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The effectiveness of enhanced cognitive behavioural therapyfor eating disorders: An open trial

Susan M. Byrne a , b , * , Anthea Fursland b , Karina L. Allen a , b , Hunna Watson ba University of Western Australia School of Psychology, 35 Stirling Highway Crawley, 6009 Perth, Western Australia, Australiab 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 2010Received in revised form20 December 2010Accepted 11 January 2011

Keywords:Eating disordersAnorexia nervosaBulimia nervosaEating disorders not otherwise speci edCognitive behaviour therapyEffectiveness

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 thecommunity. The only previously published trial of CBT-E for eating disorders was a randomisedcontrolled trial (RCT) conducted in the U.K. for patients with a BMI 17.5. The current study representsthe rst published trial of CBT-E to include patients with a BMI < 17.5. The study involved 125 patientsreferred to a public outpatient clinic in Perth, Western Australia. Patients attended, on average, 20 e 40individual sessions with a clinical psychologist. Of those who entered the trial, 53% completed treatment.Longer waiting time for treatment was signi cantly associated with drop out. By the end of treatment fullremission (cessation of all key eating disorder behaviours, BMI 18.5 kg/m 2, not meeting DSM-IV criteriafor an eating disorder) or partial remission (meeting at least 2 these criteria) was achieved by two thirdsof the patients who completed treatment and 40% of the total sample. The results compared favourablyto those reported in the previous RCT of CBT-E, with one exception being the higher drop-out rate in thecurrent study. Overall, the ndings indicated that CBT-E results in signi cant improvements, in botheating and more general psychopathology, in patients with all eating disorders attending an outpatientclinic.

2011 Elsevier Ltd. All rights reserved.

Introduction

While randomised controlled trials (RCTs) of treatments foreating 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 theresults of these RCTs are generalisable to treatment conducted inroutine clinical settings,by therapists with various levels of trainingand expertise (e.g., Couturier, Iserlin, & Lock, 2010; Loeb et al., 2007;Ricca et al., 2010; Tuschen-Caf er, Pook, & Frank, 2001 ). This lack of effectiveness research may be a contributing factor to the inade-quate dissemination of evidence-based practice outside of researchsettings in the eld of eating disorders( Wilson,1995; Wilson,1996;Wilson, Grilo, & Vitousek, 2007 ). The present study aimed to add to

the small number of effectiveness studies in the eating disorderseld by evaluating the generalisability of the newly-devised

Enhanced Cognitive Behavioural Treatment (CBT-E) for eatingdisorders 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., AnorexiaNervosa [AN], Bulimia Nervosa [BN] and Eating Disorder NotOtherwise Speci ed [EDNOS]). CBT-E stems from the trans-diagnostic theory of the processes that maintain all forms of eatingdisorder ( Fairburn et al., 2003 ). This theory is based on the obser-vation that AN, BN and EDNOS share many distinctive clinicalfeatures ( Favaro, Ferrara, & Santonastaso, 2003; Turner & Bryant-Waugh, 2004 ) including the same core psychopathology char-acterisedby a pronounced tendency to evaluate self-worth in termsof controlling eating, shape or weight ( Fairburn et al., 2003 ). Thetransdiagnostic model extends the existing, empirically supportedcognitive model of BN ( Fairburn et al., 1993 ). It encompasses keymaintaining processes such as a dysfunctional scheme for self-evaluation, strict dieting, low weight and the associated starvationsyndrome , binge eating and compensatory behaviours, and alsoincludes four additional maintaining mechanisms e clinicalperfectionism, core low self-esteem, dif culty coping with intensemood states, and interpersonal dif culties e which are external to

* Corresponding author. University of Western Australia School of Psychology, 35Stirling Highway Crawley, 6009 Perth, Western Australia, Australia. Tel.: 61 86488 3579; fax: 61 8 6488 2655.

E-mail address: [email protected] (S.M. Byrne).

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Behaviour Research and Therapy

j o u rn a l h o mep ag e : www.e l sev i e r. co m/ l o ca t e / b r a t

0005-7967/$ e see front matter 2011 Elsevier Ltd. All rights reserved.

doi: 10.1016/j.brat.2011.01.006

Behaviour Research and Therapy 49 (2011) 219 e 226
mailto:[email protected]://www.sciencedirect.com/science/journal/00057967http://www.elsevier.com/locate/brathttp://dx.doi.org/10.1016/j.brat.2011.01.006http://dx.doi.org/10.1016/j.brat.2011.01.006http://dx.doi.org/10.1016/j.brat.2011.01.006http://dx.doi.org/10.1016/j.brat.2011.01.006http://dx.doi.org/10.1016/j.brat.2011.01.006http://dx.doi.org/10.1016/j.brat.2011.01.006http://www.elsevier.com/locate/brathttp://www.sciencedirect.com/science/journal/00057967mailto:[email protected]

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the eating disorder psychopathology but, in certain cases, serve tomaintain this psychopathology and prevent change. CBT-E isdesigned as an individualised and modular form of treatment, inwhich speci c modules may be directed at the particular main-taining mechanisms operating in the individual patient s case.

