Enhanced Cognitive Behavioral Therapy for Treating Eating Disorders

Introduction

Background and Rationale

Eating disorders are some of the most prevalent mental disorders that are faced by population of different age groups. The can have considerably significant impact on the quality of life of an individual (Jenkins et al., 2011). Besides, it has presented as a major burden to the global disease both economically and socially (Erskine et al., 2016 and Mitchison et al., 2012). The most common forms of eating disorders are binge eating and bulimia disorder while anorexia nervosa is relatively rare. In previous studies, there have been reports indicating that the disease is more prevalent among the women in Asia, Europe, and Africa besides Latin America (Keski-Rahkonen and Mustelin, 2016). Studies have also shown that eating disorders are common in older people relative to the younger populations. DSM-IV is the most common diagnosis that is used for eating disorders not only in the clinical but also in the community settings (Nakai et al., 2013).

Based on previous international studies, Cognitive Behavioral Therapy (CBT) has been reported as the most commonly used treatment for the kinds of eating disorders such as bulimia nervosa and binge eating disorder. There is a specific form of CBT that is formulated for suiting the full range of eating disorder diagnoses knowns as enhance cognitive behavioral therapy (CBT-E). This therapeutic intervention is based on transdiagnostic theory of maintaining eating disorders thus assumes a common relation of mechanisms that underlie most if not all of the different kinds of eating disorders. This kind of intervention makes use of strategies as well as procedures that tackle the over-evaluation of not only weight but also shape through a focus on the mechanism that underlie the diseases. Research studies have also reported a considerable advantage possessed by CBT-E over the other protocols of the same intervention due to its transdiagnostic nature. Various studies have investigated the use of CBT in managing eating disorders but its effectiveness is yet to be established in comparison to other protocols such as CBT-E as well as other therapeutic approaches such as Family-Based Therapy (FBT) amongst other therapies.

Consequently, this systematic review aims to present the most recent studies inclusive of randomized controlled trials and open trials on the effectiveness of CBT-E on various forms of eating disorders. Besides, the study describes the features of studies that have been included besides presenting the probable explanations to identified variabilities in aspects of the studies such as the outcomes. The paper also offers recommendations for future research on the same issue

Objectives

The objectives of the study included:

To examine the effectiveness of CBT-E in treating eating disorders

To identify the effectiveness of CBT-E for different types of eating disorders

To present the most current evidence on the effectiveness of CBT-E in treating eating disorders

Methodology

Search strategy

Since this was a systematic review, the study involved literature search from five databases that were inclusive of Medline, PsycINFO, EMBASE, CINAHL, as well as the Cochrane databases. Keywords were used and combined using the ‘AND’ Boolean operator. They were then searched in the five databases. The keywords that were used were inclusive of anorexia nervosa* AND CBT-E*, cognitive behavior therapy* AND random* trial* RCT, controlled, open trial*, bulimia disorder* AND*, binge eating disorder*. Also, searchers were also undertaken to find data from trials that were unpublished. With the key words used to search the databases, extra searchers were undertaken in PsycEXTRA, ProQuest Central as well as from PsycINFO.

Study selection criteria and procedures

After the literature search, studies that were duplicates of one another were removed after the combination of the outputs of the search strategy. Also, the titles as well as the abstracts were screened in the quest for the identification of studies that administered CBT-E to patients suffering from anorexia nervosa. The selection involved reading the full-texts of these articles for the determination of whether they met the full inclusion criteria. The studies that met the inclusion criteria were screened for the determination of whether they were eligible for the systematic review. From the literature search, 13 studies met the inclusion criteria and seven studies were included in the systematic review.

Study quality assessment checklist and procedures

An assessment was carried to ascertain the validity of the trials. This was done using the Cochrane Risk of Bias tool. This tool enabled the assessment of the potential sources of biases in the randomized controlled trials. This included the adequate generation of allocation sequence as well as the concealment of the allocation to treatment conditions. Others were issues like blinding of outcome assessors and dealing with data that was incomplete. This was done at low risk when there was conduction of ITT analyses. Other criteria of the Cochrane Collaboration tool were not applied since there were no signs of selective outcome as well as other potential contributors to biases and this was noted to be consistent with the previous systematic reviews that had been conducted on the topic. Quality assessment was thus conducted and crosschecked to discuss any disagreements that resulted.

Results and Data Synthesis

Design

Out of the seven studies that were identified from the literature search, five of them were RCTs while the remaining two were open trials. Of the two open trials, one aimed to find evidence on CBT-E being a generalizable treatment that was undertaken in a noncontrolled clinical context.

