Short-term Cognitive-Behavioral Therapy for Binge Eating Disorder

Short-term Cognitive-Behavioral Therapy for Binge Eating Disorder

Behaviour Research and Therapy 58 (2014) 36e42
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Behaviour Research and Therapy
journal homepage: www.elsevier.com/locate/brat
Shorter communication
Short-term Cognitive-Behavioral Therapy for Binge Eating Disorder:
Long-term efficacy and predictors of long-term treatment success
Sophia Fischer a, b, Andrea H. Meyer c, Daniela Dremmel b, Barbara Schlup d,
Simone Munsch b, *
a
Department of Child and Adolescent Psychiatry of the University of Basel (UPK Basel), Switzerland
University of Fribourg, Institute of Psychology, Department of Clinical Psychology and Psychotherapy, Switzerland
University of Basel, Department of Psychology, Division of Clinical Psychology and Epidemiology, Switzerland
d
Psychiatric Women's Clinic of Meissenberg, Switzerland
b
c
a r t i c l e i n f o
a b s t r a c t
Article history:
Received 8 January 2014
Received in revised form
25 April 2014
Accepted 28 April 2014
Available online 24 May 2014
The present study evaluates the long-term efficacy (four years after treatment) of a short-term CognitiveBehavioral Treatment (CBT) of Binge Eating Disorder (BED). We examined patient characteristics, mostly
measured at the end of treatment, for their predictive value of long-term success. Forty-one BED-patients
between 18 and 70 years took part in a randomized controlled trial (RCT) for a short-term treatment and
were evaluated until 4 years after treatment. Assessments comprised structured interviews on comorbid
mental disorder/eating disorder pathology and questionnaires on eating disorder pathology/general
psychopathology. BED core symptoms and associated psychopathology improved substantially during
treatment phase and further improved or at least remained stable during the follow-up period. End of
treatment predictors for long term success were elevated weight and eating concern and higher frequency of objective binges. Tailoring additional interventions to patients' individual needs could further
improve treatment efficacy.
© 2014 Elsevier Ltd. All rights reserved.
Keywords:
Binge Eating Disorder
Short-term CBT
Efficacy
Long-term outcome
Predictor
Introduction
Binge Eating Disorder (BED), characterized as recurrent binge
eating accompanied by the feeling of loss of control over eating
without regular compensatory behavior, is introduced in the DSMV as a new eating disorder category with minor adaptations of the
research criteria of DSM-IV-R (lower required frequency and
duration of binge eating episodes; American Psychiatric
Association, 2013). BED represents the most common eating disorder, with prevalences in population-based studies ranging from
0.7 to 6.6% and is usually accompanied by elevated body weight and
comorbid mental disorders (Grucza, Przybeck, & Cloninger, 2007;
Westenhoefer, 2001; Yager, 2008). Cognitive-Behavioral Therapy
(CBT) seems to be one of the most efficacious treatments for BED
regarding binge eating and general eating disorder pathology
* Corresponding author. Department of Psychology, Clinical Psychology and
Psychotherapy, University of Fribourg, Avenue de Faucigny, 2, CH-1700 Fribourg,
Switzerland. Tel.: þ41 (0)26 300 76 55; fax: þ41 (0)26 300 97 12.
E-mail addresses: [email protected] (A.H. Meyer), simone.munsch@unifr.
ch (S. Munsch).
http://dx.doi.org/10.1016/j.brat.2014.04.007
0005-7967/© 2014 Elsevier Ltd. All rights reserved.
