Effectiveness of enhanced cognitive behaviour therapy for patients aged 14 to 25: A promising treatment for anorexia nervosa in transition-age youth.

OBJECTIVE: The study aimed to evaluate the effectiveness of enhanced cognitive behaviour therapy (CBT-E) on patients with anorexia nervosa (AN) aged 14 to 25 treated in a real-world setting. METHOD: One hundred and fifteen patients with AN (n = 61, age <18 years) were recruited from consecutive referrals to a clinical eating disorder service offering outpatient CBT-E. Body Mass Index (BMI), BMI centiles, Eating Disorder Examination Questionnaire, Brief Symptom Inventory, and Clinical Impairment Assessment scores were recorded at admission, at the end of treatment, and at 20-week follow-up. RESULTS: The seventy-two patients (62.6%) who finished the programme showed considerable weight gain and reduced scores for clinical impairment and eating-disorder and general psychopathology. Changes remained stable at 20 weeks. A comparison between adolescent and adult patients indicates similar improvements in eating-disorder psychopathology. CONCLUSIONS: The benchmark data yielded by this study suggest that CBT-E is a well-accepted and promising treatment that could be adopted to ensure continuity of care across the transitional age.

Validity and reliability of the Dietary Rules Inventory (DRI).

BACKGROUND: Dietary rules are common in patients with eating disorders, and according to transdiagnostic cognitive behavioural theory for eating disorders, represent a key behaviour maintaining eating-disorder psychopathology. The aim of this study was to describe the design and validation of the Dietary Rules Inventory (DRI), a new self-report questionnaire that assesses dietary rules in patients with eating disorders. METHODS: A transdiagnostic sample of 320 patients with eating disorders, as well as 95 patients with obesity and 122 healthy controls were recruited. Patients with eating disorders also completed the Dutch Eating Behaviour Questionnaire (DEBQ), the Eating Disorder Examination Questionnaire, the Brief Symptoms Inventory and the Clinical Impairment Assessment. Dietary rules were rated on a continuous Likert-type scale (0-4), rating how often (from never to always) they had been applied over the previous 28 days. RESULTS: DRI scores were significantly higher in patients with eating disorders than in patients with obesity and healthy controls. Principal factor analysis identified that 55.8% of the variance was accounted for by four factors, namely 'what to eat', 'social eating', 'when and how much to eat' and 'caloric level'. Both global score and subscales demonstrated high internal and test-retest reliability. The DRI global score was significantly correlated with the DEBQ 'restrained eating' subscale, as well as eating-disorder and general psychopathology and clinical impairment scores, demonstrating good convergent validity. CONCLUSIONS: These findings suggest that the DRI is a valid self-report questionnaire that may provide important clinical information regarding the dietary rules underlying dietary restraint in patients with eating disorders. LEVEL OF EVIDENCE: V, descriptive study.

Enhanced cognitive behavior therapy for severe and extreme anorexia nervosa: An outpatient case series.

OBJECTIVE: The study aimed to assess outcomes in patients with severe and extreme anorexia nervosa managed with enhanced cognitive behavior therapy (CBT-E) in a real-world outpatient setting. METHOD: Thirty patients with anorexia nervosa and body mass index (BMI) <16 aged ≥17 years were recruited from consecutive referrals to an eating disorder service clinic offering outpatient CBT-E. BMI and Eating Disorder Examination Questionnaire (EDE-Q), Brief Symptom Inventory (BSI), and Clinical Impairment Assessment (CIA) scores were recorded at admission, end of treatment, and 20- and 60-week follow-ups for treatment completers. RESULTS: Twenty patients (66.7%) completed the treatment and showed both considerable weight gain (Cohen's f = 1.43), and significantly reduced scores for clinical impairment (f = 1.26) and eating-disorder (f = 1.03) and general psychopathology (f = 0.99). Changes remained stable at both follow-ups. About half of the patients who completed treatment had a BMI ≥18.5 at the end of treatment and follow-ups. DISCUSSION: CBT-E seems suitable and promising for patients with severe and extreme anorexia nervosa seeking treatment in a real-world clinical setting, provided that their medical conditions are stable, and they have no current major depressive episodes or substance abuse; it may represent a valid alternative to inpatient treatment for those who are able to sustain engagement in a full course of outpatient treatment.