Recruitment and Population

The studies were all undertaken in an outpatient setting. Three studies were inclusive of participants that sought help after referral. The remaining four recruited participants by channelling information in local papers and other social media platforms. Four of the studies also included transdiagnostic sample while two had bulimia nervosa participants. Of the transdiagnostic samples, two had patients of anorexia nervosa. One study involved assessment of the condition through treatment of therapists based on DSM-IV criteria while one lacked information on the diagnosis of eating disorders (Fairburn et al., 2015). In most of the studies, adults formed the major part of the participants while one had underweight adolescents. The number of participants in the studies was significantly different.

Randomized controlled trials

Three of the five RCTs had significant differences between the groups that supported the effectiveness of CBT-E. One of the studies by Wade et al. (2017) found that CBT-E is more effective when applied to reduce eating disorders for eight weeks relative to no treatment. In a different study that was identified and was undertaken by Fairburn et al. (2015), the psychopathology levels of anorexia nervosa are decreased. In this study, it involved both CBT-EE as well as IPT participants and the researchers noted that the effects were more significant for CBT-E relative to IPT participants (Fairburn et al., 2015). Also, CBT-E patients in remission were more than the IPT patients. In the third study by Poulsen et al, the researchers noted a large variation in the treatment variation since CBT-E took five months while IPT took 24 months (2014). Also, the study made a comparison between the participants that were suffering from binge disorder and those that had purging and significant differences were noted (Fairburn et al., 2015). For instance, out of the patients that were under CBT-E, 42% ceased binge eating and purging while for those under IPT, 15% ceased the symptoms 24 months after treatment. However, both treatments reported significant improvements on the patients . (Fairburn et al., 2015).

In the other two of the five RCTs, there were no significant differences before and after treatment with CBT-E. For instance, Thomson-Brenner et al. in their study made a comparison of the two versions of CBT-E that were the focused and the broad version. No significant difference was noted as much as the primary outcome was concerned. Besides, they had no significant difference in the remission rates of the sample that was 42% of the participants. Besides, in the last RCTs that was undertaken by Wonderlich et al. (2014), the researchers compared CBT-E and ICAT and did not note much difference in the treatment outcome between the different groups of participants that were recruited in the study.

Open Trials

The two open trials from the systematic review had no considerable decrease in the scores of eating disorders. One of the studies was by Dalle Grave et al. and the researchers made reports of a re mission rate that was 67.6% (2015). The criterion for remission was however met by a substantial percentage of the participants. In the second study, Signorini et al. (2018) made use of two distinct definitions pf remission. From the study, the researchers made reports of a 42.2% and 35.4% remissions rates respectively (Signorini et al., 2018).

Follow-up activities

Five of the seven studies that were reviewed include follow up activities that had varied period of time range of 3-6 months for the smallest to the largest period. In most of the studies, there was maintenance of posttreatment results during the follow-up. However, there was a difference where by during a follow-up for the study carried out by Wade et al. (2017), there was decrease in the percentage of good outcome from 66.7% to 46.2%. In addition, another exception was noted in the study by Fairburn et al. (2015), in which the percentage of the participants that met the remission criteria during the follow-up activity. The researchers however noted an increase for the ITP from 33.3 to 49.0% while a higher rate was noted for CBT-E at 69.4% (Fairburn et al., 2015).

The Clinical Trial Assessment Measure

In this systematic review, CTAM has been used in assessing the quality of the methodologies of the RCTs that were identified. Out of the five RCTs that have been reviewed, three of them had a similar CTAM score that was 89. This was a sign that they had a good methodological quality. On the other, one of the RCTs made a description of the process of assessor binding. No study verified the binding of assessors when the study was completed. Thompson-Brenner et al. (2016) undertook a study that had a relatively smaller sample size. Besides the researchers lacked a measure for the quality of treatment thus there was a lower CTAM score of 7. This was relatively lower relative to the other four RCTs (Thompson-Brenner et al., 2016). Also, the study by Wade et al. (2017), had a lower score since it also had a smaller sample size and lacked an independent randomization like the other studies. Besides, the trial lacked a description of the randomization besides lacking an active control condition and treatment quality assessment (Wade et al., 2017).

