Behaviour Research and Therapy 49 (2011) 219e226

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Behaviour Research and Therapy
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The effectiveness of enhanced cognitive behavioural therapy for eating disorders: An open trial
Susan M. Byrne a, b, *, Anthea Fursland b, Karina L. Allen a, b, Hunna Watson b
a b

University of Western Australia School of Psychology, 35 Stirling Highway Crawley, 6009 Perth, Western Australia, Australia Centre for Clinical Interventions, 223 James Street Northbridge, 6003 Perth, Western Australia, Australia

a r t i c l e i n f o
Article history: Received 16 August 2010 Received in revised form 20 December 2010 Accepted 11 January 2011 Keywords: Eating disorders Anorexia nervosa Bulimia nervosa Eating disorders not otherwise specified Cognitive behaviour therapy Effectiveness

a b s t r a c t
The aim of this study was to examine the effectiveness of Enhanced Cognitive Behaviour Therapy (CBT-E) for eating disorders in an open trial for adults with the full range of eating disorders found in the community. The only previously published trial of CBT-E for eating disorders was a randomised controlled trial (RCT) conducted in the U.K. for patients with a BMI  17.5. The current study represents the first published trial of CBT-E to include patients with a BMI < 17.5. The study involved 125 patients referred to a public outpatient clinic in Perth, Western Australia. Patients attended, on average, 20e40 individual sessions with a clinical psychologist. Of those who entered the trial, 53% completed treatment. Longer waiting time for treatment was significantly associated with drop out. By the end of treatment full remission (cessation of all key eating disorder behaviours, BMI  18.5 kg/m2, not meeting DSM-IV criteria for an eating disorder) or partial remission (meeting at least 2 these criteria) was achieved by two thirds of the patients who completed treatment and 40% of the total sample. The results compared favourably to those reported in the previous RCT of CBT-E, with one exception being the higher drop-out rate in the current study. Overall, the findings indicated that CBT-E results in significant improvements, in both eating and more general psychopathology, in patients with all eating disorders attending an outpatient clinic. Ó 2011 Elsevier Ltd. All rights reserved.

Introduction While randomised controlled trials (RCTs) of treatments for eating disorders have increasingly sought to include a wide range of clinically representative patients (Agras, Walsh, Fairburn, Wilson, & Kraemer, 2000; Fairburn et al., 2009; Fairburn, Marcus, & Wilson, 1993; Stirman, DeRubeis, Crits-Christoph, & Rothman, 2005; Weisz, Weersing, & Henggeler, 2004) only a very small number of ‘effectiveness’ studies have been able to demonstrate that the results of these RCTs are generalisable to treatment conducted in routine clinical settings, by therapists with various levels of training and expertise (e.g., Couturier, Iserlin, & Lock, 2010; Loeb et al., 2007; Ricca et al., 2010; Tuschen-Caffier, Pook, & Frank, 2001). This lack of effectiveness research may be a contributing factor to the inadequate dissemination of evidence-based practice outside of research settings in the field of eating disorders (Wilson, 1995; Wilson, 1996; Wilson, Grilo, & Vitousek, 2007). The present study aimed to add to

* Corresponding author. University of Western Australia School of Psychology, 35 Stirling Highway Crawley, 6009 Perth, Western Australia, Australia. Tel.: þ 61 8 6488 3579; fax: þ 61 8 6488 2655. E-mail address: sbyrne@psy.uwa.edu.au (S.M. Byrne). 0005-7967/$ e see front matter Ó 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.brat.2011.01.006

the small number of effectiveness studies in the eating disorders field by evaluating the generalisability of the newly-devised Enhanced Cognitive Behavioural Treatment (CBT-E) for eating disorders in an open trial. CBT-E was developed by Fairburn, Cooper, and Shafran (2003), and is designed to be suitable for all eating disorders (i.e., Anorexia Nervosa [AN], Bulimia Nervosa [BN] and Eating Disorder Not Otherwise Specified [EDNOS]). CBT-E stems from the “transdiagnostic” theory of the processes that maintain all forms of eating disorder (Fairburn et al., 2003). This theory is based on the observation that AN, BN and EDNOS share many distinctive clinical features (Favaro, Ferrara, & Santonastaso, 2003; Turner & BryantWaugh, 2004) including the same “core psychopathology” characterised by a pronounced tendency to evaluate self-worth in terms of controlling eating, shape or weight (Fairburn et al., 2003). The transdiagnostic model extends the existing, empirically supported cognitive model of BN (Fairburn et al., 1993). It encompasses key maintaining processes such as a dysfunctional scheme for selfevaluation, strict dieting, low weight and the associated ‘starvation syndrome’, binge eating and compensatory behaviours, and also includes four additional maintaining mechanisms e clinical perfectionism, core low self-esteem, difficulty coping with intense mood states, and interpersonal difficulties e which are external to

However. Stage 2 involved a detailed review of progress and identification of barriers to change. and intention-to-treat data showed that. The results indicated that 66.4% for BN and 45.7% for BN patients and 53. In Stage 3 the emphasis was on modifying the processes maintaining the patient’s eating disorder psychopathology. As CCI is a public clinic.74 (52. for patients with a BMI  18.e.3% of patients had post-treatment global EDE scores below 1.M. we defined full remission as complete absence of eating disorder symptoms in the last 28 days. in which specific modules may be directed at the particular maintaining mechanisms operating in the individual patient’s case.24 weeks (SD ¼ 14. 