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Behaviour Research and Therapy 49 (2011) 219e226

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Behaviour Research and Therapy


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The effectiveness of enhanced cognitive behavioural therapy for eating disorders: An open trial
Susan M. Byrne a, b, *, Anthea Fursland b, Karina L. Allen a, b, Hunna Watson b
a b

University of Western Australia School of Psychology, 35 Stirling Highway Crawley, 6009 Perth, Western Australia, Australia 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 2010 Received in revised form 20 December 2010 Accepted 11 January 2011 Keywords: Eating disorders Anorexia nervosa Bulimia nervosa Eating disorders not otherwise specied Cognitive behaviour therapy Effectiveness

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 the community. The only previously published trial of CBT-E for eating disorders was a randomised controlled trial (RCT) conducted in the U.K. for patients with a BMI  17.5. The current study represents the rst published trial of CBT-E to include patients with a BMI < 17.5. The study involved 125 patients referred to a public outpatient clinic in Perth, Western Australia. Patients attended, on average, 20e40 individual sessions with a clinical psychologist. Of those who entered the trial, 53% completed treatment. Longer waiting time for treatment was signicantly associated with drop out. By the end of treatment full remission (cessation of all key eating disorder behaviours, BMI  18.5 kg/m2, not meeting DSM-IV criteria for an eating disorder) or partial remission (meeting at least 2 these criteria) was achieved by two thirds of the patients who completed treatment and 40% of the total sample. The results compared favourably to those reported in the previous RCT of CBT-E, with one exception being the higher drop-out rate in the current study. Overall, the ndings indicated that CBT-E results in signicant improvements, in both eating and more general psychopathology, in patients with all eating disorders attending an outpatient clinic. 2011 Elsevier Ltd. All rights reserved.

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

* Corresponding author. University of Western Australia School of Psychology, 35 Stirling Highway Crawley, 6009 Perth, Western Australia, Australia. Tel.: 61 8 6488 3579; fax: 61 8 6488 2655. E-mail address: sbyrne@psy.uwa.edu.au (S.M. Byrne). 0005-7967/$ e see front matter 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.brat.2011.01.006

the small number of effectiveness studies in the eating disorders eld by evaluating the generalisability of the newly-devised Enhanced Cognitive Behavioural Treatment (CBT-E) for eating disorders 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., Anorexia Nervosa [AN], Bulimia Nervosa [BN] and Eating Disorder Not Otherwise Specied [EDNOS]). CBT-E stems from the transdiagnostic theory of the processes that maintain all forms of eating disorder (Fairburn et al., 2003). This theory is based on the observation that AN, BN and EDNOS share many distinctive clinical features (Favaro, Ferrara, & Santonastaso, 2003; Turner & BryantWaugh, 2004) including the same core psychopathology characterised by a pronounced tendency to evaluate self-worth in terms of controlling eating, shape or weight (Fairburn et al., 2003). The transdiagnostic model extends the existing, empirically supported cognitive model of BN (Fairburn et al., 1993). It encompasses key maintaining processes such as a dysfunctional scheme for selfevaluation, strict dieting, low weight and the associated starvation syndrome, binge eating and compensatory behaviours, and also includes four additional maintaining mechanisms e clinical perfectionism, core low self-esteem, difculty coping with intense mood states, and interpersonal difculties e which are external to