Treatment of Eating Disorders in Adults Versus Adolescents: Similarities and Differences.

FINDINGS: Although several individual psychotherapies for adults with eating disorders are empirically supported, with family-based treatment (FBT) being the leading recommended empiric treatment in adolescents, patients with eating disorders are still difficult to treat, and outcomes are often poor. In some countries, the clinical services for adolescents and adults are separate, and it is common for patients to receive treatments that differ in terms of both theory and content when they are switched from adolescent to adult services. Changes in the nature of treatment also often occur when patients move from less intensive types of care to more intensive treatment, and vice versa. These transitions may create a discontinuity in the care pathway and disorient patients and their significant others about the strategies and procedures used for addressing eating problems. However, the observation that younger and older patients essentially share the same eating-disorder psychopathology has led to evidence-based enhanced cognitive-behavioral therapy (CBT-E) being adapted for use in adolescents. Originally an evidence-based treatment for adults with eating disorders, CBT-E has yielded promising results in trials in cohorts of adolescent outpatients and inpatients, and is recommended as an alternative to FBT in adolescent patients. IMPLICATIONS: With a unified treatment such as CBT-E, several issues that plague conventional eating-disorder services could be partially overcome, as patients can move seamlessly from adolescence to adulthood and through different levels of care, with no change in the nature of the treatment itself. Future randomized, controlled trials should compare FBT to CBT-E to better clarify the specific therapeutic needs of subgroups of adolescents and adult patients with eating disorders.

Eating disorder psychopathology in adults and adolescents with anorexia nervosa: A network approach.

OBJECTIVE: The aim of this study was to assess and compare eating disorder feature networks in adult and adolescent patients with anorexia nervosa. METHODS: Patients seeking treatment for anorexia nervosa in inpatient and outpatient settings were consecutively recruited from January 2008 to September 2019. Body mass index was measured, and each patient completed the Eating Disorder Examination Questionnaire. RESULTS: The sample comprised 547 adolescent and 724 adult patients with anorexia nervosa. Network analysis showed that in both adults and adolescents, the most central and highly interconnected nodes in the network were related to shape overvaluation and desiring weight loss. The network comparison test identified similar global strength and network invariance, confirming the similarity of the two network structures. DISCUSSION: The network structures in adult and adolescent patients with anorexia nervosa are similar, and lend weight to the cognitive behavioral theory that overvaluation of shape and weight is the core feature of anorexia nervosa psychopathology.

Personalized cognitive-behavioural therapy for obesity (CBT-OB): theory, strategies and procedures.

Personalized cognitive-behavioural therapy for obesity (CBT-OB) is a new treatment that combines the traditional procedures of standard behavioural therapy for obesity (i.e., self-monitoring, goal setting, stimulus control, contingency management, behavioural substitution, skills for increasing social support, problem solving and relapse prevention) with a battery of specific cognitive strategies and procedures. These enable the treatment to be individualized, and to help patients to address the cognitive processes that previous research has found to be associated with treatment discontinuation, the amount of weight lost and long-term weight-loss maintenance. The treatment programme can be delivered at three levels of care, outpatient, day hospital and residential, and includes six modules, which are introduced according to the individual patient's needs as part of a flexible, personalized approach. The primary goals of CBT-OB are to help patients to (i) achieve, accept and maintain healthy weight loss; (ii) adopt a lifestyle conducive to weight control; and (iii) develop a stable "weight-control mindset". A randomized controlled trial has found that 88 patients suffering from morbid obesity treated with CBT-OB followed a period of residential treatment achieved a mean weight loss of 15% after 12 months, with no tendency to regain weight between 6 and 12 months. The treatment efficacy is also supported by data from a study assessing the effects of group CBT-OB delivered in a real-world clinical setting. In that study, 77 patients with morbid obesity who completed the treatment achieved 9.9% weight loss after 18 months. These promising results, if confirmed by future clinical studies, suggest that CBT-OB has the potential to be more effective than traditional weight-loss lifestyle-modification programmes.