1993) scores less than 1 standard deviation (SD) above the community norm (i.e. Treatment Treatment was conducted on an outpatient basis and followed the protocols outlined in the detailed CBT-E treatment guide (Fairburn et al. There is only one published RCT of CBT-E for eating disorders (Fairburn et al. in certain cases. The treatment guide allows some flexibility and variability in the number of sessions required to complete each treatment stage and to progress through the entire treatment. The patients were treated by one of a team of 4 full-time clinical psychologists. All but one of the therapists (AF) were Clinical Psychology Registrars (i. The treatment moved through four stages. We hypothesised that treatment with CBT-E would be associated with significant post-treatment improvement in both the specific and associated psychopathology of eating disorders.7% for EDNOS). Range ¼ 2. CBT-E is designed as an individualised and “modular” form of treatment. and drop out was defined as non-mutual premature termination of treatment. the additional maintaining mechanisms of perfectionism. In the final stage. low self-esteem. since a body mass index 17. 51. American Psychiatric Association. Treatment completion was defined as successful transition through the four stages of treatment. In this study.g. on average. purging and severe dietary restriction.18. 1 shows the participant enrolment and flow through the study. which shaped the remainder of treatment. SB and AF attended training workshops in CBT-E conducted by Professor Fairburn. the only public outpatient eating disorders program for youth and adults in Perth. 2008). binge eating. psychotic. moreover. at the end of treatment 38. the treatment period was longer to allow for increasing motivation and weight regain. there is a relatively lengthy waiting list for treatment. In this stage.220 S. Fourth Edition (DSM-IV. the patient had to be 16 years or older. and that the degree of improvement would be comparable to that reported in the previous RCT of CBT-E. Patients were recruited between March 2005 and February 2009 from consecutive referrals from general practitioners. <1.e. Patients received 20 50 min sessions. psychiatrists and clinical psychologists. but for low-weight patients. All patients attended 2e3 assessment sessions followed by..5. Fairburn & Cooper. These data suggest that CBT-E may be more efficacious than the original CBT for BN (Agras et al. and for underweight patients treatment involved about 40 sessions. The gains made during treatment were largely maintained at a 60 week follow-up. The mean waiting time between referral and the start of treatment for participants in this trial was 22. preceded by one 90 min preparatory session. Partial remission was defined as meeting all but one of the above criteria for 1 Cessation of severe dietary restriction was defined as scoring 3 on all of the first four items of the EDE-Q (Restraint subscale).6% reported no episodes of binge eating or purging in the past 28 days.3% for EDNOS). a study that also includes low-weight patients would be of value.00e63. 20e40 50 min treatment sessions. BN or EDNOS (except for BED. The initial stage focused on engaging and educating the patient. Byrne et al.. There were no significant differences between BN and EDNOS patients in response to treatment. The training consisted of orientation to the treatment and familiarisation with the treatment guide in their first week of employment at the clinic.14 weeks). The clinical protocol in this study followed normal practice in this community clinic.5 (38% with a diagnosis of BN and 62% with a diagnosis of EDNOS). .74). Given the claim that CBT-E is also relevant to AN and the lack of research into evidence-based treatments for this eating disorder. e.4% of those who completed treatment had a good outcome in that they had post-treatment global Eating Disorder Examination (EDE. when 50% of the overall sample had a global EDE score below 1. Fig.74 (61. This study is the first effectiveness trial of CBT-E and. the focus turned to maintenance of gains and relapse prevention. interpersonal difficulties and mood intolerance were also addressed as relevant. overall. and fulfil the Diagnostic and Statistical Manual. as judged by the assessing clinician according to the EDE. creating an initial personalised formulation. and obtaining maximal behaviour change. Assessment Outcome variables The primary outcome variables were categorical measures of recovery.5 was a specific exclusion criteria. Western Australia. resulting in a total of 10 therapists being involved in the study.K.5 kg/m2 (the World Health Organisation cut-off for healthy weight) and (iii) not meeting the DSM-IV criteria for an eating disorder. The aim of the present study was to investigate the effectiveness and feasibility of conducting CBT-E at a public outpatient clinic for adults with the full range of eating disorders found in the community. which is not treated at this clinic).. the first published study of CBT-E to include patients with a BMI < 17. The therapists attended weekly individual supervision meetings with AF and a weekly team meeting with AF and SB to discuss cases and adherence to treatment protocol. recent graduates from a Masters or PhD level Clinical Psychology program) with little or no experience treating eating disorders previously. 2009). that is (i) cessation of all key eating disorder behaviours..5 treatment consisted of around 20 sessions. To be considered for treatment. Method Recruitment The sample comprised individuals referred to the Centre for Clinical Interventions (CCI) Eating Disorders Service. With regard to the BN patients. The treatment content was the same for all eating disorders. Meetings included a review of select videotaped sessions to help ensure treatment fidelity. substance dependent or had a BMI < 14.1 (ii) BMI  18.. 2000). serve to maintain this psychopathology and prevent change. For the purposes of this study. this was a single trial and it only involved patients with BN and EDNOS. This trial recruited from 2 sites in the U. During the 4 years of the trial there was considerable turnover of staff. The overall drop-out rate was 22% (14% for BN patients and 27% for EDNOS patients). N ¼ 6) or if they did not give written consent to release their de-identified data for evaluation and research purposes (N ¼ 8).. Thus patients were only excluded from the trial if their current clinical state made it inappropriate for them to receive outpatient treatment for an eating disorder (i. (Oxfordshire and Leicestershire) and involved 149 patients with a BMI  17. if they were acutely suicidal. 1994) criteria for AN. / Behaviour Research and Therapy 49 (2011) 219e226 the eating disorder psychopathology but. and the other therapists involved in this study were trained and supervised by SB and AF..