(Vocks et al., 2010; Wilson, Wilfley, Agras, & Bryson, 2010). Given
the high prevalences, especially in obese populations, and considerable long-term morbidity, facilitated accessibility of efficacious
treatment options is indispensable. For this reason, shorter costeffective versions of CBT or self-help treatments have recently
been developed (Beintner, Jacobi, & Schmidt, 2014; Masheb & Grilo,
2008a; Perkins, Murphy, Schmidt, & Williams, 2009; Peterson et al.,
2000; Schlup, Munsch, Meyer, Margraf, & Wilhelm, 2009). In a prior
non-randomized study of our group short-term CBT revealed a
comparable treatment effect to a 16-sessions CBT at 1-year followup (Schlup, Meyer, & Munsch, 2010). However, to our knowledge,
up to now no data is available on long-term efficacy beyond two
years for either self-help or treatments with a frequency of beyond
10 to 20 active treatment sessions.
Another important issue in treatment research on BED is the
identification of predictors of treatment efficacy in order to adapt
interventions to patients' individual needs or the needs of subgroups of patients (Kraemer, Wilson, Fairburn, & Agras, 2002).
Recent research revealed that higher frequency of binge eating and
elevated eating disorder pathology at baseline had a negative influence on treatment efficacy (Castellini et al., 2012; Hilbert,
S. Fischer et al. / Behaviour Research and Therapy 58 (2014) 36e42
Saelens, et al., 2007; Masheb & Grilo, 2008a; Munsch, Meyer, &
Biedert, 2012; Peterson et al., 2000; Wilson et al., 2010). Additionally, rapid response defined as early symptom improvement
during treatment turned out to be a robust within-treatment predictor of therapy outcome immediately after treatment and during
follow up (Grilo, White, Wilson, Gueorguieva, & Masheb, 2012;
Munsch et al., 2012; Schlup et al., 2010). However, up to now
post-treatment predictors of long-term outcome have not been
identified. The identification of post-treatment predictors of longterm outcome will help to identify persons who are at risk to
relapse and are in need of tailored interventions after initial
treatment.
Our study aim was first to evaluate the long-term efficacy of a
short-term treatment of BED during a 4-year follow-up period in
terms of binge eating, eating disorder pathology, BMI and general
psychopathology. Second, we attempted to identify post-treatment
predictors (number of objective binge episodes, eating disorder
pathology, negative-affect subtype, BMI, general life satisfaction,
self-efficacy) of treatment success (abstainer rate and number of
objective binge episodes) during the 4-year follow-up course. As
rapid response measured during early treatment phase was of high
negative predictive value for treatment success in several studies
(Grilo et al. 2012; Munsch et al., 2012; Schlup et al., 2010), we
additionally included this predictor, which was measured before
the end of treatment.
Methods
Participants
Forty-one patients met the research criteria for BED according to
DSM-IV (American Psychiatric Association, 2000) and took part in a
randomized controlled trial conducted at the University of Basel
(description see below). Participants were recruited through
newspaper advertisements and flyers, they had to be aged between
18 and 70 years and to meet full diagnostic criteria for BED.
Exclusion criteria were severe mental disorders, pregnancy, and
participation in other psychotherapy/weight loss programs. The
local ethics committee approved the treatment trial, and all participants provided written informed consent. In the present study,
26 participants still participated at 4-year follow up (see participant
flow chart, Fig. 1). In the initial study of Schlup et al. (2009) only
Assessed for eligibility via
telephone screening (n= 132)
Attended diagnostic assessment
(n=60)
Available for randomization (n=41)
Allocated to immediate treatment
(n=20)
Excluded (n=72)
- Not meeting inclusion criteria
(n=49)
- Refused to participate (n=22)
- Other reasons (n=1)
Excluded (n=19)
- Not meeting inclusion criteria
(n=9)
- Refused to participate (n=10)
- Other reasons (n=0)
Allocated to waitlist
(n=21)
Lost to treatment (n=4)
- Dissatisfied with treatment (n=1)
- Diet (n=2)
- Lack of time (n=1)
End of weekly treatment
Waitlist group entered treatment
(n=37)
Lost to follow-up (n=3)
- Lack of time (n=1)
- Dissatisfied with treatment (n=1)
- Moved away (n=1)
3-month follow-up
(n=34)
6-month follow-up
(n=34)
Lost to follow-up (n=1)
- Dissatisfied with treatment (n=1)
Lost to follow-up (n=8)
- Lack of time (n=1)
- Disease/accident (n=1)
- No further interest (n=1)
- Telephone number not identifiable (n=3)
- Not attainable (n=2)
37
12-month follow-up
(n=33)
4-year follow-up
(n=26)
(n=1)
Fig. 1. Participant flow chart, according Consort guidelines, www.consort-statement.org.
