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Open Access 01-12-2016 | Study protocol

Effectiveness of enhanced cognitive behavioral therapy (CBT-E) in the treatment of anorexia nervosa: a prospective multidisciplinary study

Authors: Yngvild S. Danielsen, Guro Årdal Rekkedal, Stein Frostad, Ute Kessler

Published in: BMC Psychiatry | Issue 1/2016

Abstract

Background

Anorexia nervosa (AN) is a debilitating psychiatric disorder associated with a wide array of negative health complications and psychiatric comorbidity. Existing evidence for AN treatment in adults is weak, and no empirically supported treatment has been reliably established. The primary objective of this study is to gain knowledge about the effectiveness of enhanced cognitive behavioral therapy (CBT-E) for anorexia nervosa delivered in a public hospital setting. Baseline predictors of treatment outcome and dropout are studied. Furthermore, there will be collected blood and stool samples for a general biobank to be able to initiate research on possible pathophysiological mechanisms underlying AN.

Methods

The study will assess the potency of outpatient CBT-E in a sample of patients suffering from AN (age >16) admitted to the Section for Eating Disorders at the Department for Psychosomatic Medicine, Haukeland University Hospital in Bergen, Norway. The study has a longitudinal design with five main assessment time points: before treatment, at 3 months, at the end of treatment, at 20 weeks, and at 12 months follow-up including biobank samples. A control group without an eating disorder will also be recruited.

Discussion

Treatment research in a public hospital setting is important for gaining knowledge about the transportability of treatments evaluated in research clinics into ordinary clinical practice. Furthermore, biological material from the thoroughly described patient cohort will serve as a basis for further research on the pathophysiological mechanisms in AN.

Trial registration

ClinicalTrials.gov Identifier: NCT02745067. Registered 14 April 2016.

American Psychiatric Association. Diagnostic and statistical manual of mental disorders 5ed. Washington DC: American Psychiatric Association; 2013.

Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies. Arch Gen Psychiatry. 2011;68(7):724–31. doi:10.1001/archgenpsychiatry.2011.74.CrossRefPubMed

Birmingham CL, Treasure J. Medical Management of Eating Disorders. 2nd ed. Cambridge: Cambridge University Press; 2010.CrossRef

Robinson P. Severe and Enduring Eating Disorder (SEED): Management of Complex Presentations of Anorexia and Bulimia Nervosa. Chichester: Wiley; 2009.

American Psychiatric Association. Practice guideline for the treatment of patients with eating disorders, 3rd edition. Am J Psychiatry. 2006;163(suppl):1–54.

Zerwas S, Larsen JT, Petersen L, Thornton LM, Mortensen PB, Bulik CM. The incidence of eating disorders in a Danish register study: Associations with suicide risk and mortality. J Psychiatr Res. 2015;65:16–22. doi:10.1016/j.jpsychires.2015.03.003.CrossRefPubMedPubMedCentral

Papadopoulos FC, Ekbom A, Brandt L, Ekselius L. Excess mortality, causes of death and prognostic factors in anorexia nervosa. Br J Psychiatry. 2009;194(1):10–7. doi:10.1192/bjp.bp.108.054742.CrossRefPubMed

Sullivan PF. Mortality in anorexia nervosa. Am J Psychiatry. 1995;152(7):1073–4. doi:10.1176/ajp.152.7.1073.CrossRefPubMed

Fassino S, Piero A, Tomba E, Abbate-Daga G. Factors associated with dropout from treatment for eating disorders: a comprehensive literature review. BMC Psychiatry. 2009;9:67. doi:10.1186/1471-244X-9-67.CrossRefPubMedPubMedCentral

10.

Steinhausen HC. The outcome of anorexia nervosa in the 20th century. Am J Psychiatry. 2002;159(8):1284–93.CrossRefPubMed

11.

Touyz S, Le Grange D, Lacey H, Hay P, Smith R, Maguire S, et al. Treating severe and enduring anorexia nervosa: a randomized controlled trial. Psychol Med. 2013;43(12):2501–11. doi:10.1017/S0033291713000949.CrossRefPubMed

12.

NICE. Eating disorders—core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. London: NICE; 2004.

13.

