfectionism or negative affect. [ABSTRACT FROM AUTHOR]

The transdiagnostic approach to theory and treatment of psychological disorders is gaining increasing interest. A transdiagnostic process is one that occurs across disorders and explains their onset or maintenance. The purpose of this review is to provide evidence that perfectionism is a transdiagnostic process that it is elevated in anxiety disorders, eating disorders, depression, obsessive compulsive personality disorder and somatoform disorders. Data are also reviewed to show that perfectionism can explain aetiology as it is a prospective predictor of depression and eating disorders. Perfectionism is also demonstrated to predict poorer outcome to treatment for anxiety disorders, eating disorders and depression, suggesting the need for specific treatment of perfectionism. Evidence is provided to demonstrate that perfectionism can be successfully treated with cognitive behavioural therapy which results in reduction in psychopathologies. Clinical guidelines are outlined to assist in treatment planning for individuals with elevated perfectionism. [ABSTRACT FROM AUTHOR]

Objective: The present study aimed to directly test Cooper et al.'s cognitive model of the maintenance of bulimia nervosa. Method: The major predictions of the model were tested cross-sectionally using multiple regression analyses and structural equation modeling in a mixed sample comprising nonclinical female university students ( n = 298) and clinical eating disorder patients ( n = 44). Results: Consistent with model, negative self-beliefs was associated with negative emotion, negative emotion with positive and negative beliefs about eating, beliefs about eating with eating behavior, and binge eating with negative self-beliefs. However, contrary to hypotheses, results did not consistently support a direct link between compensatory behavior and negative self-beliefs. Furthermore, the role of permissive thoughts was found to be questionable. Of note, results suggested that components of the model may operate to maintain bulimic pathology in a slightly different way for purging and nonpurging behaviors. Discussion: While the results of this research provide some preliminary evidence for the validity of the cognitive model as an explanation of the persistence of bulimic symptoms, further work is required to develop the model. (Int J Eat Disord 2012; 45:776-786) [ABSTRACT FROM AUTHOR]

Abstract: Perfectionism is a risk and maintaining factor for eating disorders, anxiety disorders and depression. The objective of this paper is to review the four bodies of evidence supporting the notion that perfectionism is a transdiagnostic process. First, a review of the literature was conducted that demonstrates the elevation of perfectionism across numerous anxiety disorders, depression, and eating disorders compared to healthy controls. Data is presented that shows perfectionism increases vulnerability for eating disorders, and that it maintains obsessive–compulsive disorder, social anxiety and depression as it predicts treatment outcome in these disorders. Second, evidence is examined showing that elevated perfectionism is associated with co-occurrence of psychopathology. Third, the different conceptualisations of perfectionism are reviewed, including a cognitive-behavioural conceptualisation of clinical perfectionism that can be utilised to understand this transdiagnostic process. Fourth, evidence that treatment of perfectionism results in reductions in anxiety, depression and eating pathology is reviewed. Finally, the importance of clinicians considering the routine assessment and treatment of perfectionism is outlined. [Copyright &y& Elsevier]

Cognitive behaviour therapy for eating disorders (CBT-ED) outperforms other treatments for non-underweight eating disorders in adults, but we have limited ability to match CBT-ED to individual profiles. We examined if we could identify who benefits most from two forms of 10-session CBT-ED; one emphasizing early behaviour change with substantial content on improving body image (CBT-T), and the other including motivational work and no content on body image using chapters from self-help books (CBTm). Participants were 98 consecutive referrals to the Flinders University Services for Eating Disorders. Fourteen clinical psychology postgraduates delivered the treatment under expert supervision. Outcome measures were completed on five occasions: baseline, 4-, 10-, 14- and 22-weeks post-randomisation. Our primary outcome was global eating psychopathology. Moderators included motivation (readiness and confidence to change) and body avoidance and body checking. Intent-to-treat analyses showed no difference between the groups with a significant main effect of time associated with large effect size improvements, commensurate with longer forms of CBT-ED. Participants with lower readiness to change in CBTm had significantly greater decreases in disordered eating over follow-up compared to those with low motivation in CBT-T. People with lower readiness to change might benefit from the incorporation of motivational work in CBT-ED. • Two 10-session cognitive behaviour therapies for eating disorders were compared • Within group effect size changes were commensurate with longer therapies • No difference was detected between the two therapies • Benefit was greater when motivation was addressed for those low in motivation [ABSTRACT FROM AUTHOR]