There is only one published RCT of CBT-E for eating disorders(Fairburn et al., 2009 ). This trial recruited from 2 sites in the U.K.(Oxfordshire and Leicestershire) and involved 149 patients witha BMI 17.5 (38% with a diagnosis of BN and 62% with a diagnosisof EDNOS). Patients received 20 50 min sessions, preceded by one90 min preparatory session. The results indicated that 66.4% of those who completed treatment had a good outcome in that theyhad post-treatment global Eating Disorder Examination (EDE;Fairburn & Cooper, 1993 ) scores less than 1 standard deviation (SD)above the community norm (i.e., < 1.74). There were no signi cantdifferences between BN and EDNOS patients in response to treat-ment. With regard to the BN patients, at the end of treatment 38.6%reported no episodes of binge eating or purging in the past 28 days.The overall drop-out rate was 22% (14% for BN patients and 27% forEDNOS patients), and intention-to-treat data showed that, overall,51.3% of patients had post-treatment global EDE scores below 1.74(52.7% for BN patients and 53.3% for EDNOS). The gains madeduring treatment were largely maintained at a 60 week follow-up,when 50% of the overall sample had a global EDE score below 1.74(61.4% for BN and 45.7% for EDNOS).

These data suggest that CBT-E may be more ef cacious than theoriginal CBT for BN ( Agras et al., 2000 ). However, this was a singletrial and it only involved patients with BN and EDNOS, since a bodymass index 17.5 was a speci c exclusion criteria. Given the claimthat CBT-E is also relevant to AN and the lack of research intoevidence-based treatments for this eating disorder, a study thatalso includes low-weight patients would be of value.

The aim of the present study was to investigate the effectivenessand feasibility of conducting CBT-E at a public outpatient clinic foradults with the full range of eating disorders found in thecommunity. We hypothesised that treatment with CBT-E would be

associated with signi cant post-treatment improvement in boththe speci c and associated psychopathology of eating disorders,and that the degree of improvement would be comparable to thatreported in the previous RCT of CBT-E. This study is the rsteffectiveness trial of CBT-E and, moreover, the rst published studyof CBT-E to include patients with a BMI < 17.5.

Method

Recruitment

The sample comprised individuals referred to the Centre forClinical Interventions (CCI) Eating Disorders Service, the only publicoutpatient eating disorders program for youth and adults in Perth,

Western Australia. Patients were recruited between March 2005 andFebruary 2009 from consecutive referrals fromgeneral practitioners,psychiatrists and clinical psychologists. To be considered for treat-ment, the patient hadto be 16 yearsor older, and ful l the Diagnosticand Statistical Manual,Fourth Edition (DSM-IV; American PsychiatricAssociation, 1994) criteria for AN, BN or EDNOS (except for BED,which is nottreated at thisclinic), as judgedby the assessing clinicianaccording to the EDE. The clinical protocol in this study followednormal practice in this community clinic. Thus patients were onlyexcluded from the trial if their current clinical state made it inap-propriate for them to receive outpatient treatment for an eatingdisorder (i.e., if they were acutely suicidal, psychotic, substancedependent or had a BMI < 14; N 6) or if they did not give writtenconsentto release their de-identi ed data forevaluation andresearch

purposes ( N 8). As CCI is a public clinic, there is a relatively lengthy

waiting list for treatment. The mean waiting time between referraland the start of treatment for participants in this trial was 22.24weeks (SD 14.18; Range 2.00 e 63.14 weeks). Fig. 1 shows theparticipant enrolment and ow through the study.

Treatment

Treatment was conducted on an outpatient basis and followedthe protocols outlined in the detailed CBT-E treatment guide(Fairburn et al., 2008 ). All patients attended 2 e 3 assessmentsessions followed by, on average, 20 e 40 50 min treatment sessions.The treatment content was the same for all eating disorders, but forlow-weight patients, the treatment period was longer to allow forincreasing motivation and weight regain. The treatment movedthrough four stages. The initial stage focused on engaging andeducating the patient, creating an initial personalised formulation,and obtaining maximal behaviour change. Stage 2 involveda detailed review of progress and identi cation of barriers tochange, which shaped the remainder of treatment. In Stage 3 theemphasis was on modifying the processes maintaining thepatient s eating disorder psychopathology. In this stage, the addi-tional maintaining mechanisms of perfectionism, low self-esteem,interpersonal dif culties and mood intolerance were alsoaddressed as relevant. In the nal stage, the focus turned tomaintenance of gains and relapse prevention.

The treatment guide allows some exibility and variability inthe number of sessions required to complete each treatment stageand to progress through the entire treatment. In this study, forpatients with a BMI 18.5 treatment consisted of around 20sessions, and for underweight patients treatment involved about40 sessions. Treatment completion was de ned as successfultransition through the four stages of treatment, and drop out wasde ned as non-mutual premature termination of treatment.

The patients were treated by one of a team of 4 full-time clinicalpsychologists. During the 4 years of the trial there was considerableturnover of staff, resulting in a total of 10 therapists being involvedin the study. All but one of the therapists (AF) were ClinicalPsychology Registrars (i.e., recent graduates from a Masters or PhDlevel Clinical Psychology program) with little or no experiencetreating eating disorders previously. SB and AF attended trainingworkshops in CBT-E conducted by Professor Fairburn, and the othertherapists involved in this study were trained and supervised by SBand AF. The training consisted of orientation to the treatment andfamiliarisation with the treatment guide in their rst week of employment at the clinic. The therapists attended weekly indi-vidual supervision meetings with AF and a weekly team meetingwith AF and SB to discuss cases and adherence to treatmentprotocol. Meetings included a review of select videotaped sessionsto help ensure treatment delity.