Enhanced cognitive behavioral therapy for adolescents with anorexia nervosa: Outcomes and predictors of change in a real-world setting.

OBJECTIVE: The study aimed to establish the outcomes and predictors of change in a cohort of adolescents with anorexia nervosa treated via enhanced cognitive behavioral therapy (CBT-E) in a real-world clinical setting. METHOD: Forty-nine adolescent patients with anorexia nervosa were recruited from consecutive referrals to a clinical eating disorder service offering outpatient CBT-E. Body Mass Index centiles and Eating Disorder Examination Questionnaire, Brief Symptom Inventory, and Clinical Impairment Assessment scores were recorded at admission, at the end of treatment, and at 20-week follow-up. RESULTS: Thirty-five patients (71.4%) who finished the program showed both considerable weight gain and reduced scores for clinical impairment and eating disorder and general psychopathology. Changes remained stable at 20 weeks. No baseline predictors of drop-out or treatment outcomes were detected. CONCLUSIONS: Based on these results, CBT-E seems suitable for adolescent patients with anorexia nervosa seeking treatment in a real-world clinical setting.

Validity and reliability of the Eating Problem Checklist.

The aim of this study was to validate the latest version of the Eating Problem Checklist (EPCL), a tool designed to assess eating-disorder behaviours and psychopathology in patients with eating disorders, session-by-session. The EPCL was completed at baseline by participants with eating disorders (n = 161) and a healthy control group (n = 379) and then administered session-by-session in a subgroup of 75 participants with eating disorders. The EPCL demonstrated good internal consistency, test-retest reliability, and concurrent and criterion validity, and principal axis analysis of the session-by-session data identified two factors ('eating concerns' and 'body image concerns') that accounted for 51.3% of the variance. Furthermore, session-by-session analysis indicated that the EPCL is able to identify specific weekly improvements and/or deterioration in eating-disorder psychopathology. These findings suggest that the EPCL is a valid and reliable self-report questionnaire that provides relevant clinical information regarding weekly changes in eating-disorder behaviours and psychopathology in patients with eating disorders.

DSM-5 severity specifiers for anorexia nervosa and treatment outcomes in adult females.

OBJECTIVE: The aim of this study was to evaluate treatment outcomes across the BMI (body mass index)-based DSM-5 severity specifiers in a sample of adult females with anorexia nervosa (AN) treated with enhanced cognitive behavioural therapy (CBT-E). METHOD: One hundred and twenty-eight participants with AN (64 outpatients and 64 inpatients) were sub-categorised using DSM-5 severity specifiers and compared by baseline clinical characteristics and treatment outcomes at the end of treatment and at 6- and 12-month follow-ups. RESULTS: No significant differences were found across the four severity groups for 'weight recovery' (i.e., BMI ≥ 18.5 kg/m2) or 'good outcome' (i.e., BMI ≥ 18.5 kg/m2 and minimal accompanying eating disorder psychopathology). DISCUSSION: Our data suggest that the DSM-5 severity specifiers for anorexia nervosa may have limited clinical utility in predicting treatment outcomes of CBT-E.

The clinical impairment assessment questionnaire: validation in Italian patients with eating disorders.