Abstract: Perfectionism is known to be a risk factor for the development and maintenance of obsessive–compulsive (OC) and depressive symptoms. The purpose of the present study was to test the effectiveness of a cognitive-behavioural self-help therapy for perfectionism, and to examine the effect of such treatment on OC and depressive symptomatology. The study compares the effectiveness of guided self-help (GSH, n=24) with pure self-help (PSH, n=25) therapy. Both GSH and PSH were found to be effective in reducing perfectionism, and also in reducing OC and depressive symptomatology. Overall, participants in the GSH condition experienced greater symptom improvement than participants in the PSH condition, and treatment gains for both groups were largely maintained at 3-month follow-up. Twenty percent of PSH participants experienced clinically significant increases in depressive symptoms over the treatment and follow-up period (compared to 0% in the GSH condition), suggesting that PSH may be a less suitable strategy than GSH in treating this population. Overall, the findings suggest that self-help for perfectionism is effective in reducing OC and depressive symptomatology in non-clinical individuals, with GSH being superior to PSH. [Copyright &y& Elsevier]

Higher Education Institutes (HEIs) have been met with an unprecedented demand on their student counselling and wellbeing services in recent years with the impacts of COVID‐19 and high rates of mental health concerns amongst student populations. Online mental health programs offer one solution by providing students with quick and easy access to effective therapeutic content. The Focused Minds Program is an evidence‐based eight‐module online self‐guided cognitive behavioural intervention that targets the transdiagnostic risk factor of perfectionism and has been shown to decrease depression, anxiety, and disordered eating. The program was implemented at a UK university between 2021 and 2023. Recruitment occurred via departmental emails, academic staff, and the university's counselling staff and website. Participants were provided with access to the intervention for 6‐weeks and completed weekly surveys of psychosocial measures. The trial's implementation was assessed using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework: reach (uptake via the recruitment channels), effectiveness (outcomes on psychometric measures of mental wellbeing), adoption (staff and organisational support), implementation (intervention engagement and attrition), and maintenance (continued implementation across the trial period). Key barriers to successful implementation, as well as proposed solutions, are discussed to guide future online mental health interventions provided in HEIs. [ABSTRACT FROM AUTHOR]

Background: Perfectionism can become a debilitating condition that may negatively affect functioning in multiple areas, including mental health. Prior research has indicated that internet-based cognitive behavioral therapy can be beneficial, but few studies have included follow-up data.Objective: The objective of this study was to explore the outcomes at follow-up of internet-based cognitive behavioral therapy with guided self-help, delivered as 2 separate randomized controlled trials conducted in Sweden and the United Kingdom.Methods: In total, 120 participants randomly assigned to internet-based cognitive behavioral therapy were included in both intention-to-treat and completer analyses: 78 in the Swedish trial and 62 in the UK trial. The primary outcome measure was the Frost Multidimensional Perfectionism Scale, Concern over Mistakes subscale (FMPS CM). Secondary outcome measures varied between the trials and consisted of the Clinical Perfectionism Questionnaire (CPQ; both trials), the 9-item Patient Health Questionnaire (PHQ-9; Swedish trial), the 7-item Generalized Anxiety Disorder scale (GAD-7; Swedish trial), and the 21-item Depression Anxiety Stress Scale (DASS-21; UK trial). Follow-up occurred after 6 months for the UK trial and after 12 months for the Swedish trial.Results: Analysis of covariance revealed a significant difference between pretreatment and follow-up in both studies. Intention-to-treat within-group Cohen d effect sizes were 1.21 (Swedish trial; 95% CI 0.86-1.54) and 1.24 (UK trial; 95% CI 0.85-1.62) for the FMPS CM. Furthermore, 29 (59%; Swedish trial) and 15 (43%; UK trial) of the participants met the criteria for recovery on the FMPS CM. Improvements were also significant for the CPQ, with effect sizes of 1.32 (Swedish trial; 95% CI 0.97-1.66) and 1.49 (UK trial; 95% CI 1.09-1.88); the PHQ-9, effect size 0.60 (95% CI 0.28-0.92); the GAD-7, effect size 0.67 (95% CI 0.34-0.99); and the DASS-21, effect size 0.50 (95% CI 0.13-0.85).Conclusions: The results are promising for the use of internet-based cognitive behavioral therapy as a way of targeting perfectionism, but the findings need to be replicated and include a comparison condition. [ABSTRACT FROM AUTHOR]