Devilly & Borkovec. The EDE-Q was administered both pre and post treatment. Waller. & Owen. Olmstead. or cessation of all key eating disorder behaviours and having BMI  18. 1988) the short form of the Depression Anxiety and Stress Scales (DASS. 5 were withdrawn. 1965). / Behaviour Research and Therapy 49 (2011) 219e226 221 Referral from GP (153). Urneo. 2006) and the second was having a score on the global subscale of the EDE-Q that is less than 1 SD above community norms in addition to a BMI  18. We used 2 additional measures of outcome for the purpose of comparison with the previous RCT of CBT-E. Mountford. Corstorphine. 4 moved to another state) AN 34 BN 40 EDNOS 51 12 Fig. Flow through of trial. Harrison. Byrne et al. Tomlinson. Mond.. The EDE was administered by the treating clinicians who had been trained in its administration by SB. self-esteem) and (iii) measures of other associated psychopathology such as depression.S. dietary restraint. 1995). Baer. Lovibond & Lovibond. 1972. 1994) at the end of treatment.. Rosenberg. Patients were classified as in full remission.5 kg/m2. . in partial remission. stress. cessation of all key eating disorder behaviours and having a BMI > 17. In addition. Measures Diagnosis was established during pre-treatment assessment using the 12th edition of the EDE. & Blumenthal. Three items assess credibility and 3 items assess expectations. interpersonal functioning. and the short form of the Quality of Life Enjoyment and Satisfaction Questionnaire (QLESQ-SF. anxiety.5 kg/m2 but still experiencing amenorrhea. The first was having a score on the global subscale of the EDE-Q that is less than 1 standard deviation (SD) above Australian community norms (i.g. patients’ ratings of treatment credibility and the likely effectiveness of the treatment were assessed during the first treatment session using the 6-item Credibility/Expectancy Questionnaire (CEQ. the Perfectionism subscale of the Eating Disorder Inventory (EDI. Horowitz. 8 did not provide consent for their data to be released) Assessed for eligibility N=176 Pre-treatment assessment at CCI N=162 (AN=31 BN=58 EDNOS=73) Excluded (n=37) (32 declined treatment. weight and shape concerns.46. or having a BMI  18. 1983). eating.5 kg/m2. Rogers. Psychiatrist (2) or Clinical Psychologist (10) other (11) N= 176 Ineligible for trial N=14 (6 not eligible for treatment. & Polivy. (ii) measures of additional variables specified in the transdiagnostic model (perfectionism. the Distress Tolerance Scale (DTS. or not recovered by the treating team. & Villasenor. 1993). Hay. below 2. Height and weight were measured using a Harpenden stadiometer and regularly calibrated digital medical scales (Tanika BWB-800). binge eating. The other secondary outcome variables were assessed both pre and post treatment using the following measures: The 10-item Rosenberg Self-Esteem Scale (RSE.M.e. Fairburn & Beglin. Rosenberg. For example. & Meyer. mood intolerance. the Inventory of Interpersonal Problems (IIP-32.5 kg/m2. 2000). Summary scores for the 2 subscales range from 3 to 27. Borkovec & Nau. 1. based on clinical judgement and patient responses on the Eating Disorder Examination Questionnaire (EDE-Q. Garner. compensatory behaviours. Secondary outcome variables included (i) dimensional measures of change in the severity of eating disorder features e. but reporting 1 or 2 episodes of binge eating in the last 28 days. self-esteem and quality of life. not meeting DSM-IV criteria for an eating disorder. 24 30 full remission. 5 were not appropriate for CBT-E) Allocated to CBT-E N=125 Completed treatment N=66 (50 dropped out.5 kg/m2 but <18. 2007). Nee. Endicott.