BACKGROUND: The Clinical Impairment Assessment (CIA) is a measure of functional impairment secondary to eating disorder symptoms. AIM: The aim of this study was to examine the psychometric proprieties of the Italian-language version of the CIA. METHODS: The tool was translated into Italian and administered to 259 Italian-speaking in- and outpatients with eating disorders and 102 healthy controls. The clinical group also completed the Eating Disorder Examination Questionnaire (EDE-Q) and the Brief Symptom Inventory (BSI). RESULTS: Confirmatory factor analysis revealed a good fit for the original three-factor structure. Internal consistency was high for both the global CIA and all subscale scores, and test-retest reliability was acceptable. The high correlation between CIA and EDE-Q and BSI confirmed the convergent validity of the instrument. T test indicated higher raw scores on CIA in patients with eating disorders than healthy controls, and a cut-off score of 16 on the CIA discriminated between eating disorder and general psychopathology scores. Finally, global CIA and subscale scores were significantly higher in patients who reported objective bulimic episodes, purging behaviours, and excessive exercising than in those who did not; in underweight than in not-underweight patients, and in inpatients than outpatients, confirming the good known-groups validity of the tool. CONCLUSIONS: Overall, the study showed the good psychometric properties of the Italian version of the CIA, and validated its use in Italian-speaking eating disorder patients. LEVEL OF EVIDENCE: Level V, Descriptive study.

The Starvation Symptom Inventory: Development and Psychometric Properties.

Background: Starvation symptoms are common in patients with anorexia nervosa, and according to the transdiagnostic cognitive behavioural theory for eating disorders, they contribute to maintaining the eating disorder psychopathology. The aim of this study was therefore to describe the design and validation of the Starvation Symptoms Inventory (SSI); a self-report questionnaire that examines the symptoms of starvation in underweight patients with eating disorders. Methods: 150 female patients with anorexia nervosa were recruited, as well as 341 healthy control subjects, 30 not-underweight patients with an eating disorder, and 15 patients with bipolar depressive episodes. The 150 patients completed the Eating Disorder Examination Questionnaire and the Brief Symptom Inventory. All participants rated their starvation symptoms on a continuous Likert-type scale (0-6), and reported the number of days in which they had experienced them in the previous 28 days. Results: Principal component analysis identified a single-factor, 15-item scale, which demonstrated good internal consistency (α = 0.91) and test-retest reliability (r = 0.90). The SSI global score was significantly correlated with eating disorder and general psychopathology, demonstrating good convergent validity. SSI scores were significantly higher in the anorexia nervosa sample than in the healthy control, not-underweight eating disorder and bipolar depressive episode samples. Conclusions: These findings suggest that the SSI is a valid self-report questionnaire that may provide important clinical information regarding symptoms of starvation in patients with anorexia nervosa.

Personalized multistep cognitive behavioral therapy for obesity.

Multistep cognitive behavioral therapy for obesity (CBT-OB) is a treatment that may be delivered at three levels of care (outpatient, day hospital, and residential). In a stepped-care approach, CBT-OB associates the traditional procedures of weight-loss lifestyle modification, ie, physical activity and dietary recommendations, with specific cognitive behavioral strategies that have been indicated by recent research to influence weight loss and maintenance by addressing specific cognitive processes. The treatment program as a whole is delivered in six modules. These are introduced according to the individual patient's needs in a flexible and personalized fashion. A recent randomized controlled trial has found that 88 patients suffering from morbid obesity treated with multistep residential CBT-OB achieved a mean weight loss of 15% after 12 months, with no tendency to regain weight between months 6 and 12. The treatment has also shown promising long-term results in the management of obesity associated with binge-eating disorder. If these encouraging findings are confirmed by the two ongoing outpatient studies (one delivered individually and one in a group setting), this will provide evidence-based support for the potential of multistep CBT-OB to provide a more effective alternative to standard weight-loss lifestyle-modification programs.

The Eating Disorder Examination Questionnaire: reliability and validity of the Italian version.