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the eating disorder psychopathology but, in certain cases, serve to maintain this psychopathology and prevent change. CBT-E is designed as an individualised and modular form of treatment, in which specic modules may be directed at the particular maintaining mechanisms operating in the individual patients 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 with a BMI  17.5 (38% with a diagnosis of BN and 62% with a diagnosis of EDNOS). Patients received 20 50 min sessions, preceded by one 90 min preparatory session. The results indicated that 66.4% of those who completed treatment had a good outcome in that they had 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 signicant differences between BN and EDNOS patients in response to treatment. 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% for EDNOS 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 made during 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 efcacious than the original CBT for BN (Agras et al., 2000). However, this was a single trial and it only involved patients with BN and EDNOS, since a body mass index 17.5 was a specic exclusion criteria. Given the claim that CBT-E is also relevant to AN and the lack of research into evidence-based treatments for this eating disorder, a study that also includes low-weight patients would be of value. The aim of the present study was to investigate the effectiveness and feasibility of conducting CBT-E at a public outpatient clinic for adults with the full range of eating disorders found in the community. We hypothesised that treatment with CBT-E would be associated with signicant post-treatment improvement in both the specic and associated psychopathology of eating disorders, and that the degree of improvement would be comparable to that reported in the previous RCT of CBT-E. This study is the rst effectiveness trial of CBT-E and, moreover, the rst published study of CBT-E to include patients with a BMI < 17.5. Method Recruitment The sample comprised individuals referred to the Centre for Clinical Interventions (CCI) Eating Disorders Service, the only public outpatient eating disorders program for youth and adults in Perth, Western Australia. Patients were recruited between March 2005 and February 2009 from consecutive referrals from general practitioners, psychiatrists and clinical psychologists. To be considered for treatment, the patient had to be 16 years or older, and full the Diagnostic and Statistical Manual, Fourth Edition (DSM-IV; American Psychiatric Association, 1994) criteria for AN, BN or EDNOS (except for BED, which is not treated at this clinic), as judged by the assessing clinician according to the EDE. The clinical protocol in this study followed normal practice in this community clinic. Thus patients were only excluded from the trial if their current clinical state made it inappropriate for them to receive outpatient treatment for an eating disorder (i.e., if they were acutely suicidal, psychotic, substance dependent or had a BMI < 14; N 6) or if they did not give written consent to release their de-identied data for evaluation and research purposes (N 8). As CCI is a public clinic, there is a relatively lengthy

waiting list for treatment. The mean waiting time between referral and the start of treatment for participants in this trial was 22.24 weeks (SD 14.18; Range 2.00e63.14 weeks). Fig. 1 shows the participant enrolment and ow through the study. Treatment Treatment was conducted on an outpatient basis and followed the protocols outlined in the detailed CBT-E treatment guide (Fairburn et al., 2008). All patients attended 2e3 assessment sessions followed by, on average, 20e40 50 min treatment sessions. The treatment content was the same for all eating disorders, but for low-weight patients, the treatment period was longer to allow for increasing motivation and weight regain. The treatment moved through four stages. The initial stage focused on engaging and educating the patient, creating an initial personalised formulation, and obtaining maximal behaviour change. Stage 2 involved a detailed review of progress and identication of barriers to change, which shaped the remainder of treatment. In Stage 3 the emphasis was on modifying the processes maintaining the patients eating disorder psychopathology. In this stage, the additional maintaining mechanisms of perfectionism, low self-esteem, interpersonal difculties and mood intolerance were also addressed as relevant. In the nal stage, the focus turned to maintenance of gains and relapse prevention. The treatment guide allows some exibility and variability in the number of sessions required to complete each treatment stage and to progress through the entire treatment. In this study, for patients with a BMI  18.5 treatment consisted of around 20 sessions, and for underweight patients treatment involved about 40 sessions. Treatment completion was dened as successful transition through the four stages of treatment, and drop out was dened as non-mutual premature termination of treatment. The patients were treated by one of a team of 4 full-time clinical psychologists. During the 4 years of the trial there was considerable turnover of staff, resulting in a total of 10 therapists being involved in the study. All but one of the therapists (AF) were Clinical Psychology Registrars (i.e., recent graduates from a Masters or PhD level Clinical Psychology program) with little or no experience treating eating disorders previously. SB and AF attended training workshops in CBT-E conducted by Professor Fairburn, and the other therapists involved in this study were trained and supervised by SB and AF. The training consisted of orientation to the treatment and familiarisation with the treatment guide in their rst week of employment at the clinic. The therapists attended weekly individual supervision meetings with AF and a weekly team meeting with AF and SB to discuss cases and adherence to treatment protocol. Meetings included a review of select videotaped sessions to help ensure treatment delity. Assessment Outcome variables The primary outcome variables were categorical measures of recovery. For the purposes of this study, we dened full remission as complete absence of eating disorder symptoms in the last 28 days, that is (i) cessation of all key eating disorder behaviours, e.g., binge eating, purging and severe dietary restriction,1 (ii) BMI  18.5 kg/m2 (the World Health Organisation cut-off for healthy weight) and (iii) not meeting the DSM-IV criteria for an eating disorder. Partial remission was dened as meeting all but one of the above criteria for

1 Cessation of severe dietary restriction was dened as scoring 3 on all of the rst four items of the EDE-Q (Restraint subscale).