38
S. Fischer et al. / Behaviour Research and Therapy 58 (2014) 36e42
female participants (n ¼ 36) were included in the analyses. In this
current study the few male patients were also included in order to
increase statistical power, resulting in a total sample of 41 participants. Analyses of the primary outcomes remission from binge
eating and number of objective binge eating episodes revealed that
there were no significant differences in the temporal trajectories
between males and females, neither during active treatment nor
during follow-up (interaction “time during treatment # sex” and
“time during follow-up # sex”, p-values > 0.33 in both cases).
Study design and treatment protocol
The study design was a randomized controlled trial, which
aimed at investigating the efficacy of a shortened version of a 16sessions group CBT that had previously demonstrated efficacy for
BED (Munsch et al., 2007; Schlup et al., 2009). Participants were
randomly assigned to either immediate treatment or the waitlist
control group (permuted block design). After completion of the
active treatment phase, the waitlist group also entered treatment.
The active treatment phase comprised eight weekly 90-min group
sessions, followed by five 90-min booster sessions over 12 months
(1, 2, 3, 6 and 12 months after active treatment) led by trained CBT
psychotherapists and co-therapists (master students). Content of
treatment encompass the identification of triggers of binge eating
and the development of individual strategies in order to cope with
the urge to binge eat.
Please refer to the initial paper of Schlup et al. (2009) regarding
the assessment and findings of treatment integrity, therapeutic
competence and suitability of treatment.
Assessments
BED-diagnoses and comorbid mental disorders
Current and lifetime mental disorders were assessed face to face
at baseline and by telephone at 4-year follow-up in order to reduce
subject burden, using the structured interview “Diagnostisches
€ rungen, DIPS” according to the DSMInterview für psychische Sto
IV-TR (Margraf, Ehlers, & Schneider, 1994; Wittchen, Zaudig, &
Fydrich, 1997). BED diagnosis was assessed similarly based on the
Eating Disorder Examination Interview with established reliability
and sensitivity to track changes in eating disorder psychopathology
(EDE; German version by Hilbert, Tuschen-Caffier, & Ohms, 2004),
and on a self-developed short structured interview according to
DSM-IV TR criteria, as at that time the DIPS did not include a BEDsection.
between two important clusters of eating disorder pathology
(Masheb & Grilo, 2008b).
In addition, we used a self-developed questionnaire to record
‘self-reported weekly binges’ at different measurement points (i.e.,
weekly during the active treatment phase, and at 3-, 6-, 12-month,
and 4-year follow-up), where participants indicated “episodes of
overeating during which you felt out of control during the past
week” (Munsch et al., 2012). The assessment of weekly binges with
a self-report questionnaire has been shown to have high convergent validity relative to ecological momentary assessment (Munsch
et al., 2009).
Body Mass Index
Weight and height were measured on an electronic balance
scale (Seca, Vogel & Halke, Germany) and by a stadiometer, except
at 4-year follow-up, where participants self-reported weight and
height. Body Mass Index (BMI) was calculated as weight in kilograms divided by the square of height in meters (kg/m2).
Depression and anxiety symptoms
Participants completed the German versions of the Beck
Depression Inventory (BDI) and the Beck Anxiety Inventory (BAI),
two well-established self-report measures of the symptoms of
depression, negative affect and anxiety, with good psychometric
properties (Hautzinger, Bailer, Worall, & Keller, 1994; Margraf &
Ehlers, 2007). The BDI encompasses 20 items, the BAI 21 items on
typical depressive/anxiety symptoms with a 4-point Likert-scale.