Halmi KA, Agras WS, Crow S, Mitchell J, Wilson GT, Bryson SW, et al. Predictors of treatment acceptance and completion in anorexia nervosa: implications for future study designs. Arch Gen Psychiatry. 2005;62(7):776–81. doi:10.1001/archpsyc.62.7.776.CrossRefPubMed

14.

Hay PJ, Touyz S, Sud R. Treatment for severe and enduring anorexia nervosa: a review. Aust N Z J Psychiatry. 2012;46(12):1136–44. doi:10.1177/0004867412450469.CrossRefPubMed

15.

Watson HJ, Bulik CM. Update on the treatment of anorexia nervosa: review of clinical trials, practice guidelines and emerging interventions. Psychol Med. 2013;43(12):2477–500. doi:10.1017/S0033291712002620.CrossRefPubMed

16.

Fairburn CG, Cooper Z, Shafran R. Cognitive behaviour therapy for eating disorders: a "transdiagnostic" theory and treatment. Behav Res Ther. 2003;41(5):509–28.CrossRefPubMed

17.

Fairburn CG. Cognitive Behavior Therapy and Eating Disorders. London/New York: The Guilford Press; 2008.

18.

Fairburn CG, Cooper Z, Doll HA, O'Connor ME, Palmer RL, Dalle Grave R. Enhanced cognitive behaviour therapy for adults with anorexia nervosa: a UK-Italy study. Behav Res Ther. 2013;51(1):R2–8. doi:10.1016/j.brat.2012.09.010.CrossRefPubMedPubMedCentral

19.

Dalle Grave R, Calugi S, Doll HA, Fairburn CG. Enhanced cognitive behaviour therapy for adolescents with anorexia nervosa: an alternative to family therapy? Behav Res Ther. 2013;51(1):R9–R12. doi:10.1016/j.brat.2012.09.008.CrossRefPubMedPubMedCentral

20.

Zipfel S, Wild B, Gross G, Friederich HC, Teufel M, Schellberg D, et al. Focal psychodynamic therapy, cognitive behaviour therapy, and optimised treatment as usual in outpatients with anorexia nervosa (ANTOP study): randomised controlled trial. Lancet. 2014;383(9912):127–37. doi:10.1016/S0140-6736(13)61746-8.CrossRefPubMed

21.

Wallace LM, von Ranson KM. Perceptions and use of empirically-supported psychotherapies among eating disorder professionals. Behav Res Ther. 2012;50(3):215–22. doi:10.1016/j.brat.2011.12.006.CrossRefPubMed

22.

Carter O, Pannekoek L, Fursland A, Allen KL, Lampard AM, Byrne SM. Increased wait-list time predicts dropout from outpatient enhanced cognitive behaviour therapy (CBT-E) for eating disorders. Behav Res Ther. 2012;50(7-8):487–92. doi:10.1016/j.brat.2012.03.003.CrossRefPubMed

23.

Bulik CM, Berkman ND, Brownley KA, Sedway JA, Lohr KN. Anorexia nervosa treatment: a systematic review of randomized controlled trials. Int J Eat Disord. 2007;40(4):310–20. doi:10.1002/eat.20367.CrossRefPubMed

24.

Fairburn CG, Agras WS, Walsh BT, Wilson GT, Stice E. Prediction of outcome in bulimia nervosa by early change in treatment. Am J Psychiatry. 2004;161(12):2322–4. doi:10.1176/appi.ajp.161.12.2322.CrossRefPubMed

25.

Hartmann A, Weber S, Herpertz S, Zeeck A, German Treatment Guideline Group for Anorexia N. Psychological treatment for anorexia nervosa: a meta-analysis of standardized mean change. Psychother Psychosom. 2011;80(4):216–26. doi:10.1159/000322360.CrossRefPubMed

26.

Mewes R, Tagay S, Senf W. Weight curves as predictors of short-term outcome in anorexia nervosa inpatients. Eur Eat Disord Rev. 2008;16(1):37–43. doi:10.1002/erv.807.CrossRefPubMed

27.

Le Grange D, Accurso EC, Lock J, Agras S, Bryson SW. Early weight gain predicts outcome in two treatments for adolescent anorexia nervosa. Int J Eat Disord. 2014;47(2):124–9. doi:10.1002/eat.22221.CrossRefPubMed

28.