Assessment

Outcome variablesThe primary outcome variables were categorical measures of

recovery. For the purposes of this study, we de ned full remission ascomplete absence of eating disorder symptoms in the last 28 days,that is (i) cessation of all key eating disorder behaviours, e.g., bingeeating, purging and severe dietary restriction, 1 (ii) BMI 18.5 kg/m 2

(the World Health Organisation cut-off for healthy weight) and(iii) not meeting the DSM-IV criteria for an eating disorder. Partialremission wasde ned asmeeting all but one of the above criteria for

1 Cessation of severe dietary restriction was de ned as scoring 3 on all of the

rst four items of the EDE-Q (Restraint subscale).

S.M. Byrne et al. / Behaviour Research and Therapy 49 (2011) 219 e 226 220

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full remission. For example, cessation of all key eating disorderbehaviours and having a BMI > 17.5 kg/m 2 but < 18.5 kg/m 2; orhaving a BMI 18.5 kg/m 2, not meeting DSM-IV criteria for aneating disorder, but reporting 1 or 2 episodes of binge eating in thelast 28 days; or cessation of all key eating disorder behaviours andhaving BMI 18.5 kg/m 2 but still experiencing amenorrhea.Patients were classi ed as in full remission, in partial remission, ornotrecoveredby thetreating team, based on clinical judgement andpatient responses on the Eating Disorder Examination Question-naire (EDE-Q; Fairburn & Beglin, 1994 ) at the end of treatment. We

used 2 additional measures of outcome for the purpose of comparison with the previous RCT of CBT-E. The rst was havinga score on the global subscale of the EDE-Q that is less than 1standard deviation (SD) above Australian community norms (i.e.,below 2.46; Mond, Hay, Rogers, & Owen, 2006 ) and the second washaving a score on the global subscale of the EDE-Q that is lessthan 1SD above community norms in addition to a BMI 18.5 kg/m 2.

Secondary outcome variables included (i) dimensional measuresof change in the severity of eating disorder features e.g., bingeeating, compensatory behaviours, dietary restraint, eating, weightand shape concerns, (ii) measures of additional variables speci edin the transdiagnostic model (perfectionism, interpersonal func-tioning, mood intolerance, self-esteem) and (iii) measures of otherassociated psychopathology such as depression, anxiety, stress,

self-esteem and quality of life.

Measures

Diagnosis was established during pre-treatment assessmentusing the 12th edition of the EDE. The EDE was administered by thetreating clinicians who had been trained in its administration by SB.Height and weight were measured using a Harpenden stadiometerand regularly calibrated digital medical scales (Tanika BWB-800).The EDE-Q was administered both pre and post treatment.

The other secondary outcome variables were assessed both preand post treatment using the following measures: The 10-item

Rosenberg Self-Esteem Scale (RSE; Rosenberg, 1965 ); the Perfec-tionism subscale of the Eating Disorder Inventory (EDI; Garner,Olmstead, & Polivy, 1983 ); the Distress Tolerance Scale (DTS;Corstorphine, Mountford, Tomlinson, Waller, & Meyer, 2007 ); theInventory of Interpersonal Problems (IIP-32; Horowitz, Rosenberg,Baer, Urneo, & Villasenor, 1988 ) the short form of the DepressionAnxiety and Stress Scales (DASS; Lovibond & Lovibond, 1995 ); andthe short form of the Quality of Life Enjoyment and SatisfactionQuestionnaire (QLESQ-SF; Endicott, Nee, Harrison, & Blumenthal,1993 ). In addition, patients ratings of treatment credibility andthe likely effectiveness of the treatment were assessed during the

rst treatment session using the 6-item Credibility/ExpectancyQuestionnaire (CEQ; Borkovec & Nau, 1972; Devilly & Borkovec,2000 ). Three items assess credibility and 3 items assess expecta-

tions. Summary scores for the 2 subscales range from 3 to 27.

Referral from GP (153),Psychiatrist (2) or Clinical

Psychologist (10) other (11)N= 176

Assessed for eligibilityN=176Ineligible for trial

N=14 (6 not eligible fortreatment, 8 did not provideconsent for their data to bereleased)

AN34

BN40

EDNOS51

Excluded (n=37) (32declined treatment, 5 werenot appropriate for CBT-E)

12 24 30

Completed treatmentN=66 (50 dropped out, 5were withdrawn, 4 movedto another state)

Pre-treatment assessment at CCIN=162

(AN=31BN=58

EDNOS=73)

Allocated to CBT-EN=125

Fig. 1. Flow through of trial.


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Data analytic strategy

Treatment outcome data were analysed using both completerand intent-to-treat approaches. In instances in which a nalmeasure was missing, initial (pre-treatment) data were carriedforward. Pre- to post-treatment change scores were calculated.Data are presented as Ns and percentages for categorical data andmeans and standard deviations for continuous data, with 95%con dence intervals used to indicate the uncertainty around theestimates as appropriate. Continuous pre- and post-treatment datawere compared using paired t -tests (for normally distributedvariables) or Wilcoxon signed-rank tests (for non-normallydistributed variables) and categorical data were analysed withMcNemar s tests. For data assessed at one time point, categoricaldata were compared using Chi-square tests. All tests were two-tailed and p value of < 0.001 was used to indicate statisticalsigni cance. Effect sizes were calculated using Cohen s d.

