A pilot randomised controlled trial of guided self-help cognitive behaviour therapy for perfectionism: Impact on diagnostic status and comorbidity.

BACKGROUND AND OBJECTIVES: Perfectionism is associated with the development and maintenance of anxiety, mood, and eating disorders. Cognitive behaviour therapy (CBT) results in significant reductions in perfectionism and psychological symptoms however, the majority of studies have not examined clinical samples or impact on diagnostic status and comorbidity. METHODS: Forty participants with elevated perfectionism, of whom 80% had a range of psychological disorders, were randomised to CBT for perfectionism or waitlist control. RESULTS: The treatment group reported significant large effect size reductions in perfectionism measures of personal standards and concern over mistakes (d = 1.1-1.6), dichotomous thinking (d = 1.2), and medium effect size reductions in depression (d = 0.55) and increases in quality of life (d = 0.73), which were maintained at 4 month follow-up. The participants in the treatment group were significantly less likely to present with comorbid psychological disorders at post-treatment than the control group. LIMITATIONS: The sample size was small, and there was no control condition at follow-up. CONCLUSIONS: Findings lend further support for CBT for perfectionism as an efficacious transdiagnostic treatment for perfectionism and related psychopathology.

The association between carer self-compassion, expressed emotion, quality of life, and paediatric eating disorder symptoms.

OBJECTIVE: The aim of this study was to investigate carer variables on paediatric eating disorders. We examined whether carer self-compassion, the tendency to treat oneself with kindness during distress and disappointments, was associated with lower carer expressed emotion, and, in turn, whether lower carer expressed emotion would be associated with both higher carer quality of life and lower eating disorder symptoms in young people. Further, we examined whether higher carer quality of life was associated with lower adolescent eating disorder symptoms. METHOD: Data were extracted from the Helping out Paediatric Eating Disorders (HOPE) project database. Participants included children and adolescents diagnosed with a DSM5 eating disorder and their primary carer (N of dyads = 359). Primary carers completed the Self-Compassion Scale-Short Form (SCS-SF), Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q-SF), and the Family Questionnaire-Expressed Emotion (FQ-EE). Children and adolescents completed an adapted version of the Eating Disorder Examination (EDE). RESULTS: As hypothesised, structural equation modelling (SEM) revealed a direct relationship between higher carer self-compassion and lower expressed emotion, and between lower expressed emotion and both higher carer quality of life and lower eating disorder symptoms. However, contrary to our hypothesis, carer quality of life was not significantly associated with paediatric eating disorder symptoms. Expressed emotion carried significant indirect effects between carer self-compassion and (a) paediatric eating disorder symptoms and (b) carer quality of life. DISCUSSION: The results highlight the importance of further research to determine whether targeting carer self-compassion is helpful in the treatment of eating disorders in young people.

Examining cognitive and behavioural symptoms across binge/purge profiles in adolescents with eating disorders.

Binge eating and purging profiles may vary in adolescents with eating disorders and this may potentially be a function of a range of cognitive and behavioural constructs. The aim was to determine whether cognitive and behavioural symptoms differed among purging profiles in 229 adolescent females (M age = 15.45). Differences were examined in three binge/purge profiles; (i) regular objective binge eating and purging (OBEP, n = 63), (ii) regular subjective binge eating and purging (SBEP, n = 41), and (iii) purging in the absence of any binge eating (P-noBE, n = 110). Adolescents with objective or subjective binge eating had significantly higher global eating disorder scores and eating, shape, and weight concerns than those without binge eating, but not more frequent compensatory behaviours. There were no significant differences on dietary restraint. The group with objective binge eating (OBEP) had significantly higher eating concerns and self-induced vomiting than adolescents with subjective binge eating (SBEP). Future research is required to understand the reasons for elevated symptoms in the OBE-P group, since the size of binge episodes is not thought to be a salient factor in binge eating. In contrast to the literature, we did not find support for a special relevance of dietary restraint to the purging only presentation (P-noBE), rather it was a universal characteristic of all binge/purge presentations. Eating concerns may be an important target in adolescents with objective binge symptoms. Future research should examine if treatment targeted at different binge/purge profiles improves efficacy of treatment in adolescents.

An examination of the transdiagnostic cognitive-behavioural model of eating disorders in adolescents.