General life satisfaction
The questionnaire on life satisfaction, “Fragebogen zur Lebenszufriedenheit” (FLZ; Henrich & Herschbach, 1998) assesses
general life satisfaction within a wide range of different aspects
(friends, hobbies, health, revenues, work, family, sexuality) and has
been shown to have good psychometric properties (Henrich &
Herschbach, 2000).
General self-efficacy
The General Self-Efficacy Scale, “Allgemeine Selbstwirksamkeitsskala” (SWE; Jerusalem & Schwarzer, 1999), a self-report
measure with 10 items, was used to assess participants' belief
about their capabilities to solve difficult problems and face critical
situations. High reliability, stability as well as construct validity
have been shown in different cultural contexts (Luszczynska,
Scholz, & Schwarzer, 2005).
Subcategorization
Eating disorder pathology
The self-report version of the EDE (EDE-Q; German version by
Hilbert & Tuschen-Caffier, 2006), with well-established psychometric properties (Hilbert, Tuschen-Caffier, Karwautz, Niederhofer,
& Munsch, 2007; Reas, Grilo, & Masheb, 2006), was subsequently
administered repeatedly until 4-year follow-up (end of treatment,
3-, 6-, 12-months and 4-year follow-up). The EDE-Q (and the EDE)
assesses the number of objective binge episodes (OBEs; i.e., binge
eating defined as consuming objective unusually large quantities of
food during the last 28 days with a subjective sense of loss of
control), from which abstainer rates have been inferred (proportion
of patients not experiencing any OBEs). In addition, they provide
four subscales, reflecting the severity of eating disorder pathology
(dietary restraint, eating concern, weight concern, and shape
concern), the scores ranging from 0 to 6, with higher scores
reflecting greater severity of eating disorder psychopathology. According to Masheb and Grilo, overvaluation of shape and weight
was built from the two subscales weight and shape concern of the
EDE-Q as this composite scale has been shown to differentiate well
Two predictor variables (rapid response and negative affectsubtype) were based on a subcategorization. Participants with a
decline of at least 65% in number of self-reported weekly binges
within the first four weeks of treatment were classified as rapid
responders (according to Grilo, Masheb, & Wilson, 2006). Participants exceeding the BDI-cutoff of 18 at the end of treatment were
classified within the negative affect subtype (according to Wilson
et al., 2010). In this sample, 17 patients (41%) were classified as
rapid responders and 11 (26%) were classified within the negative
affect-subtype.
Statistical analysis
To analyze the data we used linear mixed models (Fitzmaurice,
Laird, & Ware, 2004) for continuous or ordinal outcomes and
logistic-normal models (Agresti, 2002) for dichotomous outcomes.
To analyze the temporal course of outcomes across the 4-year
follow-up period we used a discontinuous model (Singer &
39
S. Fischer et al. / Behaviour Research and Therapy 58 (2014) 36e42
Wilett, 2003). Our model included two linear polynomials for the
predictor time (ln[weeks]), one for the active treatment and one for
the follow-up period which were estimated independently of each
other with respect to the slope parameter. Thus this model predicts
a shift in slope but no shift in level, with a turning point at the end
of treatment. Primary outcomes included remission from binge
eating and the number of OBEs. Secondary outcomes were the
number of self-reported weekly binges, the four EDE-Q-scales dietary restraint, eating concern, shape concern, weight concern, and
overvaluation of shape and weight, BMI, general life satisfaction,
general self-efficacy, BDI, and BAI.
Predictors of follow-up were assessed for primary outcomes
only and for the period end-of-treatment to 4-year follow-up. The
model included time (ln[weeks]) (linear and quadratic polynomial) and the corresponding predictor measured at the end of
treatment. We did not include pretreatment variables of the corresponding outcomes in order to avoid spurious correlations,
since adjusting for pretreatment variables could remove part of
the predictor effect, leading to biased results (Miller & Chapman,
2001).