BN and EDNOS were similar on almost all baseline characteristics.00 0.1%). Of these 176 patients.0 30. By comparison. All tests were twotailed and p value of <0.47 % 97. only 42. psychiatrists (1.I.43 6.8 SD/range 9. Different superscripts denote significant differences between groups. with the exception that our participants were more likely to have had previous treatment for an eating disorder (34% vs 20%) and were more likely to be suffering from a current depressive episode (31% vs 20%).1a 41. .00e80. the ratings were Table 1 Characteristics of the sample by diagnosis.21b % 100 90. Byrne et al. or other mental health professionals (6.6 81. Patients with AN. With regard to these baseline characteristics.1 2.0 60.95e80.13 38.0 37.0 29.70 49.0 SD/range 8.02 6.00 0.6 0.222 S. 3 had no diagnosable eating disorder. Of the 51 not entered into the current trial.5 28.8 32.8 48.03 7.9 8.M.27b 63.37 14. Results Patient characteristics One hundred and seventy six patients were referred and assessed for individual treatment at CCI.3 5.8%) had a diagnosis of EDNOS.32 32e72 12. / Behaviour Research and Therapy 49 (2011) 219e226 Data analytic strategy Treatment outcome data were analysed using both completer and intent-to-treat approaches.6 33. and 32 patients declined treatment). 22 had a co-existing Axis 1 psychiatric disorder that precluded eating disorder-focused treatment and 39 were not available for the 28 weeks of treatment). Effect sizes were calculated using Cohen’s d.2 2.4 43.0%) had a diagnosis of BN.0 29.14 63. For data assessed at one time point.5 77.0 0 90.6 20. only 154 were randomised.6 23. 40 (32. of 360 patients assessed for eligibility.2%). except that patients with AN had lower minimum and maximum adult weights than those with BN or EDNOS and were more likely to have been hospitalised previously for treatment of their eating disorder.88 43.5%) were referred by their general practitioner.0 1.5e59 9.0 0 10.0 0.63 46. 1998) was used to assess current Axis 1 disorders. reported that.36a 57.9 0 17.80 20. 1 patient was found to be suffering from cancer. Pre..5 0 22.5 0.44ab % 98. Continuous pre.00 Bulimia Nervosa (N ¼ 40) N 40 36 0 4 24 15 1 0 9 13 0 17 0 1 31 11 16 12 8 Mean 27.0 2.60 6.82 10.6 SD/range 12.5e22 7.41 23. 125 (70%) entered the trial. Characteristic All patients (N ¼ 125) N Female Ethnicity White Asian Other Marital status Single.43 0.0 20.80 30.56 43.1 21.9 2.2%).84b 68.0 Anorexia Nervosa (N ¼ 34) N 32 30 1 3 21 11 2 0 6 8 1 18 0 1 26 16 14 6 7 Mean 26.0 0 2. Almost all patients (86.2 17.45 0.4 0 51. 8 did not provide consent) and 37 did not progress from assessment to CBT-E (4 were 16 year old patients who were offered family based therapy instead of CBT-E.6 SD/range 7.2%) had a diagnosis of AN.50 32e80 12.5 2. 14 were not eligible for treatment (1 was psychotic.79 45.00 0.9 76. and 41 declined to participate.0 17. Data are presented as Ns and percentages for categorical data and means and standard deviations for continuous data. Ninety-two were excluded because their eating disorder was not sufficiently severe or because they were under age 18.41 9. (2009) trial.and post-treatment data were compared using paired t-tests (for normally distributed variables) or Wilcoxon signed-rank tests (for non-normally distributed variables) and categorical data were analysed with McNemar’s tests.8 61.N.8 0 1.6 92.6 36.I.5 32.36 47e100 EDNOS (N ¼ 51) N 50 49 1 1 36 12 2 1 9 16 0 26 0 0 45 15 15 22 11 Mean 24.2b 40. 114 met exclusion criteria (12 had previously received treatment resembling CBT-E for an eating disorder.7% of those patients assessed for eligibility entered the Fairburn et al. 2 were diagnosed with BED.6 23.6 31.0 96.0 31.5e59 7. never married Married or de facto Separated/divorced Widowed Occupation Management/Professional Skilled Unskilled Home duties/student/unemployed Retired Unknown Prior psychological treatment Prior inpatient eating disorder treatment Currently on psychotropic medication Current depressive episode Any anxiety disorder Age (years) Duration of eating disorder (years) Lowest adult weight (kg) Highest adult weight (kg) 122 115 2 8 81 38 5 1 24 37 1 61 0 2 102 42 45 39 26 Mean 26.1 88.0 42.2 20. between March 2005 and February 2009. Fairburn et al. Treatment credibility and patient expectations On the CEQ.0 70.40 64.44 7.4b 29. which was administered after assessment and immediately before the initial treatment session.to post-treatment change scores were calculated.5e35 9.5 0 2.96 7.5 2.40 4. our sample appeared to be very similar to that described in the Fairburn et al. (2009) trial. Characteristics of the sample by diagnosis are presented in Table 1.99 45e110 Note: The Mini International Neuropsychiatric Interview (M.9 53.001 was used to indicate statistical significance. categorical data were compared using Chi-square tests.00 12. with a small number being referred by clinical psychologists (6. with 95% confidence intervals used to indicate the uncertainty around the estimates as appropriate.86a % 94..5 47.5 3. Sheehan et al.50 23. and 51 (40. Of the 125 patients who entered treatment 34 (27. initial (pre-treatment) data were carried forward.00e110. In instances in which a final measure was missing.9e59 9.