Abstract Objective Early decrease in symptoms is a consistent predictor of good treatment outcome across all eating disorders. The current study explored the predictive value of novel early change variables in a transdiagnostic, non-underweight sample receiving 10-session cognitive behavioural therapy. Method Participants who reported bingeing and/or purging in the week preceding baseline assessment (N = 62) were included in analyses. Early change variables were calculated for novel (body image flexibility, body image avoidance, body checking, and fear of compassion) and established predictors (behavioural symptoms and therapeutic alliance). Outcomes were global eating disorder psychopathology and clinical impairment at posttreatment and three-month follow-up. Intent-to-treat analyses were conducted using linear regression, adjusting for baseline values of the relevant outcome and early change in behavioural symptoms. Results Early improvement in body image flexibility was the most consistent predictor of good outcome. Early change in body image avoidance and the fear of expressing and receiving compassion to/from others were significant predictors in some analyses. Discussion Novel early change variables were significant predictors of eating disorder outcomes in this exploratory study. Model testing is required to understand the exact mechanisms by which these variables impact on outcomes, and whether there is potential benefit of modifying existing protocols. ANZCTR Trial Number ACTRN12615001098527. Highlights • Early change in body image flexibility was the most consistent predictor of outcome. • Early change in body image avoidance predicted outcome in some analyses. • Early change in fear of compassion predicted outcome in some analyses. [ABSTRACT FROM AUTHOR]

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. • Fifteen RCTs of CBT for perfectionism have shown that it is effective at reducing perfectionism. • CBT for perfectionism impacts positively on anxiety, depression and eating disorders. • Future RCTs require long-term follow-up, active comparisons and independent replication. • Innovations in CBT provide an opportunity to improve access to, and outcome of, treatment. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic has had a severe impact on mental health worldwide, with increased rates of anxiety and depression widely documented. The aim of this study was to examine unguided low intensity cognitive behaviour therapy for anxiety and depression during the pandemic. A sample of 225 individuals in Australia and the United Kingdom (M age 37.79, SD = 14.02, range 18–80 years; 85% female) were randomised into intervention or waitlist control. The intervention group demonstrated significant decreases in anxiety (d = 0.36 [0.18, 0.54]) and depression (d = 0.28 [0.11, 0.45]) compared to controls. The majority of participants (96%) rated the intervention as useful, and most (83%) reported they spent 30 min or less reading the guide, with 83% agreeing the intervention was easy to read. The results indicate that low intensity cognitive behaviour therapy has efficacy in reducing anxiety and depression during the COVID-19 pandemic. There is an urgent need to disseminate low intensity psychological therapies to improve mental health in this challenging time. • Increased anxiety and depression have occurred during the COVID-19 pandemic. • Participants were randomised to low intensity cognitive behaviour therapy (CBT) or control. • The intervention group demonstrated significant decreases in anxiety and depression. • The majority of participants rated the intervention as useful. • Low intensity CBT has efficacy targeted for pandemic related anxiety and depression. [ABSTRACT FROM AUTHOR]

Perfectionism is a risk factor for the development and maintenance of eating disorders. The objective of this study was to examine the efficacy of unguided Internet cognitive behaviour therapy for perfectionism (ICBT-P) as a treatment and prevention for perfectionism and symptoms of eating disorders, anxiety, depression and self-esteem in female adolescents. Young women (N = 94, 14–19 years) who self-identified as having difficulties with perfectionism but did not have a clinical eating disorder diagnosis were recruited. Participants were randomly allocated into one of three groups: unguided ICBT-P, unguided ICBT for nonspecific stress management (ICBT-S), or waitlist control. All analyses were intent-to-treat. ICBT-P resulted in the most favorable outcomes at post-treatment and 3- and 6-months follow-up. ICBT-P was superior to control on all outcome measures at 3- and 6-months and superior to ICBT-S on all outcomes over most time points (d s = 0.13–0.94). Clinical significance analysis demonstrated that the treatment prevented symptom increases over 6-month follow-up, with ICBT-P superior to ICBT-S in prevention of clinical perfectionism and depressive symptoms, and ICBT-P superior to waitlist control in prevention of eating disorder symptoms. There was relatively high attrition, although there were no differences in attrition between the groups at 3- and 6-month follow-up and rates were commensurate with other Internet interventions. The findings support unguided ICBT-P as a useful target for preventing eating disorder and associated symptoms in female youth who self-identify as perfectionistic. ACTRN12615001098527. • Perfectionistic female adolescents with no eating disorder diagnosis participated. • Participants were randomized to three conditions. • Unguided Internet cognitive behaviour therapy for perfectionism (ICBT-P). • Unguided Internet stress management (ICBT-S) or waitlist control. • ICBT-P was superior to control on all outcome measures at 3- and 6-months. [ABSTRACT FROM AUTHOR]