Altogether we performed a total of 22 analyses (11
predictors # 2 outcomes). Due to the explorative nature of the
study we did not correct error probabilities for multiple testing
(Bender & Lange, 2001).
Results
Participants' characteristics
Participants' mean age was 45.6 (SD ¼ 11.2). Altogether 33% of
the patients suffered from at least one additional mental disorder at
baseline, and 24% at 4-year follow-up (Table 1).
Temporal course
The probability of a diagnose for BED according to DSM-IV
significantly declined from 100% at pretreatment to 4.6% at the
end-of-treatment and remained constant (4.2%) at 4-year followup.
Primary outcomes (Tables 2 and 3)
The abstainer rate according to EDE-Q strongly increased during
active treatment from less than 1% at pretreatment to c. 30% at the
end of treatment and further improved, reaching four-year followup values of c. 67%. The number of OBEs significantly declined from
7.4 at pretreatment to 2.1 at the end of active treatment. During
follow-up there was again a significant decline leading to c. 0.7
OBEs at 4-year follow-up. Thus abstainer rates increased by c. 66
percentage points and the number of OBEs decreased by more than
90% between pretreatment and 4-year follow-up.
Secondary outcomes (Tables 2 and 3)
Self-reported weekly binges, EDEQ-scales eating concern, shape
concern and weight concern, and BDI-values all significantly
decreased during active treatment whereas BMI, BAI-values,
overvaluation of weight and shape (according to EDE-Q), life
satisfaction, and self-efficacy all exhibited no temporal trend in
that period. In contrast, the EDE-Q-scale dietary restraint significantly increased during active treatment. During follow-up EDEQscales eating concern, shape concern, weight concern, and overvaluation of weight and shape (according to EDE-Q), and BMI all
decreased whereas for the remaining secondary outcomes no
significant trend was found. Thus there was no indication of
deterioration during follow-up for any of the investigated
outcomes.
Table 1
Sample description and clinical characteristics at pretreatment and 4-year followup.
Patient characteristics
Pretreatment
(N ¼ 41)
M
SD
%
4-year
Follow-up
(N ¼ 26)
n
M
SD
Age in years
45.6 11.2
52.3 11.3
BMI
34.3 8.2
30.18 4.35
ISEI
49.2 11.1
Female sex, %
87.8 36
Mental Disorders, DSM-IV-TR:
33.3 12
comorbiditya
Anxiety disorders
25
9
Affective disorders
13.5 5
Substance abuse
0
0
Sleep disorder
0
0
Regular intake of medicine, %
… of which psychotropics
Seeking additional psychological
treatment after end of active
therapy
Undergoing a diet to lose weight
after active treatment
Critical life event between end
of active treatment and 4-year
follow-up in
terms of …
physical problem/death in
family
Loss of friend/living
alone/marriage/lack
of social support
unemployment/change of
employment
financial problems
High negative affect (BDI $ 18)
26.8 11
Score of overvaluation > 4
58.5 24
%
n
88.0 23
24.0 6
8.0
7.7
4.0
8.7
33.3
0
26.9
2
2
1
2
2
0
7
26.9
7
8.3
2
12.5
3
12.5
3
12.5
5.4
7.3
3
2
3
Note. BDI, Becks Depression Inventory; BMI, overvaluation: built from the two
subscales weight and shape concern of the EDE-Q; body mass index (calculated as
weight in kilograms divided by height in meters squared); ISEI: International SocioEconomic Index of Occupational Status (Ganzeboom, de Graaf, & Treiman, 1992).
a
comorbidity: at least one comorbid mental disorder.
Predictors
The following post-treatment characteristics were predictive of
the follow-up course of primary outcomes: Patients with elevated
EDEQ-scale values for weight concern were characterized by a
higher number of OBEs (p ¼ 0.008) and a lower remission rate
(p ¼ 0.048) during follow-up. Similarly, patients with elevated
EDEQ-scale values for eating concern exhibited higher numbers of
OBEs (p ¼ 0.012) during follow-up. Further, a higher number of
OBEs at the end of treatment predicted a higher number of OBEs
during follow-up (p ¼ 0.002).