OBJECTIVE: The validity of the transdiagnostic cognitive-behavioural model of eating disorders has been examined in adults, however there is limited examination in adolescents with eating disorders. The present study examined the direct and indirect relationships between eating disorder symptoms and the four maintaining processes: perfectionism, low core self-esteem, mood intolerance, and interpersonal difficulties. METHOD: Using a correlational cross-sectional design, adolescents with eating disorders (N = 270; anorexia nervosa [restricting; 35.9%]; anorexia nervosa [binge purge; 8.1%]; bulimia nervosa [9.3%]; atypical anorexia nervosa [27.4%]; bulimia nervosa [of low frequency and/or limited duration; 3%]; purging [1.1%]; and unspecified feeding or eating disorders [15.2%]) completed measures of perfectionism, self-esteem, mood intolerance, interpersonal difficulties, and eating disorder symptoms as part of the intake assessment to an eating disorders program. RESULTS: Path analysis revealed that low self-esteem and mood intolerance were directly associated with eating disorder symptoms. Perfectionism was indirectly associated with eating disorder symptoms through self-esteem and mood intolerance. DISCUSSION: The findings provide partial support for the transdiagnostic model of eating disorders in an adolescent clinical sample. In particular, core low self-esteem and mood intolerance were found to be pertinent in adolescents with eating disorders. A limitation of the current study was the use of cross-sectional data. Future research should examine the transdiagnostic model with the use of longitudinal data. Furthermore, future research is required to examine potential differences in the way the maintaining mechanisms operate between adolescents and adults with eating disorders and the implications for treatment.

The relationships between perfectionism, anxiety and depression across time in paediatric eating disorders.

OBJECTIVE: The aim was to examine in children and adolescents with eating disorders the relationship between perfectionism, anxiety, and depression at intake assessment and whether intake perfectionism was significantly associated with anxiety and depression at 6 months and 12 months post-intake review. METHOD: Participants were 167 females aged 10-17 years (M = 14.6, SD = 1.20) with a diagnosis of an eating disorder, who were assessed at intake to an eating disorders treatment program to receive either inpatient, day or outpatient care. Participants were re-assessed at 6 and 12 months post-intake review. RESULTS: At intake and 6 and 12 months post intake review perfectionism had a significant positive correlation with anxiety and depression. Perfectionism did not however determine change in anxiety and depression over time at 6 and 12 months post-intake review. CONCLUSIONS: Despite perfectionism being significantly associated with anxiety and depression, further research is required to explore the relationships between perfectionism, anxiety and depression over time.

An examination of direct, indirect and reciprocal relationships between perfectionism, eating disorder symptoms, anxiety, and depression in children and adolescents with eating disorders.

OBJECTIVE: Perfectionism is a transdiagnostic factor across eating disorders, anxiety, and depression. Previous research has shown anxiety mediates the relationship between perfectionism and eating disorders in adults. The aim of this study was to investigate the relationships between anxiety/depression, perfectionism and eating disorder symptoms in children and adolescents with eating disorders. METHOD: Structural equation modeling was used to investigate three models in a clinical sample of children and adolescents (N = 231, M age = 14.5, 100% female): (1) anxiety and depression as mediators of the relationship between perfectionism and eating disorder symptoms, (2) eating disorder symptoms as a mediator of the relationship between perfectionism and anxiety and/or depression, and (3) perfectionism as a mediator of the relationship between anxiety/depression and eating disorders. RESULTS: Results indicated that both models 1 and 2 fit the data well, while model 3 provided a poor fit. These findings suggest that in clinical populations of children and adolescents, anxiety and depression mediate the relationship between perfectionism and eating disorder symptoms, and there is also a reciprocal relationship whereby eating disorders mediate the association between perfectionism, and anxiety and/or depression. DISCUSSION: The results highlight the importance of further research to determine whether targeting perfectionism is helpful in the treatment of eating disorders and comorbid anxiety and depression in young people. It would be useful for clinicians to consider assessing for and treating perfectionism directly when it is elevated in children and adolescents with eating disorders.

Perfectionism is associated with higher eating disorder symptoms and lower remission in children and adolescents diagnosed with eating disorders.