for the purposes of this comparison. 35. except when recovery was defined as having a post-treatment global EDE-Q score < 2. Across the diagnoses the mean number of sessions attended for completers and non-completers respectively were: for AN 46.46 (less than 1 SD above Australian community norms).M.74).3%)b Note: Different superscripts denote significant differences between groups. community norms (<1.0%)b 22 (43.72 kg [SD ¼ 10.78] vs 48. good outcome was defined as having a post-treatment global EDE score < 1 SD above U.85 to À1. p ¼ .46 Post-Tx Global EDE-Q < 2.05.3% (19/51) for patients with EDNOS (X2 (2) ¼ 3.7%) 37 (56. the outcomes were even more positive.70]). a significant difference in waiting time for treatment (weeks between referral and start of treatment) between completers and non-completers.90 kg [SD ¼ 13. As can be seen from Table 2 Treatment outcome for each diagnostic category in treatment completers and the total (intent-to-treat) sample.1% of treatment completers (37/66) were in full remission and an additional 10.58] vs 60.5 kg/m2 Definition of outcome Full remission (No ED symptoms over the past 28 days) Full or partial remission Post-Tx Global EDE-Q < 2.5 kg/m2.73 for treatment completers (range ¼ 5e100) and 12.46 in addition to a BMI  18.0%) 53 (42.K.08 kg [SD ¼ 8.5) so that a direct comparison between the 2 studies was possible for the patients with a BMI > 17. Almost half of the sample (42.3%) 19 (63.38).S.0% (10/125) for partial remission.3%) 22 (73.5%)b 18 (45. 5 (4. for BN 27.0%) 16 (66.73 (range ¼ 26e77) and 13.5 kg/m2.28] vs 18.15 (range ¼ 5e100) and 13. and for EDNOS 29.83.6%)a 13 (38. (2009) OxfordeLeicester RCT of CBT-E on equivalent outcome variables.5 kg/m2 37 (56. Attrition Of the 125 patients who started treatment.29 for non-completers (range ¼ 1e55).8%) 17 (70. As shown in Table 2. There was.96 kg [SD ¼ 8.6% (7/66) were in partial remission.2% (39/125) had a post-treatment global EDE-Q score <2.15 weeks [SD ¼ 13.06. Table 2 sets out these various recovery rates for each diagnostic category for both treatment completers and the intentto-treat sample. compared to non-completers.81 kg [SD ¼ 9.5.3%) 17 (56.0%) were withdrawn (3 moved out of state. For those patients who completed treatment.46 and 56. In the Fairburn et al. and a higher desired weight (51.46 plus BMI  18. 66. By the end of treatment 56.44 (range ¼ 1e29).0%) dropped out of treatment. For both treatment completers and the total sample.1%) 44 (66.0%)b EDNOS (N ¼ 51) 21 (41. Since the Fairburn et al. There were no significant differences in perceptions of credibility or treatment expectations between the diagnostic groups. (25. interpersonal problems. Definition of outcome Treatment completers Total (N ¼ 66) Full remission (No ED symptoms over the past 28 days) Full or partial remission Post-Tx Global EDE-Q < 2. as well as on measures of depression.77]) weight.98) and (ii) expected the treatment to be useful (mean ¼ 19.7%)b AN (N ¼ 34) 6 (17. 53/125) had a post-treatment score on the global subscale of the EDE-Q < 2.2%) AN (N ¼ 12) 6 (50.0%) 6 (50.90 weeks [SD ¼ 15. Almost 70% of treatment completers (44/66.1%) 18 (35.46 Post-Tx Global EDE-Q < 2.2%) were transferred to another service (3 to an inpatient psychiatric unit and 1 to a sexual assault referral centre).4%) 39 (31. the WA sample was categorised into 2 groups (BMI  17.7%) 17 (70.7%) had a post-treatment score on the global subscale of the EDE-Q < 2.28.71 to À2.36]).45 (range ¼ 1e48). SD ¼ 4. Table 3 presents the pre.7%) 3 (25. Byrne et al. trial only involved patients with a pre-treatment BMI > 17.1% of treatment completers (37/66) had a score on the global subscale of the EDE-Q < 2.5 vs BMI > 17. in the intent-to-treat sample patients with AN had lower rates of recovery than those with BN or EDNOS. this was not the case for treatment completers. The drop-out rates were 50% (17/34) for patients with AN. SD ¼ 5. anxiety. 1 fell pregnant and 1 died) and 4 (3. (2009) trial. (2009) RCT Table 4 presents a comparison of the results from the current Western Australian (WA) trial with the results from the previous Fairburn et al.0%) 18 (45. Effects of CBT-E at the end of treatment At the end of treatment 32. The mean number of treatment sessions attended was 31.15 kg [SD ¼ 5. completers reported a higher minimum (47. p < .and post-treatment scores on the measures of eating and more general psychopathology used in this study.0%) 8 (66.46 in addition to a BMI  18. The mean change in global EDE-Q score over treatment was À1. t (108) ¼ À2. Comparison with the Fairburn et al.0% of the total sample (40/125) fulfilled our criteria for full remission e and an additional 8.1%) Intention-to-treat sample Total (N ¼ 125) 40 (32. self-esteem and quality of life.52).3 (range ¼ 1e55).46 plus BMI  18.6%)a 6 (17. however.42). However.7%) 44 (66.0% (14/40) for patients with BN and 37. On all of the outcomes reported above (remission rates. stress. the WA study used the EDE-Q rather than the EDE in the post-treatment assessment (since it was not feasible to administer the EDE). 