Discussion
The aim of the present study was for the first time to shed light
on the following two research questions: The long-term efficacy of
a short-term CBT followed by booster sessions in patients suffering
from BED and the predictive role of end of treatment patient
characteristics (number of OBEs, BMI, eating disorder pathology,
general life satisfaction, self-efficacy, belongingness to the negative
affect-subtype) regarding long-term treatment success.
Our results have revealed a strong improvement of BED core
symptoms during the treatment phase, followed by a further
though less strong improvement during the follow-up period. Thus
the probability of a BED diagnosis as well as the number of OBEs
both significantly decreased and the abstainer rate significantly
40
Table 2
Parameter estimates from linear and generalized linear mixed models for each outcome.
Primary outcomes
Self efficacy Life satis-faction BDI (ln)
(selbstw)
(flzatot)
BAI (ln)
1.990**,b
%0.484***
%0.362***
0.199*
%0.373***
%0.178*
%0.164*
%0.101
e0.023
0.226
0.156
%0.177**
%0.130
0.472*,b
%0.176*
%0.096
%0.123
%0.204**
%0.281**
%0.267**
%0.420**
%0.574*** 0.440
0.079
0.014
%0.011
e
1.789***
e
0.372***
0.535**
0.077
0.219***
0.305***
0.067*
0.725***
0.504**
e
0.362***
0.764**
0.153*
0.468***
1.227***
e
0.502***
0.735***
e
2.149***
1.296**
e
0.705*** 5.622***
59.690*** 14.634***
e
e
1.013***
1.945***
e
0.301***
0.485***
e
0.339***
0.842***
0.025
e
0.085*
0.071**
0.110*
0.022
0.077
0.078
0.086
0.547***
2.577**
0.066
0.008
0.022
0.360
0.324
e0.241
e
0.020
e
e
e0.330
e
e
0.045
e
e
e0.354
e
e
e0.223
e
e
e0.332
e
e
0.337
e
0.558
e0.566
e0.426
0.431
0.542
0.340
0.363
0.360
0.289
0.288
0.152
0.164
0.635
0.175
0.370
0.137
0.101
0.174
0.104
0.111
0.133
e
e
e
0.211a
e
0.665
e0.431
e0.556
0.517
0.558
0.399
e0.666**
e0.826*
0.378
0.338
e
e0.302
e
0.168
0.197
220.8
499.0
790.7
516.0
511.0
521.0
500.4
691.7
973.1
951.2
587.5
375.8
416.9
179.0
432.9
692.6
512.1
456.0
486.0
472.0
699.9
861.7
934.0
588.6
371.7
424.0
R2 Correlation between observed and predicted values, R2E Change in s2E between unconditional means model and unconditional growth model relative to unconditional means model.
y
y;b
*p < .05, **p < .01, ***p < .001.
a
1 e (deviance of fitted model/deviance of unconditional means model).
b
based on the logit function of the probability of remission.
S. Fischer et al. / Behaviour Research and Therapy 58 (2014) 36e42
Fixed coefficients
Slope e
active treatment
Slope e follow-up
Random coefficients
Level 1 s2E
Level 2 Intercept s20
Level 2 Slope e
active treatment s21
Level 2 Slope e
follow-up s22
Level 2 correlation r01
Level 2 correlation r02
Level 2 correlation r12
Pseudo R2 statistics
R2
y;b
y
R2E
Goodnesseof fit
AIC unconditional
means model
AIC fitted model
Secondary outcomes
EDEQerestraint EDEQeeating EDEQe shape EDEQeweight EDEQeOvervaluation BMI
EDEQeabstainer Number of Number of
concern
concern
concern
of weight and shape
rate
OBEs (ln) self reported eating
weekly binges
(ln)
41
S. Fischer et al. / Behaviour Research and Therapy 58 (2014) 36e42
Table 3
Point estimates of outcomes at different assessment time points. Estimated means from linear and generalized linear mixed models including standard errors in parentheses.