Horvath AO, Symonds BD. Relation between working alliance and outcome in psychotherapy: A meta-analysis. J Couns Psychol. 1991;38(2):139–49.CrossRef

29.

Martin DJ, Garske JP, Davis MK. Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review. J Consult Clin Psychol. 2000;68(3):438–50.CrossRefPubMed

30.

Guarda AS. Treatment of anorexia nervosa: insights and obstacles. Physiol Behav. 2008;94(1):113–20. doi:10.1016/j.physbeh.2007.11.020.CrossRefPubMed

31.

Brown A, Mountford V, Waller G. Therapeutic alliance and weight gain during cognitive behavioural therapy for anorexia nervosa. Behav Res Ther. 2013;51(4-5):216–20. doi:10.1016/j.brat.2013.01.008.CrossRefPubMed

32.

Pereira T, Lock J, Oggins J. Role of therapeutic alliance in family therapy for adolescent anorexia nervosa. Int J Eat Disord. 2006;39(8):677–84. doi:10.1002/eat.20303.CrossRefPubMed

33.

Stiles-Shields C, Touyz S, Hay P, Lacey H, Crosby RD, Rieger E, et al. Therapeutic alliance in two treatments for adults with severe and enduring anorexia nervosa. Int J Eat Disord. 2013;46(8):783–9. doi:10.1002/eat.22187.CrossRefPubMed

34.

Bourion-Bedes S, Baumann C, Kermarrec S, Ligier F, Feillet F, Bonnemains C, et al. Prognostic value of early therapeutic alliance in weight recovery: a prospective cohort of 108 adolescents with anorexia nervosa. J Adolesc Health. 2013;52(3):344–50. doi:10.1016/j.jadohealth.2012.06.017.CrossRefPubMed

35.

Godart NT, Perdereau F, Rein Z, Berthoz S, Wallier J, Jeammet P, et al. Comorbidity studies of eating disorders and mood disorders. Critical review of the literature. J Affect Disord. 2007;97(1-3):37–49. doi:10.1016/j.jad.2006.06.023.CrossRefPubMed

36.

Keys A, Brozek J, Henschel A, Mickelsen O, Taylor HL. The Biology of Human Starvation: University of Minnesota Press; 1950.

37.

Mattar L, Huas C, Duclos J, Apfel A, Godart N. Relationship between malnutrition and depression or anxiety in Anorexia Nervosa: a critical review of the literature. J Affect Disord. 2011;132(3):311–8. doi:10.1016/j.jad.2010.09.014.CrossRefPubMed

38.

Davis C, Kennedy SH, Ravelski E, Dionne M. The role of physical activity in the development and maintenance of eating disorders. Psychol Med. 1994;24(4):957–67.CrossRefPubMed

39.

Dalle Grave R, Calugi S, Marchesini G. Compulsive exercise to control shape or weight in eating disorders: prevalence, associated features, and treatment outcome. Compr Psychiatry. 2008;49(4):346–52. doi:10.1016/j.comppsych.2007.12.007.CrossRefPubMed

40.

Danielsen M, Bratberg GH, Rø O. A pilot study of a new assessment of physical activity in eating disorder patients. Eat Weight Disord. 2012;17(1):e70–7.CrossRefPubMed

41.

Taranis L, Touyz S, Meyer C. Disordered eating and exercise: development and preliminary validation of the compulsive exercise test (CET). Eur Eat Disord Rev. 2011;19(3):256–68. doi:10.1002/erv.1108.CrossRefPubMed

42.

Gummer R, Giel KE, Schag K, Resmark G, Junne FP, Becker S, et al. High Levels of Physical Activity in Anorexia Nervosa: A Systematic Review. Eur Eat Disord Rev. 2015;23(5):333–44. doi:10.1002/erv.2377.CrossRefPubMed

43.

Alberti M, Galvani C, El Ghoch M, Capelli C, Lanza M, Calugi S, et al. Assessment of physical activity in anorexia nervosa and treatment outcome. Med Sci Sports Exerc. 2013;45(9):1643–8. doi:10.1249/MSS.0b013e31828e8f07.CrossRefPubMed

44.