50 (40. with non-completers having a longer mean waiting time than completers.4%.75 (range ¼ 14e51) and 9.0%)a BN (N ¼ 24) 12 (50. The mean change in global EDE-Q score for treatment completers was À2. Thus. good outcome in the WA study was defined as having a post-treatment global EDE-Q score < 1 SD above Australian community norms (<2.05.74).26]) and maximum (65.11 (95% CI ¼ À0. / Behaviour Research and Therapy 49 (2011) 219e226 223 high and indicated that participants (i) perceived the treatment as credible (mean ¼ 22.5.5.0%) 50 (40.8%)b EDNOS (N ¼ 30) 19 (63.0%)b 18 (45.2%) 3 (8.77] vs 42. . change in global EDE-Q score and change on other measures of psychopathology) no differences were found between the subset of patients on psychotropic medication (N ¼ 45) and those not on medication.07 (95% CI ¼ À1.8%)a BN (N ¼ 40) 13 (32. there were significant improvements over treatment on all of the eatingrelated measures.2%)b 26 (51. There were no significant differences between completers and non-completers on any pretreatment measures except that.147). and 31. However.46 plus a BMI  18.

70) (5.5) Fairburn et al.2) 24 (19.60) (9.68) 1.50) (1.5..37)** (6.08 (1.07)** (1.62 68.15) (1.28) (1.0) 11/16 (68.and post-treatment scores on measures of eating and more general psychopathology.16 À0. By the end of treatment.36 49.0) 20 (16. laxatives and driven exercise) it was found that. interpersonal difficulties. 41 37 13 41 58 8 (62.5.67 -0.4) 44/66 (66.1) (87.8)** (36.65 22.46) (7.89 3.49 1.57 20. The changes in scores from pre to post treatment on all of these variables were associated with medium to large effect sizes.32 (1.20)** (18.64) (12.64 3. Byrne et al.82 1.21 1.76) (5.62)** (12.68 (0.1) (56.25 0.68 1.8)** (5.50 20.20 17.34) (4.71) (5.81) (0.87 1.78 (13.99 (9.74) (0.75 1.5) was almost exactly the same as the percentage of the total sample achieving good outcome in the Fairburn et al.45 8.5) 149 22. which was substantially higher in the WA trial (40% vs 22.96 3.23 1.66 0.36 7.17 49.3 18 (45.04)** (1.17) (16.66)** (3.8)** (1.2) 69(55.53)** (1.38 4.93(11.31 1. Discussion The aim of this study was to evaluate the effectiveness and feasibility of CBT-E as a treatment for all eating disorders.1) (19. It was expected that treatment with CBT-E would result in substantial improvements in both the specific and associated psychopathology of eating disorders and that.2) 33/50 (66.42)** Mean (SD) 3. In the WA sample 6 patients diagnosed with EDNOS had a pre-treatment BMI  17.8) 6/20 (30. including low-weight patients.81)** (2. of those reporting these at baseline.29 1.28) (9. With regard to binge eating and compensatory behaviours (self-induced vomiting.5. the main point of difference between the 2 trials was the drop-out rate. (2009) RCT on equivalent outcome variables. trial.12)** (1.21 1. Substantial improvements were also found on measures of depression.71 21.52) (0.30 4.84 (1.82) 13.21 3.39 0.90 11.53 0.) or EDE-Q (for WA) score less than 1 standard deviation above community norms (UK and Australian respectively).68) (0. 2009).97 1.7) 37/93 (39.5)** (15.50 À0.1% in full remission and an additional 10.7) (62.7%) of the patients who completed treatment (56.53)** (0.1%). .22) (0.60)** (20.50 3.40) (1.10 1.24) (17.94 19.55) (12. Total Sample WA trial BMI  17. full or partial remission was achieved by two thirds (66.98)** (3.64) (1.00 2.78) (6.21)** (1.81) (5.99)** (5. No previous published trials of CBT-E have involved patients with a BMI  17.77 3.4) 55/130 (42.4)** (45.21) (8.50 1.11 0.M.69) (0.36 0. stress.0) Post N (%) 46 46 7 26 57 68 48/105 (36.71 1.50 55.63 -0.48 1.41) (0.7) d 0.80) (5.50 Effect size Mean (SD) 3. in a sample of adults presenting to a public outpatient clinic. Trial Total sample (all BMI > 17.52) (1.58 2.06 1.02)** 8.13 4.224 S.09)** Table 4.16 1.5 N Drop-out rate (%) Good outcome total sample (%) Good outcome completers (%) Cessation of binge eating and purging if present at baseline (ITT) (%) 125 40 54 (42.1) Post N (%) 15 19 1 10 28 38 29/58 (22. In addition.1 79 (53. anxiety.23 5.7% of the total sample had ceased all of these behaviours by the end of treatment. for patients with a BMI > 17.2) 69 (55.54 1.58) (0. Good outcome was defined as having a post-treatment Global EDE (for Fairburn et al.0) BMI > 17. self-esteem and quality of life.42 1.58)** (1. Variable Treatment completers (N ¼ 66) Pre N (%) Eating Disorder Symptoms Objective bulimic episodes Self-induced vomiting Laxative misuse Driven exercise Any of the above Absence of all of the above Cessation of all these forms of behaviour.53 19.8) 40 54.0) d 1.20) (3.06 21.4)** (57.30) Note.63 0.28) (1.001. the degree of improvement would be similar to that reported in the RCT of CBT-E (Fairburn et al.64) (0.2) 105 (84.9) (12.6)** (54.07 1.74 24.74) (0.14 À0.82 1.00 À0.5 85 38.68) (0. Table 