Primary outcome
EDEQ-abstainer rate (%)a
Number of OBEsb
Secondary outcome
Number of self reported weekly binges (0 range to 20)b
EDEQ-restraint eating (range 0e6)
EDEQ-eating concern (range 0e6)
EDEQ-shape concern (range 0e6)
EDEQ-weight concern (range 0e6)
EDEQ-Overvaluation of weight and shape (range 0e6)
BMI
Self efficacy (range 10e40)
Life satisfaction (range %3 to þ5)
BDI (range 0e63)b
BAI (range 0e63)b
a
b
Baseline
End-of-treatment
12-month follow-up
4-years follow-up
0.67 (%0.48/þ1.62)
7.41 (þ1.17/e1.03)
29.7 (%9.2/þ11.1)
2.06 (þ0.50/e0.43)
51.8 (%10.2/þ10.1)
1.16 (þ0.32/e0.28)
66.8 (%14.2/þ11.5)
0.72 (þ0.40/e0.33)
2.97
1.76
2.43
4.05
3.49
4.23
34.4
28.2
1.77
9.06
6.55
0.87
2.17
1.65
3.68
3.15
4.02
34.3
28.7
2.10
5.97
4.77
0.55
1.93
1.25
3.12
2.62
3.19
33.2
29.5
2.25
6.16
4.89
0.36
1.77
0.98
2.75
2.27
2.63
32.4
30.1
2.36
6.29
4.97
(þ0.48/e0.43)
(0.18)
(0.18)
(0.20)
(0.18)
(0.29)
(1.2)
(0.7)
(0.27)
(þ1.50/e1.31)
(þ1.26/e1.08)
(þ0.19/e0.17)
(0.17)
(0.17)
(0.20)
(0.17)
(0.28)
(1.2)
(0.7)
(0.27)
(þ1.01/e0.89)
(þ1.05/e0.89)
(þ0.14/e0.13)
(0.17)
(0.18)
(0.22)
(0.16)
(0.27)
(1.2)
(0.8)
(0.24)
(þ1.08/e0.93)
(þ0.91/e0.78)
(þ0.21/e0.18)
(0.27)
(0.23)
(0.28)
(0.23)
(0.39)
(1.2)
(1.1)
(0.31)
(þ1.43/e1.19)
(þ1.12/e0.94)
Values back-transformed from logit, resulting in unequal confidence ranges.
Values back-transformed from log, resulting in unequal confidence ranges.
increased during active treatment. The values obtained at the end
of treatment did not deteriorate during the 4-year follow-up but
further improved slightly.
Self-reported weekly binges, eating disorder pathology (shape,
weight and eating concern) and depressive symptoms, all significantly decreased during the treatment phase, but only eating
concern, shape concern, weight concern, and overvaluation of
weight and shape further improved during the follow-up period.
Similar results were reported in the study of Fichter, Quadflieg, and
Hedlund (2008) over a 12-years course, where significant symptom
reductions in eating disorder pathology, general psychopathology
and depressive symptoms were found. The lack of a decrease of
depressive symptoms during follow-up in our study was also found
in a previous study of Hilbert et al. (2012), examining the long-term
treatment-success in patients suffering from BED. Interestingly, dietary restraint (measured by the EDE-Q) increased during active
treatment. Some of the corresponding subscale items reflect
potentially adaptive behaviors in the context of healthy weight loss
goals, while others are more exclusively associated with eating
disorder pathology. Thus, increasing dietary restraint does not
necessarily represent a worsening of symptoms in this sample.
Regarding BMI, as in other studies there was no significant change
during the treatment phase (Vocks et al., 2010). However, there was
a significant though small decline of BMI of 5% during the follow-up
period. This is in line with previous studies that administered longer
and more intensive treatments and that revealed a significant
decline in BMI between three to six years after BED-treatment of
approximately 5% (Munsch et al. 2012; Ricca et al. 2010). It should be
kept in mind, that a decrease of BMI of 5% is associated with clinically
relevant improvement of risk factors even though individual weight
goals are probably unachievable (Tuomilehto et al., 2001).