Solenberger SE. Exercise and eating disorders: a 3-year inpatient hospital record analysis. Eat Behav. 2001;2(2):151–68.CrossRefPubMed

45.

Strober M, Freeman R, Morrell W. The long-term course of severe anorexia nervosa in adolescents: survival analysis of recovery, relapse, and outcome predictors over 10-15 years in a prospective study. Int J Eat Disord. 1997;22(4):339–60.CrossRefPubMed

46.

Ng LW, Ng DP, Wong WP. Is supervised exercise training safe in patients with anorexia nervosa? A meta-analysis. Physiotherapy. 2013;99(1):1–11. doi:10.1016/j.physio.2012.05.006.CrossRefPubMed

47.

Herpertz-Dahlmann B, Seitz J, Konrad K. Aetiology of anorexia nervosa: from a "psychosomatic family model" to a neuropsychiatric disorder? Eur Arch Psychiatry Clin Neurosci. 2011;261 Suppl 2:S177–81. doi:10.1007/s00406-011-0246-y.CrossRefPubMed

48.

Tennoune N, Chan P, Breton J, Legrand R, Chabane YN, Akkermann K, et al. Bacterial ClpB heat-shock protein, an antigen-mimetic of the anorexigenic peptide alpha-MSH, at the origin of eating disorders. Transl Psychiatry. 2014;4:e458. doi:10.1038/tp.2014.98.CrossRefPubMedPubMedCentral

49.

Lock J, Le Grange D. Treatment Manual for Anorexia Nervosa. A Family-Based Approach. 2 ed. New York: The Guilford Press; 2013.

50.

Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, et al. The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry. 1998;59 Suppl 20:22–33.PubMed

51.

Dalle Grave R. Intensive Cognitive Behavior Therapy for Eating Disorders. 1 ed. Hauppauge: Nova Science Publisher; 2012.

52.

Dalle GR. Inpatient Cognitive Behavior Therapy for Severe Eating Disorders. Psychological Topics. 2010;19(2):323–40.

53.

Leiknes A, Malt UF. M.I.N.I. - Mini Internasjonalt Nevropsykiatrisk Intervju 6.0. Norwegian version of Mini-International Neuropsychiatric Interview (MINI). Norway: Mapi Research Institute; 2009.

54.

Mordal J, Gundersen O, Bramness JG. Norwegian version of the Mini-International Neuropsychiatric Interview: feasibility, acceptability and test-retest reliability in an acute psychiatric ward. Eur Psychiatry. 2010;25(3):172–7. doi:10.1016/j.eurpsy.2009.02.004.CrossRefPubMed

55.

Fairburn CG, Beglin S. Eating disorder examination questionnaire. In: Fairburn CG, editor. Cognitive Behavior Therapy and Eating Disorders. New York: Guilford Press; 2008. p. 309–13.

56.

Berg KC, Peterson CB, Frazier P, Crow SJ. Psychometric evaluation of the eating disorder examination and eating disorder examination-questionnaire: a systematic review of the literature. Int J Eat Disord. 2012;45(3):428–38. doi:10.1002/eat.20931.CrossRefPubMed

57.

Rø O, Reas DL, Lask B. Norms for the Eating Disorder Examination Questionnaire among female university students in Norway. Nord J Psychiatry. 2010;64(6):428–32. doi:10.3109/08039481003797235.CrossRefPubMed

58.

Rø O, Reas DL, Rosenvinge J. The impact of age and BMI on Eating Disorder Examination Questionnaire (EDE-Q) scores in a community sample. Eat Behav. 2012;13(2):158–61. doi:10.1016/j.eatbeh.2011.12.001.CrossRefPubMed

59.

Bohn K, Doll HA, Cooper Z, O'Connor M, Palmer RL, Fairburn CG. The measurement of impairment due to eating disorder psychopathology. Behav Res Ther. 2008;46(10):1105–10. doi:10.1016/j.brat.2008.06.012.CrossRefPubMedPubMedCentral

60.