OBJECTIVE: The link between perfectionism and eating disorders is well established in adults, however little research has been conducted in children and adolescents. The aim was to examine if perfectionism was a predictor of eating disorder symptoms at intake assessment, and 6 and 12 month review. METHOD: There were 175 children and adolescents aged 10-17 years (M = 14.47 years, SD = 1.31) who were assessed using the Eating Disorders Inventory-3 perfectionism subscale and the child adapted Eating Disorders Examination at intake, 6 and 12 months review. RESULTS: There was a significant association between perfectionism and symptoms of eating disorders at intake assessment and at 6 and 12 month review. Higher perfectionism at intake predicted a lower likelihood of remission at 12 months. DISCUSSION: The findings suggest that similar to adult samples, perfectionism is significantly associated with eating disorder symptoms in children and adolescents. Further research is required to examine the impact of perfectionism on eating disorder symptoms in longitudinal research with children and adolescents with eating disorders.

Implications of DSM-5 for the diagnosis of pediatric eating disorders.

OBJECTIVE: The aim of the study was to compare the DSM-IV, DSM-5, and ICD-10 eating disorders (ED) nomenclatures to assess their value in the classification of pediatric eating disorders. We investigated the prevalence of the disorders in accordance with each system's diagnostic criteria, diagnostic concordance between the systems, and interrater reliability. METHOD: Participants were 1062 children and adolescents assessed at intake to a specialist Eating Disorders Program (91.6% female, mean age 14.5 years, SD = 1.75). Measures were collected from routine intake assessments. RESULTS: DSM-5 categorization led to a lower prevalence of unspecified EDs when compared with DSM-IV. There was almost complete overlap for specified EDs. Kappa values indicated almost excellent agreement between the two coders on all three diagnostic systems, although there was higher interrater reliability for DSM-5 and ICD-10 when compared with DSM-IV. DISCUSSION: DSM-5 nomenclature is useful in classifying eating disorders in pediatric clinical samples.

Consensus-based perspectives of pediatric inpatient eating disorder services.

OBJECTIVE: There are few evidence-based guidelines for inpatient pediatric eating disorders. The aim was to gain perspectives from those providing and receiving inpatient pediatric eating disorder care on the essential components treatment. METHOD: A modified Delphi technique was used to develop consensus-based opinions. Participants (N = 74) were recruited for three panels: clinicians (n = 24), carers (n = 31), and patients (n = 19), who endorsed three rounds of statements online. RESULTS: A total of 167 statements were rated, 79 were accepted and reached a consensus level of at least 75% across all panels, and 87 were rejected. All agreed that families should be involved in treatment, and thatpsychological therapy be offered in specialist inpatient units. Areas of disagreement included that patients expressed a desire for autonomy in sessions being available without carers, and that weight gain should be gradual and admissions longer, in contrast to carers and clinicians. Carers endorsed that legal frameworks should be used to retain patients if required, and that inpatients are supervised at all times, in contrast to patients and clinicians. Clinicians endorsed that food access should be restricted outside meal times, in contrast to patients and carers. DISCUSSION: The findings indicate areas of consensus in admission criteria, and that families should be involved in treatment, family involvement in treatment, while there was disagreement across groups on topics including weight goals and nutrition management. Perspectives from patients, carers, and clinicians may be useful to consider during future revisions of best practice guidelines.

Prevention of eating disorders: A systematic review of randomized, controlled trials.

OBJECTIVE: This systematic review evaluated the efficacy of universal, selective, and indicated eating disorder prevention. METHOD: A systematic literature search was conducted in Medline, PsycINFO, Embase, Scopus, and the Cochrane Collaboration Library databases to January 2016. Studies were included if they were randomized, controlled trials (RCT) and tested an eating disorder prevention program. We retrieved 13 RCTs of universal prevention (N = 3,989 participants, 55% female, M age = 13.0 years), 85 RCTs of selective prevention (N = 11,949 participants, 99% female, M age = 17.6 years), and 8 RCTs of indicated prevention (N = 510 participants, 100% female, M age = 20.1 years). Meta-analysis was performed with selective prevention trials. As there were a limited number of universal and indicated trials, narrative synthesis was conducted. RESULTS: Media literacy had the most support for universal prevention. Most universal approaches showed significant modest effects on risk factors. Dissonance-based was the best supported approach for selective prevention. Cognitive-behavior therapy (CBT), a healthy weight program, media literacy, and psychoeducation, were also effective for selective prevention and effects were maintained at follow-up. CBT was supported for indicated prevention and effects were maintained at follow-up. DISCUSSION: The modest effects for universal prevention were likely due to floor effects. The evidence for selective prevention suggests that empirically supported approaches should be disseminated on a wider basis. Our findings suggest CBT should be offered for indicated populations. Overall, results suggest efficacy of several prevention programs for reducing risk for eating disorders, and that wider dissemination is required. © 2016 Wiley Periodicals, Inc.