Results

Patient characteristics

One hundred and seventy six patients were referred andassessed for individual treatment at CCI, between March 2005 andFebruary 2009. Almost all patients (86.5%) were referred by theirgeneral practitioner, with a small number being referred by clinicalpsychologists (6.2%), psychiatrists (1.1%), or other mental healthprofessionals (6.2%). Of these 176 patients, 125 (70%) entered thetrial. By comparison, only 42.7% of those patients assessed foreligibility entered the Fairburn et al. (2009) trial. Fairburn et al.reported that, of 360 patients assessed for eligibility, only 154 were

randomised. Ninety-two were excluded because their eatingdisorder was notsuf ciently severe or because they were under age18; 114 met exclusion criteria (12 had previously received treat-ment resembling CBT-E for an eating disorder, 22 had a co-existingAxis 1 psychiatric disorder that precluded eating disorder-focusedtreatment and 39 were not available for the 28 weeks of treat-ment); and 41 declined to participate.Of the 51 notentered into thecurrent trial, 14 were not eligible for treatment (1 was psychotic, 2were diagnosed with BED, 3 had no diagnosable eating disorder, 8did not provide consent) and 37 did not progress from assessmentto CBT-E (4 were 16 year old patients who were offered familybased therapy instead of CBT-E, 1 patient was found to be sufferingfrom cancer, and 32 patients declined treatment).

Of the 125 patients who entered treatment 34 (27.2%) hada diagnosis of AN; 40 (32.0%) had a diagnosis of BN; and 51 (40.8%)had a diagnosis of EDNOS. Characteristics of the sample by diagnosisare presented in Table 1 . Patients with AN, BN and EDNOS weresimilar on almost all baseline characteristics, except that patientswith AN had lower minimum and maximum adult weights thanthose with BN or EDNOS and were more likely to have been hospi-talised previously for treatment of their eating disorder. With regardto these baseline characteristics, our sample appeared to be verysimilar to that described in the Fairburn et al. (2009) trial, with theexceptionthat ourparticipants were more likely tohave hadprevioustreatment foran eatingdisorder(34% vs20%) andwere morelikely tobe suffering from a current depressive episode (31% vs 20%).

Treatment credibility and patient expectations

On the CEQ, which was administered after assessment andimmediately before the initial treatment session, the ratings were

Table 1

Characteristics of the sample by diagnosis.

Characteristic All patients ( N 125) Anorexia Nervosa ( N 34) Bulimia Nervosa

(N 40)

EDNOS (N 51)

N % N % N % N %

Female 122 97.6 32 94.1 40 100 50 98.0Ethnicity

White 115 92.0 30 88.2 36 90.0 49 96.1Asian 2 1.60 1 2.9 0 0 1 2.0Other 8 6.40 3 8.8 4 10.0 1 2.0

Marital statusSingle, never married 81 64.80 21 61.8 24 60.0 36 70.6Married or de facto 38 30.40 11 32.3 15 37.5 12 23.5Separated/divorced 5 4.00 2 5.9 1 2.5 2 3.9Widowed 1 0.80 0 0 0 0 1 2.0

OccupationManagement/Professional 24 20.0 6 17.6 9 22.5 9 17.6Skilled 37 29.6 8 23.5 13 32.5 16 31.4Unskilled 1 0.8 1 2.9 0 0.0 0 0Home duties/student/unemployed 61 48.8 18 53.0 17 42.5 26 51.0Retired 0 0 0 0 0 0 0 0.0Unknown 2 1.6 1 2.9 1 2.5 0 0

Prior psychological treatment 102 81.6 26 76.5 31 77.5 45 90.0Prior inpatient eating disorder treatment 42 33.6 16 47.1 a 11 28.2 b 15 29.4 b

Currently on psychotropic medication 45 36.0 14 41.2 16 40.0 15 29.4Current depressive episode 39 31.2 6 17.6 12 30.0 22 43.1Any anxiety disorder 26 20.8 7 20.6 8 20.0 11 21.6

Mean SD/range Mean SD/range Mean SD/range Mean SD/rangeAge (years) 26.03 9.41 26.82 12.37 27.44 8.02 24.43 7.96Duration of eating disorder (years) 7.79 9.00 10.13 14.00 7.70 6.43 6.63 7.45

0.5e 59 0.5 e 59 0.5 e 22 0.5 e 35Lowest adult weight (kg) 45.14 9.50 38.36 a 7.41 49.84 b 7.32 46.27 b 9.50

23.95 e 80.00 23.9 e 59 32 e 72 32 e 80Highest adult weight (kg) 63.47 12.56 57.86 a 9.88 68.21 b 12.36 63.44 ab 12.99

43.00 e 110.0 43.00 e 80.00 47 e 100 45 e 110

Note: The Mini International Neuropsychiatric Interview (M.I.N.I.; Sheehan et al., 1998 ) was used to assess current Axis 1 disorders. Different superscripts denote signi cant

differences between groups.


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high and indicated that participants (i) perceived the treatment ascredible (mean 22.28, SD 4.98) and (ii) expected the treatmentto be useful (mean 19.06, SD 5.52). There were no signi cantdifferences in perceptions of credibility or treatment expectationsbetween the diagnostic groups.