PURPOSE: To examine the validity and reliability of a new Italian language version of the latest edition of the Eating Disorder Examination Questionnaire (EDE-Q 6.0). METHODS: The sixth edition of the EDE-Q was translated into Italian and administered to 264 Italian-speaking inpatient and outpatient (257 females in their mid-20s) with eating disorder (75.4% anorexia nervosa) and 216 controls (205 females). RESULTS: Internal consistency was high for both the global EDE-Q and all subscale scores. Test-retest reliability was good to excellent (0.66-0.83) for global and subscale scores, and for items assessing key behavioral features of eating disorders (0.55-0.91). Patients with an eating disorder displayed significantly higher EDE-Q scores than controls, demonstrating the good criterion validity of the tool. Confirmatory factor analysis revealed a good fit for a modified seven-item three-factor structure. CONCLUSIONS: The study showed the good psychometric properties of the new Italian version of the EDE-Q 6.0, and validated its use in Italian eating disorder patients, particularly in young females with anorexia nervosa.

Cognitive Behavioral Therapy for Anorexia Nervosa: An Update.

Cognitive behavioral therapy (CBT) for anorexia nervosa (AN), based on Beck's cognitive theory, was developed in a "generic" form in the early eighties. In recent years, however, improved knowledge of the mechanisms involved in maintaining eating disorder psychopathology has led to the development of a "specific" form of CBT, termed CBT-E (E = enhanced), designed to treat all forms of eating disorders, including AN, from outpatient to inpatient settings. Although more studies are required to assess the relative effectiveness of CBT-E with respect to other available treatments, the data indicate that in outpatient settings it is both viable and promising for adults and adolescents with AN. Encouraging results are also emerging from inpatient CBT-E, particularly in adolescents, and clinical services offering CBT-E at different levels of care are now offered in several countries around the world. However, CBT-E requires dissemination in order to become widely available to patients.

Transdiagnostic cognitive behaviour therapy for adolescents with an eating disorder who are not underweight.

Little is known about the treatment of adolescents with an eating disorder who are not underweight. Enhanced cognitive behaviour therapy (CBT-E) is a potential option as it is a treatment for adult patients with eating disorders of this type and it has been shown to be effective with adolescent patients who are underweight. The aim of the present cohort study was to evaluate the effects of CBT-E on non-underweight adolescents with an eating disorder. Sixty-eight adolescent patients with an eating disorder and a body mass index (BMI) centile corresponding to an adult BMI ≥ 18.5 were recruited from consecutive referrals to a community-based eating disorder clinic. Each was offered 20 sessions of CBT-E over 20 weeks. Three-quarters completed the full 20 sessions. There was a marked treatment response with two-thirds (67.6%, intent-to-treat) having minimal residual eating disorder psychopathology by the end of treatment. CBT-E therefore appears to be a promising treatment for those adolescents with an eating disorder who are not underweight.

Time to restore body weight in adults and adolescents receiving cognitive behaviour therapy for anorexia nervosa.

BACKGROUND: The aim of the present study was to provide benchmark data on the duration of treatment required to restore body weight (to BMI ≥18.5 or a corresponding BMI centile) in adolescents and adults with anorexia nervosa treated with outpatient cognitive behaviour therapy. METHODS: Ninety-five participants (46 adolescents and 49 adults) were recruited from consecutive referrals to a specialist eating disorder clinic. Each was offered 40 sessions of enhanced cognitive behaviour therapy (CBT-E) over 40 weeks, the conventional length of this treatment. RESULTS: Twenty-nine (63.1%) of the adolescents and 32 (65.3%) of the adults completed all 40 sessions of treatment (P = 0.818). Significantly more adolescents reached the goal BMI than adults (65.3% vs. 36.5%; P = 0.003). The mean time required by the adolescents to restore body weight was about 15 weeks less than that for the adults (14.8 (SE = 1.7) weeks vs. 28.3 (SE = 2.0) weeks, log-rank = 21.5, P < 0.001). CONCLUSIONS: The findings indicate that adolescent patients receiving CBT-E are able to regain weight more successfully than adults and at a faster rate. If these findings are replicated and extend to eating disorder psychopathology, then their treatment could be shorter than that of adults.