Discussion

A consistency in the findings of this systematic review to previous studies is thus a demonstration of the effectiveness of CBT-E in the treatment of eating disorders. For almost a decade, various randomized controlled trials have directly compared CBT-E and other active treatment option for eating disorders. These are inclusive of the interpersonal psychotherapy (IPT), integrative cognitive-effective therapy (ICAT), and psychoanalytic psychotherapy (Wonderlich et al., 2014). IPT has been established to also be effective in the treatment of various eating disorders. In first, in the first comparison that was made between the two, CBT-E was showed to be superior and thus more effective in the management of eating disorders. A different comparison has been made in a sample that consisted of bulimia nervosa and CBT-E was noted to be superior to psychoanalytic psychotherapy. One study has however, indicated that CBT-E and ICAT have comparable effectiveness in the management of eating disorders (Wonderlich et al., 2014).

Based on this systematic review and the reviews undertaken in the past, CBT-E seems to be ultimately acceptable in groups when compared to individual CBT-E. In the review, Dalle Grave et al. (2015) made reports that indicated a possibility of CBT-E being a potential treatment approach for adolescents that are not underweight suffering from eating disorders. In adolescents, studies have reported that family-based therapy is usually more effective thus, the most preferable approach to the management of eating disorders in adolescents. CBT-E can still be a considerable alternative for managing eating disorders in adolescents (Dalle Grave et al., 2015). This is so since FBT is not effective in a sufficient way and in some cases, it is never available. The study by Signorini et al. (2018) indicated that CBT-E is a generalizable to a noncontrolled clinical context but a high attrition rate has also been reported. This has been tied to an increased percentage pf participants that were suffering from anorexia nervosa in the sample included in the study by researchers (Signorini et al., 2018).

This review has established significant dissimilarities in the remission rates of posttreatment that ranged between 22.2% to 67.6% (Signorini et al., 2018). Also, various factors need to be given consideration while trying to interpret and make an understanding out of these differences. There is an inevitable difficult in making comparison between the studies owing to the significant variations that exist in the samples included in each of them (Signorini et al., 2018). Besides, differences have also been noted in the definition of clinical significant change as well as in the quality of deployed methodologies that all make comparison of the studies a great challenge. In the study by Dalle Grave et al. (2015), a heightened percentage that met the criterion for the remission had a bias with the higher posttreatment remission rate. Besides, a difference has also been noted in what is termed as the desired outcome between the two studies by Wade et al. (2017) and by Signorin et al. (2018) the two studies were all carried out in Australia but have difference in the sample mean of the community used in defining the clinical considerable change. In the study by Signorini et al. (2018), the researchers noted that they were a remission rate of 42.2% in posttreatment. For Wade et al. (2017), there was a posttreatment remission rate of 66.7%.

It is not easy to explain the differences between the studies. For instance, the significant dissimilarities in the CBT-E outcome between the study by Poulsen et al. (2014) and Wonderlich et al. (2014), that had a posttreatment abstinence rates of 42% and 22.5% respectively. Is difficult since they all have similarities considering their samples as well as their operationalization of clinical significant change. Besides, both the studies are of good quality. However, a notable difference between the two studies is that Poulsen et al. (2014) involved a close involvement in the training as well as the supervision of therapists. Another difference is on the mode of completion as the researchers termed completion to be the complete treatment while the other researchers termed it as the study participants taking part in at least 16 therapy sessions (Poulsen et al., 2014), (Wonderlich et al., 2014 ).

This systematic review assess the methodological qualities of reviewed studies besides providing extra and large evidence on the effectiveness of CBT-E in treatment patients that suffer from eating disorders. Studies that focused only on anorexia nervosa patients alone have been excluded despite the fact that they show positive results as much as the effectiveness of CBT-E is concerned. Also, CBT-E has been noted to be a promising intervention in the treatment of anorexia nervosa though some level of inconsistency has been noted in such results. In one of the open trials that were reviewed, there was a preliminary report for the use of CBT-E for anorexia nervosa (Wade et al., 2017). Another implementation study of CBT-E for a sample of anorexia nervosa patients noted that half of the participants failed to get to completion while a substantial increase was noted in the remaining half of the sample size. Dalle Grave et al. (2015) carried out one of the open studies and the researchers noted that CBT-E has been accepted sufficiently and is thus not only a variable but also a promising intervention for treating anorexia nervosa even in severe cases. Treatment with CBT-E has been noted to be more effective for other eating disorders when compared with the treatment for anorexia nervosa. There is need to interpret these findings for a larger context of treatment of anorexia nervosa with general poor posttreatment results.