Attrition

Of the 125 patients who started treatment, 50 (40.0%) droppedout of treatment, 5 (4.0%) were withdrawn (3 moved out of state, 1fell pregnant and 1 died) and 4 (3.2%) were transferred to anotherservice (3 to an inpatient psychiatric unit and 1 to a sexual assaultreferral centre). The drop-out rates were 50% (17/34) for patientswith AN, 35.0% (14/40) for patients with BN and 37.3% (19/51) forpatients with EDNOS ( X 2 (2) 3.83, p .147). The mean number of treatment sessions attended was 31.73 for treatment completers(range 5e 100) and 12.29 for non-completers (range 1e 55).Across the diagnoses the mean number of sessions attended forcompleters and non-completers respectively were: for AN 46.73(range 26 e 77) and 13.45 (range 1e 48), for BN 27.75(range 14e 51) and 9.44 (range 1e 29), and for EDNOS 29.15

(range 5e 100) and 13.3 (range 1e 55). There were no signi cantdifferences between completers and non-completers on any pre-treatment measures except that, compared to non-completers,completers reported a higher minimum (47.81 kg [SD 9.77] vs42.08 kg [SD 8.26]) and maximum (65.90 kg [SD 13.58] vs60.72 kg [SD 10.77]) weight, and a higher desired weight(51.96 kg [SD 8.78] vs 48.15 kg [SD 5.70]). There was, however,a signi cant difference in waiting time for treatment (weeksbetween referral and start of treatment) between completers andnon-completers, with non-completers having a longer meanwaiting time than completers, t (108) 2.05, p < .05, (25.90weeks [SD 15.28] vs 18.15 weeks [SD 13.36]).

Effects of CBT-E at the end of treatment

At the end of treatment 32.0% of the total sample (40/125) ful-lledourcriteriafor full remission e and an additional8.0% (10/125)

for partial remission. Almost half of the sample (42.4%; 53/125) hada post-treatment score on the global subscale of the EDE-Q < 2.46(less than 1 SD above Australian community norms), and 31.2%(39/125) had a post-treatmentglobalEDE-Q score < 2.46 in additionto a BMI 18.5 kg/m 2. The mean change in global EDE-Q score overtreatment was 1.11 (95% CI 0.85 to 1.38).

For those patients who completed treatment, the outcomeswere even more positive. By the end of treatment 56.1% of treat-ment completers (37/66) were in full remission and an additional10.6% (7/66) were in partial remission. Almost 70% of treatmentcompleters (44/66; 66.7%) had a post-treatment score on the globalsubscale of the EDE-Q < 2.46 and 56.1% of treatment completers(37/66) had a score on the global subscale of the EDE-Q < 2.46 inaddition to a BMI 18.5 kg/m 2. The mean change in global EDE-Q score for treatment completers was 2.07 (95% CI 1.71 to

2.42). Table 2 sets out these various recovery rates for eachdiagnostic category for both treatment completers and the intent-to-treat sample. As shown in Table 2 , in the intent-to-treat samplepatients with AN had lower rates of recovery than those with BN orEDNOS. However, this was not the case for treatment completers,except when recovery was de ned as having a post-treatmentglobal EDE-Q score < 2.46 plus a BMI 18.5.

Table 3 presents the pre- and post-treatment scores on themeasures of eating and more general psychopathology used in thisstudy. For both treatment completers and the total sample, therewere signi cant improvements over treatment on all of the eating-related measures, as well as on measures of depression, anxiety,stress, interpersonal problems, self-esteem and quality of life.

On all of the outcomes reported above (remission rates, changein global EDE-Q score and change on other measures of psycho-pathology) no differences were found between the subset of patients on psychotropic medication ( N 45) and those not onmedication.

Comparison with the Fairburn et al. (2009) RCT

Table 4 presents a comparison of the results from the currentWestern Australian (WA) trial with the results from the previousFairburn et al. (2009) Oxford e Leicester RCT of CBT-E on equivalentoutcome variables. Since the Fairburn et al. trial only involvedpatients with a pre-treatment BMI > 17.5, the WA sample wascategorised into 2 groups (BMI 17.5 vs BMI > 17.5) so that a directcomparison between the 2 studies was possible for the patientswith a BMI > 17.5. In the Fairburn et al. (2009) trial, good outcomewas de ned as having a post-treatment global EDE score < 1 SDabove U.K. community norms ( < 1.74). However, the WA study usedthe EDE-Q rather than the EDE in the post-treatment assessment(since it was not feasible to administer the EDE). Thus, for thepurposes of this comparison, good outcome in the WA study wasde ned as having a post-treatment global EDE-Q score < 1 SDabove Australian community norms ( < 2.74). As can be seen from

Table 2

Treatment outcome for each diagnostic category in treatment completers and the total (intent-to-treat) sample.

De nition of outcome Treatment completers

Total ( N 66) AN (N 12) BN (N 24) EDNOS (N 30)

Full remission (No ED symptomsover the past 28 days)

37 (56.1%) 6 (50.0%) 12 (50.0%) 19 (63.3%)

Full or partial remission 44 (66.7%) 6 (50.0%) 16 (66.7%) 22 (73.3%)Post-Tx Global EDE-Q < 2.46 44 (66.7%) 8 (66.7%) 17 (70.8%) 19 (63.3%)Post-Tx Global EDE-Q < 2.46 plus

BMI 18.5 kg/m 237 (56.1%) 3 (25.0%) a 17 (70.8%) b 17 (56.7%) b

Intention-to-treat sampleDe nition of outcome Total ( N 125) AN ( N 34) BN (N 40) EDNOS (N 51)Full remission (No ED symptoms

over the past 28 days)40 (32.0%) 6 (17.6%) a 13 (32.5%) b 21 (41.2%) b

Full or partial remission 50 (40.0%) 6 (17.6%) a 18 (45.0%) b 26 (51.0%) b

Post-Tx Global EDE-Q < 2.46 53 (42.4%) 13 (38.2%) 18 (45.0%) 22 (43.1%)Post-Tx Global EDE-Q < 2.46 plus

BMI 18.5 kg/m 239 (31.2%) 3 (8.8%) a 18 (45.0%) b 18 (35.3%) b

Note: Different superscripts denote signi cant differences between groups.


