Psychotherapy for transdiagnostic binge eating: A randomized controlled trial of cognitive-behavioural therapy, appetite-focused cognitive-behavioural therapy, and schema therapy
Introduction
Cognitive-behavioural therapy (CBT) is the treatment of choice for adults with binge eating, including both bulimia nervosa (BN) and binge eating disorder (BED), yet many individuals do not recover with CBT (Smink et al., 2013), or relapse following successful treatment, and novel and more effective treatments have been called for (Hay, 2013). Continued research is needed to examine ways to augment and improve upon CBT. This could be achieved by increasing the therapeutic focus on specific domains of psychopathology in individuals with BN and BED, by addressing domains of therapy that are not currently addressed, or by importing elements of treatments that have demonstrated efficacy for other related disorders (for example, schema therapy for mood disorders (Carter et al., 2013). It has been suggested that additive designs, in which an additional element or focus is added to an existing evidence-based treatment to test whether outcome is improved, maximize the amount of basic knowledge and specific conclusions generated from randomized controlled trials (RCTs) (Borkovec and Sibrava, 2005). Study designs comparing an existing effective treatment with augmented or novel elements can yield useful conclusions either if outcomes improve relative to the original treatment or if alternative versions of treatments perform comparably, giving additional treatment options to clinicians and patients.
Two promising directions for the augmentation of CBT, one targeting appetite, and the other targeting underlying schema, were used in the current study. Appetite-focused CBT (CBT-A), developed for the present study, was based on an etiological model in which diminished hunger recognition and insensitivity to satiety cues are instrumental in initiating and perpetuating binge eating (Hetherington and Rolls, 1989). Neuroendocrine and metabolic systems involved in the regulation of appetite, satiety, and weight can be disturbed in individuals who binge (Jimerson et al., 2000, Tanaka et al., 2003, Yanovski, 1995). Appetite-focused CBT emphasises how disregarding appetite is important in the development and maintenance of disordered eating, and focuses on recognising and responding to hunger and satiety in eliminating binge eating. Evidence exists that focusing on appetite in treatment can be efficacious in reducing binge eating, and that patients may prefer monitoring appetite over traditional monitoring of food and fluid intake (Dicker and Craighead, 2004). Appetite-focused CBT has not been the subject of clinical trials, although a small trial of appetite-focused dialectical behaviour therapy has shown some promise for bulimia nervosa (Hill et al., 2011).
Schema therapy was adapted for eating disorders based on the observed link between early life experiences and the development and maintenance of eating problems (Waller et al., 2007). The association between childhood experiences and psychological disorders, including eating disorders (Steiger et al., 2010), has been shown to be mediated by the development of maladaptive schemas (Wright et al., 2009). It has been suggested that improved treatment efficacy may be obtained with models that better incorporate past experiences in the etiology of these disorders (Waller et al., 2007). Schema therapy is efficacious in treating psychological disturbances, including borderline personality disorder (Farrell et al., 2009, Giesen-Bloo et al., 2006), depression (Carter et al., 2013), substance abuse (Ball, 1998), agoraphobia (Bamber, 2004), and posttraumatic stress disorder (Young, 2005). There is evidence of an association between schemas and eating disorder behaviours (Waller, 2003); and clinical improvement has been reported in single case studies using video therapy schema therapy (Simpson and Slowey, 2011) and imagery rescripting (Ohanian, 2002) for eating disorders, and in a case series of group schema modes therapy (Simpson et al., 2010). Therapy aims first to increase awareness of maladaptive schemas or schema modes and the early experiences from which they developed, and then to treat the maladaptive schemas, thereby reducing the current drive for eating disordered behaviours.
The present study reports a randomized controlled trial of traditional CBT for transdiagnostic DSM-IV binge eating, and two versions of CBT, one that augments the appetite-focus, CBT-A, and one that augments the cognitive component, schema therapy. It was hypothesized that schema therapy and appetite-focused CBT would result in better eating disorder and general outcome, as measured by the frequency of binge eating and purging, the severity of eating disorder attitudes, and overall functioning, as measured by the Global Assessment of Functioning, Axis V of DSM-IV.
Section snippets
Participants
Participants were recruited by referrals from general practitioners or other health professionals and by advertisements. Inclusion criteria were female gender, age 16–65, and a primary DSM-IV binge eating diagnosis, with objective binge episodes, the consumption of an abnormally large quantity of food within a discrete time period, the subjective experience of dyscontrol, and not currently underweight. Exclusion criteria were other conditions requiring treatment – severe major depression or
Results
Fig. 1 shows the flow of participants through the study. Three hundred and forty-seven participants were screened for the study, 112 women with transdiagnostic binge eating were randomized to therapy, 38 to CBT, 38 to schema therapy, and 36 to CBT-A.
Table 1 shows the pre-treatment demographic and psychiatric comorbidity data for the total sample, and for the three treatment groups. Mean age of participants was 35.3 years, with a body mass index (kg/m2) of 29.9. Mean duration of the eating
Discussion
The current study found the augmented focus on appetite and on schemas within a cognitive behavioural approach to binge eating did not result in improved outcomes compared with CBT at the end of treatment or at 12 month follow-up. At the end of treatment 49% of the total sample was abstinent from binge eating, and 47% of the sample was abstinent from binge eating and purging and met no eating disorder diagnoses in the past month. Overall, 60% scored within one standard deviation of the
Conflict of interest
Authors have no conflict of interest to declare.
Financial support
This work was supported by a programme Grant from the Health Research Council of New Zealand, Grant number HRC04/282B.
Role of funding source
Funding sources had no further role in study design, analysis and interpretation of the data, writing, or decision to submit the manuscript for publication. Authors are responsible for statements and assertions, which do not constitute the views of the funding sources.
Ethical standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.
Acknowledgements
Parts of this paper were presented at the International Conference for Eating Disorders in Montreal, 2–4 May 2013. The trial was registered with the Australian New Zealand Clinical Trial Registry, #12605000721606. We thank Sarah Rowe, Andrea Bartram, Kathryn Taylor, Bridget Kimber, Robyn Abbott and Barbara Malthus.
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