Eating disorder examination: Factor structure and norms in a clinical female pediatric eating disorder sample.

OBJECTIVE: The factor structure of the eating disorder examination (EDE) has never been tested in a clinical pediatric sample, and no normative data exist. METHOD: The factor structure of an adapted EDE was examined in a clinical sample of 665 females aged 9-17 years with anorexia nervosa spectrum (70%), bulimia nervosa spectrum (12%), purging disorder (3%), and unspecified feeding and eating disorders (15%). RESULTS: The original four-factor model was a good fit in a confirmatory factor analysis as well a higher order model with three dimensions of restraint, eating concern, and combined weight concern/shape concern. Normative data are reported for clinicians to identify the percentiles in which their patients' score. DISCUSSION: The findings support dimensions of restraint, eating concern, weight concern, and shape concern in a clinical pediatric sample. This supports the factorial validity of the EDE, and the norms may assist clinicians to evaluate symptoms in females under 18 years.

Clinical presentation of eating disorders in young males at a tertiary setting.

BACKGROUND: Young males with eating disorders are a neglected study population in eating disorders. The aim of this study was to provide knowledge about the clinical presentation of eating disorders in young males. METHODS: The data source was the Helping to Outline Paediatric Eating Disorders (HOPE) Project (N ~ 1000), a prospective, ongoing registry comprising consecutive paediatric (<18 years) tertiary eating disorder referrals. Young males with DSM-5 eating disorders (n = 53) were compared with young females with eating disorders (n = 704). RESULTS: There was no significant difference in the prevalence of diagnosis of bulimia nervosa (2 % vs 11 %, p = 0.26) among sexes. Males had comparable duration of illness (9 months; p = 0.28) and a significantly earlier age of onset (M = 12 years; p <0.001). Shape concern (2.39 vs 3.57, p <0.001) and weight concern (1.97 vs 3.09, p <0.001) were lower in males, and body mass index z score (-1.61 vs -1.42, p = 0.29) and medical compromise (odds ratio [OR] = 0.64, 95 % CI: 0.36, 1.12) were comparable. Males had a two-folder higher odds of being diagnosed with unspecified feeding or eating disorders (40 % vs 22 % for females, p = 0.004). Driven exercise to control weight and shape was common and comparable in prevalence among males and females (51 % vs 47 %, p = 0.79) and males were less likely to present with self-induced vomiting (OR = 0.23, 95 % CI: 0.09, 0.59). CONCLUSION: Boys with eating disorders are an understudied group with similarities and differences in clinical presentation from girls with eating disorders. Parents and physicians are encouraged to consider changes in weight, disturbed vital signs, and driven, frequent exercise for the purposes of controlling weight or shape, as possible signs of eating disorders among male children. Diagnostic classification, assessment instruments, conceptualisation, and treatment methods need to be refined to improve application to young males.

Brief report: Correlates of inpatient psychiatric admission in children and adolescents with eating disorders.

OBJECTIVE: To examine the prevalence and importance of psychological, behavioural, and situational correlates of impending psychiatric inpatient admissions in children and adolescents with eating disorders. METHOD: The sample consisted of 285 patients (8-17 years, M = 14.4, SD = 1.49) with DSM-5 eating disorders assessed between 2006 and 2013 from the Helping to Outline Pediatric Eating Disorders (HOPE) Project. The sample was split into two groups, those with (n = 38) and without (n = 247) impending psychiatric admission; Discriminant function analysis was used to examine correlates. RESULTS: The prevalence of impending psychiatric admission was 13.3%. Suicidal ideation provided the greatest discriminating power, followed by eating pathology, depressive symptoms, anxiety, multiple methods of weight control, binge eating, and family functioning. CONCLUSIONS: Earlier recognition of comorbid symptoms in eating disorders in the community may reduce the number of young people with eating disorders who present needing critical psychiatric care.