Rø O, Bang L, Reas DL, Rosenvinge JH. The impact of age and BMI on impairment due to disordered eating in a large female community sample. Eat Behav. 2012;13(4):342–6. doi:10.1016/j.eatbeh.2012.05.010.CrossRefPubMed

61.

Beck AT, Steer RA, Brown GK. BDI-II: Beck Depression Inventory, Manual. 2nd ed. San Antonio: The Psychological Corporation; 1996.

62.

Beck AT, Steer RA, Carbin MG. Psychometric properties of the Beck Depression Inventory: Twenty-five years of evaluation. Clin Psych Rev. 1988;8(1):77–100.CrossRef

63.

Wang YP, Gorenstein C. Psychometric properties of the Beck Depression Inventory-II: a comprehensive review. Rev Bras Psiquiatr. 2013;35(4):416–31. doi:10.1590/1516-4446-2012-1048.CrossRefPubMed

64.

Beck AE N, Brown G, Steer RA. An inventory for measuring clinical anxiety: Psychometric properties. J Consult Clin Psych. 1988;56(6):893–7. doi:http://dx.doi.org/10.1037/0022-006X.56.6.893.CrossRef

65.

Hays RD, Sherbourne CD, Mazel R. The RAND 36-item health survey 1.0. Santa Monica: RAND Corporation; 1993.

66.

Ware Jr JE, The SCD, MOS. 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care. 1992;30(6):473–83.CrossRefPubMed

67.

Hays RD, Morales LS. The RAND-36 Measure of Health-Related Quality of Life. Santa Monica: RAND Corporation; 2001. Available from: http://www.rand.org/pubs/reprints/RP971.

68.

VanderZee KI, Sanderman R, Heyink JW, de Haes H. Psychometric qualities of the RAND 36-Item Health Survey 1.0: a multidimensional measure of general health status. Int J Behav Med. 1996;3(2):104–22. doi:10.1207/s15327558ijbm0302_2.CrossRefPubMed

69.

DeRogatis LR, Unger R. Symptom Checklist-90-Revised. Corsini Encyclopedia of Psychology. 2010:1-2;doi:10.1002/9780470479216.corpsy0970.

70.

Horvath AO, Greenberg LS. Development and validation of the Working Alliance Inventory. J Couns Psych. 1989;36(2):223–33.CrossRef

71.

Tracey TJ, Kokotovic AM. Factor structure of the Working Alliance Inventory. Psychological Assessment: A Journal of Consulting and Clinical Psychology. 1989;1(3):207–10.CrossRef

72.

Busseri MA, Tyler JD. Interchangeability of the Working Alliance Inventory and Working Alliance Inventory. Short Form Psychol Assess. 2003;15(2):193–7.CrossRefPubMed

73.

Puyau MR, Adolph AL, Vohra FA, Zakeri I, Butte NF. Prediction of activity energy expenditure using accelerometers in children. Med Sci Sports Exerc. 2004;36(9):1625–31.PubMed

74.

Hoos MB, Kuipers H, Gerver WJ, Westerterp KR. Physical activity pattern of children assessed by triaxial accelerometry. Eur J Clin Nutr. 2004;58(10):1425–8. doi:10.1038/sj.ejcn.1601991.CrossRefPubMed

75.

Faul F, Erdfelder E, Buchner A, Lang A-G. Statistical power analyses using G*Power 3.1: Tests for correlation and regression analyses. Behav Res Methods. 2009;41(4):1149–60. doi:10.3758/BRM.41.4.1149.CrossRefPubMed

Title: Effectiveness of enhanced cognitive behavioral therapy (CBT-E) in the treatment of anorexia nervosa: a prospective multidisciplinary study
Authors: Yngvild S. Danielsen
Guro Årdal Rekkedal
Stein Frostad
Ute Kessler
Publication date: 01-12-2016
Publisher: BioMed Central
Published in: BMC Psychiatry / Issue 1/2016
Electronic ISSN: 1471-244X
DOI: https://doi.org/10.1186/s12888-016-1056-6

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Effectiveness of enhanced cognitive behavioral therapy (CBT-E) in the treatment of anorexia nervosa: a prospective multidisciplinary study

Abstract

Background

Methods

Discussion

Trial registration

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Background

Methods

Discussion

Trial registration

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