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Referral from GP (153), Psychiatrist (2) or Clinical Psychologist (10) other (11) N= 176

Ineligible for trial N=14 (6 not eligible for treatment, 8 did not provide consent for their data to be released)

Assessed for eligibility N=176

Pre-treatment assessment at CCI N=162 (AN=31 BN=58 EDNOS=73)

Excluded (n=37) (32 declined treatment, 5 were not appropriate for CBT-E) Allocated to CBT-E N=125

Completed treatment N=66 (50 dropped out, 5 were withdrawn, 4 moved to another state)

AN 34

BN 40

EDNOS 51

12
Fig. 1. Flow through of trial.

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30

full remission. For example, cessation of all key eating disorder behaviours and having a BMI > 17.5 kg/m2 but <18.5 kg/m2; or having a BMI  18.5 kg/m2, not meeting DSM-IV criteria for an eating disorder, but reporting 1 or 2 episodes of binge eating in the last 28 days; or cessation of all key eating disorder behaviours and having BMI  18.5 kg/m2 but still experiencing amenorrhea. Patients were classied as in full remission, in partial remission, or not recovered by the treating team, based on clinical judgement and patient responses on the Eating Disorder Examination Questionnaire (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 having a score on the global subscale of the EDE-Q that is less than 1 standard deviation (SD) above Australian community norms (i.e., below 2.46; Mond, Hay, Rogers, & Owen, 2006) and the second was having a score on the global subscale of the EDE-Q that is less than 1 SD above community norms in addition to a BMI  18.5 kg/m2. Secondary outcome variables included (i) dimensional measures of change in the severity of eating disorder features e.g., binge eating, compensatory behaviours, dietary restraint, eating, weight and shape concerns, (ii) measures of additional variables specied in the transdiagnostic model (perfectionism, interpersonal functioning, mood intolerance, self-esteem) and (iii) measures of other associated psychopathology such as depression, anxiety, stress, self-esteem and quality of life.

Measures Diagnosis was established during pre-treatment assessment using the 12th edition of the EDE. The EDE was administered by the treating clinicians who had been trained in its administration by SB. Height and weight were measured using a Harpenden stadiometer and 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 pre and post treatment using the following measures: The 10-item Rosenberg Self-Esteem Scale (RSE; Rosenberg, 1965); the Perfectionism subscale of the Eating Disorder Inventory (EDI; Garner, Olmstead, & Polivy, 1983); the Distress Tolerance Scale (DTS; Corstorphine, Mountford, Tomlinson, Waller, & Meyer, 2007); the Inventory of Interpersonal Problems (IIP-32; Horowitz, Rosenberg, Baer, Urneo, & Villasenor, 1988) the short form of the Depression Anxiety and Stress Scales (DASS; Lovibond & Lovibond, 1995); and the short form of the Quality of Life Enjoyment and Satisfaction Questionnaire (QLESQ-SF; Endicott, Nee, Harrison, & Blumenthal, 1993). In addition, patients ratings of treatment credibility and the likely effectiveness of the treatment were assessed during the rst treatment session using the 6-item Credibility/Expectancy Questionnaire (CEQ; Borkovec & Nau, 1972; Devilly & Borkovec, 2000). Three items assess credibility and 3 items assess expectations. Summary scores for the 2 subscales range from 3 to 27.