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Table 4 , the main point of difference between the 2 trials was thedrop-out rate, which was substantially higher in the WA trial (40%vs 22.1%). Among those in the WA trial who completed treatment,

the percentage of patients achieving good outcome (even amongpatients with a pre-treatment BMI 17.5) was almost exactly thesame as the percentage of the total sample achieving good outcomein the Fairburn et al. trial. In addition, the percentage of the totalsample (intention-to-treat) who ceased binge eating and purgingwas almost identical in the 2 trials for patients with a pre-treatment BMI > 17.5 (although this percentage was lower for thelow-weight WA patients).

Discussion

The aim of this study was to evaluate the effectiveness andfeasibility of CBT-E as a treatment for all eating disorders, includinglow-weight patients, in a sample of adults presenting to a public

outpatient clinic. It was expected that treatment with CBT-E wouldresult in substantial improvements in both the speci c and asso-ciated psychopathology of eating disorders and that, for patients

with a BMI > 17.5, the degree of improvement would be similar tothat reportedin the RCT of CBT-E( Fairburn et al., 2009 ). No previouspublished trials of CBT-E have involved patients with a BMI 17.5.

In terms of effectiveness, the results did indeed support thehypothesis that CBT-E would result in signi cant improvements inboth eating and more general psychopathology. By the end of treatment, full or partial remission was achieved by two thirds(66.7%) of the patients who completed treatment (56.1% in fullremission and an additional 10.6% in partial remission) and 40% of the total sample (32% in full remission and an additional 8% inpartial remission). With regard to binge eating and compensatorybehaviours (self-induced vomiting, laxatives and driven exercise) itwas found that, of those reporting these at baseline, 50% of treat-ment completers and 45.7% of the total sample had ceased all of these behaviours by the end of treatment. Substantial improve-ments were also found on measures of depression, anxiety, stress,interpersonal dif culties, self-esteem and quality of life, for both

completers and the intent-to-treat sample. The changes in scoresfrom pre to post treatment on all of these variables were associatedwith medium to large effect sizes.

Table 3

Pre- and post-treatment scores on measures of eating and more general psychopathology.

Variable Treatment completers ( N 66) All patients ( N 125)

Pre Post Effect size Pre Post Effect size

N (%) N (%) N (%) N (%)

Eating Disorder SymptomsObjective bulimic episodes 41 (62.1) 15 (22.7)** 79 (63.2) 46 (36.8)**

Self-induced vomiting 37 (56.1) 19 (29.8)** 69(55.2) 46 (36.8)**Laxative misuse 13 (19.7) 1 (1.5)** 24 (19.2) 7 (5.60)**Driven exercise 41 (62.1) 10 (15.1)** 69 (55.2) 26 (20.8)**Any of the above 58 (87.9) 28 (42.4)** 105 (84.0) 57 (45.6)**Absence of all of the above 8 (12.1) 38 (57.6)** 20 (16.0) 68 (54.4)**Cessation of all these forms

of behaviour, if present at baseline29/58 (50.0) 48/105 (45.7)

Mean (SD) Mean (SD) d Mean (SD) Mean (SD) dEDE-Q Global 3.89 (1.15) 1.82 (1.58)** 1.49 3.96 (1.28) 3.00 (1.77)** 0.68Dietary Restraint 3.64 (1.50) 1.16 (1.21)** 1.81 3.77 (1.64) 2.80 (2.04)** 0.66Eating Concern 3.30 (1.40) 1.07 (1.12)** 1.75 3.38 (1.48) 2.50 (1.81)** 0.63Weight Concern 4.23 (1.28) 1.58 (1.53)** 1.87 4.13 (1.52) 3.13 (2.07)** 0.62Shape Concern 4.50 (1.20) 2.06 (1.66)** 1.67 4.53 (1.34) 3.57 (1.98)** 0.63Body Mass index 20.20 (3.64) 21.23 (3.46) -0.29 19.8 (4.55) 20.40 (3.82) -0.13DASSDepression 17.43 (12.09) 5.21 (7.40)** 1.21 18.90 (12.60) 13.78 (13.02)** 0.53Anxiety 9.94 (7.21) 3.17 (5.37)** 1.06 11.71 (9.28) 8.99 (9.94)** 0.55Stress 19.16 (8.71) 8.36 (6.99)** 1.36 21.45 (9.70) 16.93(11.45)** 0.62Perfectionism 8.10 (5.41) 7.39 (5.22) 0.13 8.23 (5.69) 7.90 (5.68) 0.11Interpersonal dif culties 1.50 (0.52) 0.97 (0.53)** 1.00 1.54 (0.60) 1.33 (0.67)** 0.50Distress ToleranceAnticipate and Distract 1.64 (0.64) 1.82 (0.81) 0.25 1.68 (0.68) 1.71 (0.74) 0.05Avoidance of Affect 1.31 (0.58) 1.21 (0.69) 0.16 1.48 (0.68) 1.42 (0.74) 0.14Accept and Manage Emotions 1.71 (0.80) 1.98 (0.81) 0.33 1.65 (0.76) 1.74 (0.78) 0.16Self-Esteem 23.17 (5.24) 28.62 (5.62)** 1.00 22.36 (5.17) 24.50 (6.20)** 0.54Quality of Life 49.84 (17.63) 68.32 (12.42)** 1.20 49.08 (16.99) 55.68 (18.09)** 0.50

Note . ** p < 0.001.