A randomised controlled trial of face to face versus pure online self-help cognitive behavioural treatment for perfectionism.

Previous research has shown cognitive-behavioural treatment (CBT) to be effective in reducing perfectionism. The present study investigated the efficacy of two formats of CBT for perfectionism (CBT-P), face-to-face and pure online self-help, in reducing perfectionism and associated psychological symptoms. Participants were randomly allocated to face-to-face CBT-P (n = 18), pure online self-help CBT-P (n = 16), or a waitlist control period (n = 18). There was no significant change for the waitlist group on any of the outcome measures at the end of treatment. Both the face-to-face and pure online self-help groups reported significant reductions at the end of treatment for the perfectionism variables which were maintained at the 6-month follow-up. The face-to-face group also reported significant reductions over this time in depression, anxiety, and stress, and a significant pre-post increase in self-esteem, all of which were maintained at the 6-month follow-up. In contrast, the pure online self-help group showed no significant changes on these outcomes. The face-to-face group was statistically superior to the pure online self-help group at follow-up on the perfectionism measures, concern over mistakes and personal standards. The results show promising evidence for CBT for perfectionism, especially when offered face to face, where sustained benefit across a broad range of outcomes can be expected.

A decade of data from a specialist statewide child and adolescent eating disorder service: does local service access correspond with the severity of medical and eating disorder symptoms at presentation?

BACKGROUND: Eating disorders affect up to 3% of children and adolescents, with recovery often requiring specialist treatment. A substantial literature has accrued suggesting that lower access to health care services, experienced by rural populations, has a staggering effect on health-related morbidity and mortality. The aim of this study was to evaluate whether lower service access foreshadowed a more severe medical and symptom presentation among children and adolescents presenting to a specialist eating disorders program. METHOD: The data source was the Helping to Outline Paediatric Eating Disorders (HOPE) Project registry (N ~1000), a prospective ongoing registry study comprising consecutive paediatric tertiary eating disorder referrals. The sample consisted of 399 children and adolescents aged 8 to 16 years (M =14.49, 92% female) meeting criteria for a DSM-5 eating disorder. RESULTS: Consistent with the hypotheses, lower service access was associated with a lower body mass index z-score and a higher likelihood of medical complications at intake assessment. Contrary to our hypothesis, eating pathology assessed at intake was associated with higher service access. No relationship was observed between service access and duration of illness or percentage of body weight lost. CONCLUSIONS: Lower service access is associated with more severe malnutrition and medical complications at referral to a specialist eating disorder program. These findings have implications for service planning and provision for rural communities to equalize health outcomes.

Parent skills training treatment for parents of children and adolescents with eating disorders: a qualitative study.

OBJECTIVE: This study examined the experience of parents of children with eating disorders after having participated in a skills-based training intervention. METHOD: Eleven parents were interviewed and transcripts were analysed using inductive thematic analysis. RESULTS: Parent responses were organised around key themes of (1) effectiveness and acceptability of the intervention; (2) interpersonal experience of the group process; and (3) feedback on intervention content. Overall, the transfer of specialist skills was highly valued by parents and applied within the home and hospital setting. DISCUSSION: This study contributes preliminary evidence that skills-based training may improve parent self-efficacy,psychological distress, anxiety, and burden.This intervention can also be a cost-effective method for supporting carers,and future research is required to contribute data on treatment efficacy for patients in addition to parents.

Normative data for female adolescents with eating disorders on the Children's Depression Inventory.