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Data analytic strategy Treatment outcome data were analysed using both completer and intent-to-treat approaches. In instances in which a nal measure was missing, initial (pre-treatment) data were carried forward. Pre- to post-treatment change scores were calculated. Data are presented as Ns and percentages for categorical data and means and standard deviations for continuous data, with 95% condence intervals used to indicate the uncertainty around the estimates as appropriate. Continuous pre- and post-treatment data were compared using paired t-tests (for normally distributed variables) or Wilcoxon signed-rank tests (for non-normally distributed variables) and categorical data were analysed with McNemars tests. For data assessed at one time point, categorical data were compared using Chi-square tests. All tests were twotailed and p value of <0.001 was used to indicate statistical signicance. Effect sizes were calculated using Cohens d. Results Patient characteristics One hundred and seventy six patients were referred and assessed for individual treatment at CCI, between March 2005 and February 2009. Almost all patients (86.5%) were referred by their general practitioner, with a small number being referred by clinical psychologists (6.2%), psychiatrists (1.1%), or other mental health professionals (6.2%). Of these 176 patients, 125 (70%) entered the trial. By comparison, only 42.7% of those patients assessed for eligibility 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 eating disorder was not sufciently severe or because they were under age 18; 114 met exclusion criteria (12 had previously received treatment resembling CBT-E for an eating disorder, 22 had a co-existing Axis 1 psychiatric disorder that precluded eating disorder-focused treatment and 39 were not available for the 28 weeks of treatment); and 41 declined to participate. Of the 51 not entered into the current trial, 14 were not eligible for treatment (1 was psychotic, 2 were diagnosed with BED, 3 had no diagnosable eating disorder, 8 did not provide consent) and 37 did not progress from assessment to CBT-E (4 were 16 year old patients who were offered family based therapy instead of CBT-E, 1 patient was found to be suffering from cancer, and 32 patients declined treatment). Of the 125 patients who entered treatment 34 (27.2%) had a 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 diagnosis are presented in Table 1. Patients with AN, BN and EDNOS were similar on almost all baseline characteristics, except that patients with AN had lower minimum and maximum adult weights than those with BN or EDNOS and were more likely to have been hospitalised previously for treatment of their eating disorder. With regard to these baseline characteristics, our sample appeared to be very similar to that described in the Fairburn et al. (2009) trial, with the exception that our participants were more likely to have had previous treatment for an eating disorder (34% vs 20%) and were more likely to be suffering from a current depressive episode (31% vs 20%). Treatment credibility and patient expectations On the CEQ, which was administered after assessment and immediately before the initial treatment session, the ratings were

Table 1 Characteristics of the sample by diagnosis. Characteristic All patients (N 125) N Female Ethnicity White Asian Other Marital status Single, never married Married or de facto Separated/divorced Widowed Occupation Management/Professional Skilled Unskilled Home duties/student/unemployed Retired Unknown Prior psychological treatment Prior inpatient eating disorder treatment Currently on psychotropic medication Current depressive episode Any anxiety disorder Age (years) Duration of eating disorder (years) Lowest adult weight (kg) Highest adult weight (kg) 122 115 2 8 81 38 5 1 24 37 1 61 0 2 102 42 45 39 26 Mean 26.03 7.79 45.14 63.47 % 97.6 92.0 1.60 6.40 64.80 30.40 4.00 0.80 20.0 29.6 0.8 48.8 0 1.6 81.6 33.6 36.0 31.2 20.8 SD/range 9.41 9.00 0.5e59 9.50 23.95e80.00 12.56 43.00e110.0 Anorexia Nervosa (N 34) N 32 30 1 3 21 11 2 0 6 8 1 18 0 1 26 16 14 6 7 Mean 26.82 10.13 38.36a 57.86a % 94.1 88.2 2.9 8.8 61.8 32.3 5.9 0 17.6 23.5 2.9 53.0 0 2.9 76.5 47.1a 41.2 17.6 20.6 SD/range 12.37 14.00 0.5e59 7.41 23.9e59 9.88 43.00e80.00 Bulimia Nervosa (N 40) N 40 36 0 4 24 15 1 0 9 13 0 17 0 1 31 11 16 12 8 Mean 27.44 7.70 49.84b 68.21b % 100 90.0 0 10.0 60.0 37.5 2.5 0 22.5 32.5 0.0 42.5 0 2.5 77.5 28.2b 40.0 30.0 20.0 SD/range 8.02 6.43 0.5e22 7.32 32e72 12.36 47e100 EDNOS (N 51) N 50 49 1 1 36 12 2 1 9 16 0 26 0 0 45 15 15 22 11 Mean 24.43 6.63 46.27b 63.44ab % 98.0 96.1 2.0 2.0 70.6 23.5 3.9 2.0 17.6 31.4 0 51.0 0.0 0 90.0 29.4b 29.4 43.1 21.6 SD/range 7.96 7.45 0.5e35 9.50 32e80 12.99 45e110

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 signicant differences between groups.

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high and indicated that participants (i) perceived the treatment as credible (mean 22.28, SD 4.98) and (ii) expected the treatment to be useful (mean 19.06, SD 5.52). There were no signicant differences in perceptions of credibility or treatment expectations between the diagnostic groups.