Table 4

Comparison of the results from the current Western Australian (WA) trial with results from the Fairburn et al. (2009) RCT on equivalent outcome variables.

Total Sample WA trial Fairburn et al. Trial

BMI 17.5 BMI > 17.5 Total sample (all BMI > 17.5)

N 125 40 85 149Drop-out rate (%) 40 54.3 38.3 22.1Good outcome total sample (%) 54 (42.4) 18 (45.0) 35 (41.2) 79 (53.0)Good outcome completers (%) 44/66 (66.7) 11/16 (68.8) 33/50 (66.0) 77/116 (66.4)Cessation of binge eating and purging if present at baseline (ITT) (%) 37/93 (39.8) 6/20 (30.0) 31/73 (42.5) 55/130 (42.30)

Note. Good outcome was de ned as having a post-treatment Global EDE (for Fairburn et al.) or EDE-Q (for WA) score less than 1 standard deviation above community norms

(UK and Australian respectively). In the WA sample 6 patients diagnosed with EDNOS had a pre-treatment BMI 17.5.


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In the Fairburn et al. (2009) RCT, which only included patientswith a pre-treatment BMI > 17.5, good outcome (de ned as havinga post-treatment global EDE score < 1 SD above communitynorms), was achieved by 66.4% of treatment completers and 51.3%of the total sample. Using an equivalent de nition (having a globalEDE-Q score < 1 SD above Australian community norms) amongparticipants in the WA trial with a BMI > 17.5, good outcome wasachieved by 66.0% of treatment completers and 41.2% of the totalsample. With regard to binge eating and purging we found that, of those with a BMI > 17.5 reporting these behaviours at baseline,42.5% of the total sample had ceased these behaviours by the end of treatment. Once again this is very similar to the Fairburn et al.(2009) study where, at the end of treatment, 42.3% of the totalsample reported no episodes of binge eating or purging over theprevious 28 days. Thus, the outcome for CBT-E with these patientsappears to be positive and similar regardless of whether it is con-ducted in an outpatient clinic setting or in the context of a RCT.

The current study is the rst to report treatment outcome forCBT-E with low-weight AN patients. In this study, full or partialremission was achieved by 50.0% of AN patients (6/12) whocompleted treatment, compared to 66.7% of BN patients (16/24)and 73.3% of EDNOS patients (22/30). When good outcome wasde ned according to post-treatment global EDE-Q score, thepercentage of AN patients achieving good outcome was 66.7% fortreatment completers. When the total sample was considered,however, the outcomes for AN were poorer than those for BN andEDNOS due to the high drop-out rate among the AN patients (50%vs 35% and 37.3% respectively). Thus, overall, the results do appeartoindicate that CBT-E may be less effective for AN than for the othereating disorders.

While Fairburn et al. have not yet published outcome dataregarding the use of CBT-E with AN patients, preliminary results of a multi-site RCT have indicated that CBT-E is appropriate for about60% of outpatients with a BMI between 15 and 17.5 and that, of these patients, approximately 60% will have a good outcome(Fairburn, 2009; Murphy, Straebler, Cooper, & Fairburn, 2010 ). Only

a small number of previous studies of treatments for AN providesan appropriate comparison for the current WA study in that theyhave involved outpatient psychological treatments, an adultsample, and low-weight patients. A recent uncontrolled trial of traditional CBT ( Garner, Vitousek, & Pike, 1997; Pike, Loeb, &Vitousek, 1996 ) for AN and sub-threshold AN patients (N 103)conducted in Italy ( Ricca et al., 2010 ) reported recovery rates (notmeeting DSM-IV criteria for any eating disorder) of 30% at the endof a 1-year treatment period, and 33% 3 years later. Dare, Eisler,Russell, Treasure, and Dodge (2001) reported good outcome(recovered or signi cantly improved) in 32.3% of a sample of adultswith AN (BMI < 17.5) after 1 year of treatment with cognitiveanalytic therapy, focal psychotherapy or family therapy. The overalldrop-out rate was 37%. McIntosh et al. (2005) compared 3 outpa-

tient treatments for patients with a BMI of 15 e 19 kg/m2

(CBT,Interpersonal Therapy and Non-speci c Supportive ClinicalManagement). Good outcome across the 3 treatment conditionswas observed in 45% of treatment completers and 30% of the totalsample, and there was a 38% drop-out rate. Therefore the outcomefor CBT-E with the AN patients in our WA study is comparable tothat reported in these studies, except for our higher drop-out rate.