OBJECTIVE: Given the importance of assessing depressive symptoms and suicidal ideation in adolescents with eating disorders (EDs), the aim was to provide normative data on the Children's Depression Inventory (CDI) for female adolescents presenting for treatment of an ED. METHOD: The data source was the Helping to Outline Paediatric Eating Disorders (HOPE) Project registry (N = 1000), a prospective, ongoing registry study comprising consecutive pediatric tertiary ED referrals. Females (N = 256; 12-17 years) with DSM-5 EDs completed the CDI at intake. RESULTS: Results on the CDI revealed a pattern of increasing depressive scores with age and higher scores among patients with anorexic spectrum disorders. The prevalence of suicidal ideation was high and had the same pattern as CDI scores. The mean score on the CDI in the sample was higher than community samples and clinical samples of adolescents with post-traumatic stress disorder, obsessive compulsive disorder, and other clinical disorders. DISCUSSION: Females adolescents with EDs are at high-risk of depression and suicidal ideation. These data provide information about variation in CDI scores to guide clinicians in interpretation of scores.

Normative data for female adolescents with eating disorders on the Multidimensional Anxiety Scale for Children.

OBJECTIVE: To provide normative data on the Multidimensional Anxiety Scale for Children (MASC) for female adolescents presenting for eating disorder (ED) treatment. METHOD: This study is part of the Helping to Outline Paediatric Eating Disorders Project registry (N ∼ 1,000), a prospective ongoing registry study comprising consecutive pediatric tertiary ED referrals. Female adolescents (N = 278; 13-17 years) with EDs completed the MASC at intake. RESULTS: Summary data including percentiles are given for the MASC total and subscales. MASC scores were higher than community norms as expected and increased with age (p <.001) and an anorexic spectrum diagnosis (p < .001). DISCUSSION: The norms reported will aid clinicians in the understanding and interpretation of individual MASC scores among female adolescents with EDs and could assist future research to better understand the role of anxiety in the onset and maintenance of EDs.

The HOPE (Helping to Outline Paediatric Eating Disorders) Project: development and debut of a paediatric clinical eating disorder registry.

BACKGROUND: The HOPE (Helping to Outline Paediatric Eating Disorders) Project is an ongoing registry study made up of a sequential cross-sectional sample prospectively recruited over 17 years, and is designed to answer empirical questions about paediatric eating disorders. This paper introduces the HOPE Project, describes the registry sample to-date, and discusses future directions and challenges and accomplishments. The project and clinical service were established in a tertiary academic hospital in Western Australia in 1996 with a service development grant. Research processes were inbuilt into the initial protocols and data collection was maintained in the following years. Recognisable progress with the research agenda accelerated only when dedicated research resources were obtained. The registry sample consists of consecutive children and adolescents assessed at the eating disorder program from 1996 onward. Standardised multidisciplinary data collected from family intake interview, parent and child clinical interviews, medical review, parent, child and teacher psychometric assessments, and inpatient admission records populate the HOPE Project database. RESULTS: The registry database to-date contains 941 assessments, of whom 685 met DSM-IV diagnostic criteria for an eating disorder at admission. The majority of the sample were females (91%) from metropolitan Perth (83%). The cases with eating disorders consist of eating disorders not otherwise specified (68%), anorexia nervosa (25%) and bulimia nervosa (7%). Among those with eating disorders, a history of weight loss since illness onset was almost universal (96%) with fear of weight gain (71%) common, and the median duration of illness was 8 months. CONCLUSIONS: Over the next five years and more, we expect that the HOPE Project will make a strong scientific contribution to paediatric eating disorders research and will have important real-world applications to clinical practice and policy as the research unfolds.

The validity of the transdiagnostic cognitive behavioural model of eating disorders in predicting dietary restraint.

The study examined the validity of the transdiagnostic cognitive behavioural theory of eating disorders. The aim was to determine if the maintaining mechanisms of clinical perfectionism, core low self esteem, mood intolerance and interpersonal difficulties have a direct impact on dietary restraint or an indirect impact via eating, shape and weight concerns. The model was tested in a community sample of 224 females recruited via the internet. The structural equation model provided a good fit for the data. The relationship between maintaining mechanisms and dietary restraint was due to maintaining mechanisms impacting indirectly on dietary restraint via eating disorder psychopathology. The results lend support for the validity of the transdiagnostic model of eating disorders as the maintaining mechanisms lead to restraint via the core psychopathology of eating concerns, weight concerns and shape concerns. The findings suggest the four maintaining mechanisms alone are not enough to lead to dietary restraint, the core psychopathology of eating disorders needs to be present, which supports the predictions of the theory. These results help establish the validity of the transdiagnostic cognitive behavioural theory of eating disorders.