Recommendations

In future research, a trial that would directly make a comparison between different CBT-E protocols would be helpful in realising the dissimilar effects that the therapy has. Besides, studies on how the therapy works would also be of great help in strengthening its theoretical foundation. Based on the results of this systematic review, it can be recommended that future research consider how different studies compare as much as the topic of study is concerned. There should also be an agreement on the kind of variable that is useful in the establishment of the clinical significant change as well as the level of competence needed by a CBT-E therapist as well as the tool that can be applied in the measurement of the integrity of treatment.

Limitations

There are a number of limitations that this study has presented with. First, a single researcher has been involved in the literature search as well as in the identification of the studies that have been reviewed; this is an implication of a possible miss or a possibility that the features of the studies or the results might have been misinterpreted. Another limitation of the study is associated with practical reasons in that only studies published in English were given consideration. There was a limitation of the literature search to five databases.

Conclusion

A great size of evidence is in existence to prove the effectiveness of CBT-E in treating eating disorders. In future research, their might be a revelation of theoretical foundations as well as specificity of CBT-E if they examining not only the mechanism but also the differential effects of CBT-E with other protocols of the therapy for eating disorders. This study is ultimately important in understanding the effectiveness of CBT-E in the treatment of eating disorders among adults as well as for adolescents.

References

Dalle Grave, R., Calugi, S., Sartirana, M. and Fairburn, C.G., 2015. Transdiagnostic cognitive behaviour therapy for adolescents with an eating disorder who are not underweight. Behaviour Research and Therapy, 73, pp.79-82.

Erskine, H.E., Whiteford, H.A. and Pike, K.M., 2016. The global burden of eating disorders. Current opinion in psychiatry, 29(6), pp.346-353.

Fairburn, C.G., Bailey-Straebler, S., Basden, S., Doll, H.A., Jones, R., Murphy, R., O'Connor, M.E. and Cooper, Z., 2015. A transdiagnostic comparison of enhanced cognitive behaviour therapy (CBT-E) and interpersonal psychotherapy in the treatment of eating disorders. Behaviour research and therapy, 70, pp.64-71

Jenkins, P.E., Hoste, R.R., Meyer, C. and Blissett, J.M., 2011. Eating disorders and quality of life: A review of the literature. Clinical psychology review, 31(1), pp.113-121.

Keski-Rahkonen, A. and Mustelin, L., 2016. Epidemiology of eating disorders in Europe: prevalence, incidence, comorbidity, course, consequences, and risk factors. Current opinion in psychiatry, 29(6), pp.340-345.

Mitchison, D., Hay, P., Slewa-Younan, S. and Mond, J., 2012. Time trends in population prevalence of eating disorder behaviors and their relationship to quality of life. PloS one, 7(11), p.e48450.

Nakai, Y., Fukushima, M., Taniguchi, A., Nin, K. and Teramukai, S., 2013. Comparison of DSM‐IV versus proposed DSM‐5 diagnostic criteria for eating disorders in a Japanese sample. European Eating Disorders Review, 21(1), pp.8-14.

Poulsen, S., Lunn, S., Daniel, S.I., Folke, S., Mathiesen, B.B., Katznelson, H. and Fairburn, C.G., 2014. A randomized controlled trial of psychoanalytic psychotherapy or cognitive-behavioral therapy for bulimia nervosa. American Journal of Psychiatry, 171(1), pp.109-116.

Signorini, R., Sheffield, J., Rhodes, N., Fleming, C. and Ward, W., 2018. The effectiveness of enhanced cognitive behavioural therapy (CBT-E): a naturalistic study within an out-patient eating disorder service. Behavioural and Cognitive Psychotherapy, 46(1), pp.21-34.

Thompson‐Brenner, H., Shingleton, R.M., Thompson, D.R., Satir, D.A., Richards, L.K., Pratt, E.M. and Barlow, D.H., 2016. Focused vs. Broad enhanced cognitive behavioral therapy for bulimia nervosa with comorbid borderline personality: A randomized controlled trial. International Journal of Eating Disorders, 49(1), pp.36-49.

Wade, S., Byrne, S. and Allen, K., 2017. Enhanced cognitive behavioral therapy for eating disorders adapted for a group setting. International Journal of Eating Disorders, 50(8), pp.863-872.

Wonderlich, S.A., Peterson, C.B., Crosby, R.D., Smith, T.L., Klein, M.H., Mitchell, J.E. and Crow, S.J., 2014. A randomized controlled comparison of integrative cognitive-affective therapy (ICAT) and enhanced cognitive-behavioral therapy (CBT-E) for bulimia nervosa. Psychological medicine, 44(3), pp.543-553. (Wonderlich et al., 2014)

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