Characteristics that are not explicitly targeted by a disorderspecific BED treatment such as anxiety, general life-satisfaction and
self-efficacy did not improve during active treatment or follow-up. As
such, levels of general life satisfaction were already high at baseline
and measures of self-efficacy were low at baseline and remained
comparable to values of persons suffering from coronary-heart diseases or cancer during follow-up (Luszczynska et al., 2005). Anxiety
scores at follow-up were still comparable in their degree of severity to
those obtained by a treatment-seeking sample with subclinical anxiety disorder (Leyfer, Ruberg, & Woodruff-Borden, 2006). Thus, it
seems noteworthy to further evaluate the role of anxiety regarding
the maintenance of disordered eating behavior and decreased psychological well-being in BED patients (Keel, 2013). Future studies
should further focus on the evaluation of additive modules after BED
treatments such as training of emotion regulation (e.g. affect
tolerance) as these can improve general psychopathology and selfefficacy (Luszczynska et al., 2005).
Patients with higher frequency of OBEs or elevated weight or
eating concern at the end of treatment showed less favorable
treatment success in terms of number of OBEs and, for subjects
with weight concern only, lowered remission rate during followup. This is contradictory to the results of Safer, Lively, Telch, and
Agras (2002), where mainly dietary restraint at the end of treatment was predictive of relapse at 6-month follow-up. The comparison of the results of the two studies is hindered by
methodological differences, since Safer and colleagues administered another treatment protocol (DBT vs. CBT), averaged weight
and shape concern, indicated solely effect sizes and applied statistical analyses for dichotomous outcomes. Rapid response has
shown to be a reliable predictor of treatment outcome (Grilo et al.,
2012; Munsch et al., 2012; Schlup et al., 2010) but we didn't find a
corresponding effect in our short-term CBT at 4-year follow-up. In
line with Grilo et al. (2012) we suggest that circumstances under
which rapid response exerts its predictive effect should be further
investigated.
Limitations of the current study are the small sample size
limiting the validity of the findings. Further limitations refer to the
generalizability of the findings, since our sample consisted mostly
of women due to recruiting difficulties in the male population. We
also cannot rule out that adding booster sessions to a short-term
CBT influenced the effect of the initial treatment. When interpreting the long-term efficacy in this study it has to be taken into account that additional health care utilizations as well as the
experience of adverse life events encountered by a substantial part
of our participants may well have had an impact on the course of
the symptomatology during subsequent 4-year follow-up.
Reversely, persisting eating disorder or associated symptoms such
as comorbid conditions may have led to additional treatment
seeking. In order to lower subject burden at 4-year follow-up, solely
self-report measures were applied and interviews were administered by telephone. Whereas the validity of self-report measures as
well as telephone-based interviews seem to be comparable to faceto-face interviews when screening for diagnoses (Lee et al., 2010;
Mond, Hay, Rodgers, Owen, & Beumont, 2004; Sysko et al., 2012),
self-reporting height and weight is more critical.
Conclusions
In conclusion, short-term treatment followed by booster sessions for BED showed preliminary long-term efficacy in this study.
Binge eating symptomatology as well as eating disorder pathology
42
S. Fischer et al. / Behaviour Research and Therapy 58 (2014) 36e42
and depressive symptoms improved markedly during the 8-week
treatment and either slightly further improved or remained stable during the 4-year follow-up period. Future studies should
encompass larger samples and evaluate whether addressing
symptoms such as anxiety and self-efficacy during active treatment
may further improve psychological health and support weight loss
in BED. It should further be investigated, whether tailoring booster
sessions to persons with elevated weight and eating concern at the
end of treatment, lead to an increase of the long-term success in
this subpopulation.
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