4 Comparison of the results from the current Western Australian (WA) trial with results from the Fairburn et al.23 4. the percentage of the total sample (intention-to-treat) who ceased binge eating and purging was almost identical in the 2 trials for patients with a pretreatment BMI > 17.0) 31/73 (42.98 28.17 8.67)** 1.5 (although this percentage was lower for the low-weight WA patients).1)** (42.00 À1.40)** (5.43 9.3 35 (41.33 (0.6)** (50. the percentage of patients achieving good outcome (even among patients with a pre-treatment BMI  17.05 0.20 Effect size All patients (N ¼ 125) Pre N (%) 79 (63. **p < 0.71 23.77)** (2.62 0.80 2.09) (7. / Behaviour Research and Therapy 49 (2011) 219e226 Table 3 Pre. Among those in the WA trial who completed treatment. In terms of effectiveness.13 0.48) (1.33 À1.60) (0. 50% of treatment completers and 45.7)** (29.16 À0.63) Mean (SD) 1.69) (0.62 0.8)** (45.45)** 7.8 18.68 0.94)** 16.6% in partial remission) and 40% of the total sample (32% in full remission and an additional 8% in partial remission).13 3. for both completers and the intent-to-treat sample. if present at baseline EDE-Q Global Dietary Restraint Eating Concern Weight Concern Shape Concern Body Mass index DASS Depression Anxiety Stress Perfectionism Interpersonal difficulties Distress Tolerance Anticipate and Distract Avoidance of Affect Accept and Manage Emotions Self-Esteem Quality of Life Note.99) Mean (SD) 3.54 À0.64 1.40 (1.13 1. the results did indeed support the hypothesis that CBT-E would result in significant improvements in both eating and more general psychopathology.90 (5.81 1.55 0.0) 77/116 (66.16 8.

of these patients. compared to less than half (42. However. if relevant. The high staff turnover during the W. it is much higher than the dropout rate reported in the Fairburn et al. Alternatively. and 33% 3 years later. These constructs are 2 of the additional purported maintaining mechanisms which have been included in the transdiagnostic model (Fairburn et al. and both also offered free treatment. 2009). was achieved by 66.5% of the total sample had ceased these behaviours by the end of treatment. Good outcome across the 3 treatment conditions was observed in 45% of treatment completers and 30% of the total sample. and Dodge (2001) reported good outcome (recovered or significantly improved) in 32. Patients scoring highly on the DTS pre-treatment did not show improvement on this measure over treatment.4% of treatment completers and 51. it is possible that patients’ level of motivation may diminish or that their circumstances may change in such a way as to affect their commitment to.01. preliminary results of a multi-site RCT have indicated that CBT-E is appropriate for about 60% of outpatients with a BMI between 15 and 17.63. Loeb. trial (22. Straebler. good outcome (defined as having a post-treatment global EDE score < 1 SD above community norms). site actually entered the trial. the percentage of AN patients achieving good outcome was 66. where commitment to treatment may be more limited than in a research trial. Vitousek. While in RCTs there is generally no waiting list.01. This was despite patients of all diagnoses reporting early in treatment that they considered the treatment to be highly acceptable and rating the therapeutic alliance very positively. The amount of training and the degree of supervision required for the therapists involved in this study were considered to be appropriate and realistic for a public outpatient clinic.3% of the total sample reported no episodes of binge eating or purging over the previous 28 days. 2010). (2005) compared 3 outpatient treatments for patients with a BMI of 15e19 kg/m2 (CBT.0% of treatment completers and 41. & Pike. full or partial remission was achieved by 50. there was a significant group by time (pre to post treatment) interaction F (1. The overall drop-out rate was 37%. sample than in the U. When the total sample was considered. & Abbate-Daga.5. on average. Additional analyses were conducted with patients classified into high (above the mean for eating disorder patients) and low groups on pre-treatment measures of perfectionism and mood intolerance. Interpersonal Therapy and Non-specific Supportive Clinical Management). (2009) RCT of CBT-E. and low-weight patients.12. overall. 2003) and which are specifically targeted in CBT-E. The lack of change in these variables overall may reflect the fact that only a subset of patients (those for whom perfectionism or mood intolerance were particularly problematic) received these treatment modules.1%). both sites in the Fairburn et al. approximately 60% will have a good outcome (Fairburn. trial (Oxford and Leicester) were providing the main outpatient eating disorder services locally. Thus. Pike. at the end of treatment.A. The current study is the first to report treatment outcome for CBT-E with low-weight AN patients.5. One explanation for this may relate to our previous observation that current measures of mood intolerance are less than adequate (Raykos. except for our higher drop-out rate. in the W. good outcome was achieved by 66. In this study. an adult sample. While Fairburn et al. trial may also have affected retention. the experience level of the therapists and staff turnover. trial.0% of AN patients (6/12) who completed treatment. 