Indeed, overall attrition rate is an important point of differencebetween the WA trial and the Fairburn et al. (2009) RCT of CBT-E.Although the drop-out rate in the WA study (40% for the totalsample) was not outside the realm of drop-out rates reported foroutpatient trials of eating disorders (29 e 73%; Fassino, Piero,Tomba, & Abbate-Daga, 2009 ), it is much higher than the drop-out rate reported in the Fairburn et al. trial (22.1%). This was despite

patients of all diagnoses reporting early in treatment that they

considered the treatment to be highly acceptable and rating thetherapeutic alliance very positively.

The high drop-out rate in the WA study may be partly due to thefact that the sample consisted of patients attending an inner-citypublic clinic offering free treatment, where commitment to treat-ment may be more limited than in a research trial. However, bothsites in the Fairburn et al. trial (Oxford and Leicester) wereproviding the main outpatient eating disorder services locally, andboth also offered free treatment. It is also notable that the majority(70%) of patients assessed for eligibility at the W.A. site actuallyentered the trial, compared to less than half (42.7%) of thoseassessed in the Fairburnet al. trial; and the prevalence of co-morbiddepression was higher in the W.A. sample than in the U.K. sample(31% vs 20%).

Other factors that may explain the different drop-out rates mayinclude the waiting time for treatment, the experience level of thetherapists and staff turnover. While in RCTs there is generally nowaiting list, in the W.A. trial, on average, patients were on a waitinglist for treatment for over 5 months, and the waiting time wasalmost twice as long for drop outs (around 6.5 months) than fortreatment completers (around 3.5 months). As the period of timebetween referral and the start of treatment increases, it is possiblethat patients level of motivation may diminish or that theircircumstances may change in such a way as to affect theircommitment to, or desire for, treatment. The majority of the ther-apists in the W.A. trial was relatively inexperienced and had notreceived the same amount of formal training and supervision inCBT-E as had therapists in the Fairburn et al. trial. The high staff turnover during the W.A. trial may also have affected retention.Further investigation is required if drop out is to be minimised inthe future.

Interestingly, in the current study, there was no overallimprovement noted on measures of perfectionism or mood intol-erance at the end of treatment. These constructs are 2 of theadditional purported maintaining mechanisms which have beenincluded in the transdiagnostic model ( Fairburn et al., 2003 ) and

which are speci cally targeted in CBT-E, if relevant, during the thirdstage of treatment. The lack of changein these variables overall mayre ect the fact that only a subset of patients (those for whomperfectionism or mood intolerance were particularly problematic)received these treatment modules. Additional analyses were con-ducted with patients classi ed into high (abovethe mean for eatingdisorder patients) and low groups on pre-treatment measures of perfectionism and mood intolerance. For perfectionism, there wasa signi cant group by time (pre to post treatment) interaction F (1,59) 8.63, p < 0.01, h .12, such that patients initially high onperfectionism did show a signi cant decrease in perfectionism overtreatment, t (1,31) 2.51, p < .01, whereas those initially lowon perfectionism, as would be expected, did not. Thus, it appearsthat perfectionism did improve signi cantly in patients for whom

perfectionism was a problem. This was not the case for moodintolerance. Patients scoring highly on the DTS pre-treatment didnot show improvement on this measure over treatment. Oneexplanation for this may relate to our previous observation thatcurrent measures of mood intolerance are less than adequate(Raykos, Byrne, & Watson, 2009 ). Alternatively, the mood intoler-ance treatment module in CBT-E may not be potent enough to fullyaddress this complex construct.

In terms of feasibility, the current study offers evidence thatCBT-E can be effectively delivered in a community clinic by thera-pists with little experience in treating eating disordered patientswithout extensive training or time-consuming supervision. Theamount of training and the degree of supervision required for thetherapists involved in this study were considered to be appropriate

and realistic for a public outpatient clinic.


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A major strength of this study was that it was able to evaluatea newly-devised treatment (CBT-E) in an open trial in a publicoutpatient setting. In addition, the range of standardised measuresused in this study allowed for a comparison of the ndings with theonly previous RCT of CBT-E. Limitations of the study are those thatare commonly associated with a naturalistic effectiveness trial,such as lengthy waiting lists, high staff turnover, high attrition ratesand lack of follow-up data. At this stage, we are in the process of collectingfollow-updata for the sampledescribed in this study, andwe hope to have these data available for a subsequent publication.However, in contrast to formal RCTs where participants commit tocompleting post-treatment assessments and attending follow-upassessment sessions, to date we have had limited success in gettingparticipants to attend follow-up sessions or to respond to writtenor telephone requests to provide follow-up data. An additionallimitation was the fact that therapist adherence to the treatmentprotocol was not directly measured. Rather, adherence was moni-tored via weekly supervision and team meetings with SB and AFwhich included reviewing video recordings of a random selectionof treatment sessions.

In conclusion,this study represented the rsteffectiveness trial of CBT-E forall eating disordersincluding AN patients witha BMI < 17.5.Overall, CBT-E was found to result in signi cant improvements inboth eating disorder and general psychopathology. With regard toeating disorder features, CBT-E was shown to be highly effective forabout 40% of patients whoentered treatment,and forover twothirdsof patients who completed treatment. These results comparefavourably in many respects to those reported in the only RCT of CBT-E, with one exception being the considerably higher drop-out rate inthe WA study. The ndings provide strong evidence that CBT-E, asconducted in a RCT, is generalisable to treatment conducted in a realworld clinical setting and feasible as a treatment conducted bytherapists with a range of clinical experience.

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