1997. (2009) study where. Thus.5 reporting these behaviours at baseline. Murphy. Cooper. Although the drop-out rate in the WA study (40% for the total sample) was not outside the realm of drop-out rates reported for outpatient trials of eating disorders (29e73%. focal psychotherapy or family therapy.3% of the total sample.31) ¼ 2.A. & Vitousek. Further investigation is required if drop out is to be minimised in the future. & Watson. sample (31% vs 20%).5 months) than for treatment completers (around 3. (2009) RCT.. Indeed. Fassino. Treasure. 42.5 months). trial. The high drop-out rate in the WA study may be partly due to the fact that the sample consisted of patients attending an inner-city public clinic offering free treatment. it appears that perfectionism did improve significantly in patients for whom perfectionism was a problem. & Fairburn. As the period of time between referral and the start of treatment increases.K. of those with a BMI > 17. Thus. patients were on a waiting list for treatment for over 5 months. the current study offers evidence that CBT-E can be effectively delivered in a community clinic by therapists with little experience in treating eating disordered patients without extensive training or time-consuming supervision.3% of EDNOS patients (22/30). or desire for. and there was a 38% drop-out rate.A.7% of BN patients (16/24) and 73. the outcomes for AN were poorer than those for BN and EDNOS due to the high drop-out rate among the AN patients (50% vs 35% and 37. h ¼ . 2010) reported recovery rates (not meeting DSM-IV criteria for any eating disorder) of 30% at the end of a 1-year treatment period. In terms of feasibility. the outcome for CBT-E with these patients appears to be positive and similar regardless of whether it is conducted in an outpatient clinic setting or in the context of a RCT. t(1. and the prevalence of co-morbid depression was higher in the W. compared to 66. however. Piero. The majority of the therapists in the W. 2009. . in the current study. during the third stage of treatment. and the waiting time was almost twice as long for drop outs (around 6. This was not the case for mood intolerance. 2009).S. Using an equivalent definition (having a global EDE-Q score < 1 SD above Australian community norms) among participants in the WA trial with a BMI > 17.. McIntosh et al. Therefore the outcome for CBT-E with the AN patients in our WA study is comparable to that reported in these studies. which only included patients with a pre-treatment BMI > 17. When good outcome was defined according to post-treatment global EDE-Q score.3% of a sample of adults with AN (BMI < 17. the mood intolerance treatment module in CBT-E may not be potent enough to fully address this complex construct.5 and that. / Behaviour Research and Therapy 49 (2011) 219e226 225 In the Fairburn et al. as would be expected. the results do appear to indicate that CBT-E may be less effective for AN than for the other eating disorders. Interestingly. trial was relatively inexperienced and had not received the same amount of formal training and supervision in CBT-E as had therapists in the Fairburn et al. With regard to binge eating and purging we found that. whereas those initially low on perfectionism. For perfectionism. Russell.7%) of those assessed in the Fairburn et al.5) after 1 year of treatment with cognitive analytic therapy.2% of the total sample.51. such that patients initially high on perfectionism did show a significant decrease in perfectionism over treatment.7% for treatment completers.A. have not yet published outcome data regarding the use of CBT-E with AN patients. did not. Byrne. Dare. trial. treatment. Tomba. overall attrition rate is an important point of difference between the WA trial and the Fairburn et al. Byrne et al. p < . Eisler. 42. Only a small number of previous studies of treatments for AN provides an appropriate comparison for the current WA study in that they have involved outpatient psychological treatments. Other factors that may explain the different drop-out rates may include the waiting time for treatment. It is also notable that the majority (70%) of patients assessed for eligibility at the W. p < 0.59) ¼ 8. 1996) for AN and sub-threshold AN patients (N ¼ 103) conducted in Italy (Ricca et al.M. Once again this is very similar to the Fairburn et al. there was no overall improvement noted on measures of perfectionism or mood intolerance at the end of treatment.A.3% respectively). A recent uncontrolled trial of traditional CBT (Garner.

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