Attrition Of the 125 patients who started treatment, 50 (40.0%) dropped out of treatment, 5 (4.0%) were withdrawn (3 moved out of state, 1 fell pregnant and 1 died) and 4 (3.2%) were transferred to another service (3 to an inpatient psychiatric unit and 1 to a sexual assault referral centre). The drop-out rates were 50% (17/34) for patients with AN, 35.0% (14/40) for patients with BN and 37.3% (19/51) for patients with EDNOS (X2 (2) 3.83, p .147). The mean number of treatment sessions attended was 31.73 for treatment completers (range 5e100) and 12.29 for non-completers (range 1e55). Across the diagnoses the mean number of sessions attended for completers and non-completers respectively were: for AN 46.73 (range 26e77) and 13.45 (range 1e48), for BN 27.75 (range 14e51) and 9.44 (range 1e29), and for EDNOS 29.15 (range 5e100) and 13.3 (range 1e55). There were no signicant differences between completers and non-completers on any pretreatment measures except that, compared to non-completers, completers reported a higher minimum (47.81 kg [SD 9.77] vs 42.08 kg [SD 8.26]) and maximum (65.90 kg [SD 13.58] vs 60.72 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 signicant difference in waiting time for treatment (weeks between referral and start of treatment) between completers and non-completers, with non-completers having a longer mean waiting time than completers, t (108) 2.05, p < .05, (25.90 weeks [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) fullled our criteria for full remission e and an additional 8.0% (10/125) for partial remission. Almost half of the sample (42.4%; 53/125) had a 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-treatment global EDE-Q score <2.46 in addition to a BMI  18.5 kg/m2. The mean change in global EDE-Q score over treatment was 1.11 (95% CI 0.85 to 1.38).

For those patients who completed treatment, the outcomes were even more positive. By the end of treatment 56.1% of treatment completers (37/66) were in full remission and an additional 10.6% (7/66) were in partial remission. Almost 70% of treatment completers (44/66; 66.7%) had a post-treatment score on the global subscale 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 in addition to a BMI  18.5 kg/m2. 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 each diagnostic category for both treatment completers and the intentto-treat sample. As shown in Table 2, in the intent-to-treat sample patients with AN had lower rates of recovery than those with BN or EDNOS. However, this was not the case for treatment completers, except when recovery was dened as having a post-treatment global EDE-Q score < 2.46 plus a BMI  18.5. Table 3 presents the pre- and post-treatment scores on the measures of eating and more general psychopathology used in this study. For both treatment completers and the total sample, there were signicant improvements over treatment on all of the eatingrelated 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, change in global EDE-Q score and change on other measures of psychopathology) no differences were found between the subset of patients on psychotropic medication (N 45) and those not on medication. Comparison with the Fairburn et al. (2009) RCT Table 4 presents a comparison of the results from the current Western Australian (WA) trial with the results from the previous Fairburn et al. (2009) OxfordeLeicester RCT of CBT-E on equivalent outcome variables. Since the Fairburn et al. trial only involved patients with a pre-treatment BMI > 17.5, the WA sample was categorised into 2 groups (BMI  17.5 vs BMI > 17.5) so that a direct comparison between the 2 studies was possible for the patients with a BMI > 17.5. In the Fairburn et al. (2009) trial, good outcome was dened as having a post-treatment global EDE score < 1 SD above U.K. community norms (<1.74). However, the WA study used the EDE-Q rather than the EDE in the post-treatment assessment (since it was not feasible to administer the EDE). Thus, for the purposes of this comparison, good outcome in the WA study was dened as having a post-treatment global EDE-Q score < 1 SD above 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. Denition of outcome Treatment completers Total (N 66) Full remission (No ED symptoms over the past 28 days) Full or partial remission Post-Tx Global EDE-Q < 2.46 Post-Tx Global EDE-Q < 2.46 plus BMI  18.5 kg/m2 Denition of outcome Full remission (No ED symptoms over the past 28 days) Full or partial remission Post-Tx Global EDE-Q < 2.46 Post-Tx Global EDE-Q < 2.46 plus BMI  18.5 kg/m2 37 (56.1%) 44 (66.7%) 44 (66.7%) 37 (56.1%) Intention-to-treat sample Total (N 125) 40 (32.0%) 50 (40.0%) 53 (42.4%) 39 (31.2%) AN (N 12) 6 (50.0%) 6 (50.0%) 8 (66.7%) 3 (25.0%)a BN (N 24) 12 (50.0%) 16 (66.7%) 17 (70.8%) 17 (70.8%)b EDNOS (N 30) 19 (63.3%) 22 (73.3%) 19 (63.3%) 17 (56.7%)b

AN (N 34) 6 (17.6%)a 6 (17.6%)a 13 (38.2%) 3 (8.8%)a

BN (N 40) 13 (32.5%)b 18 (45.0%)b 18 (45.0%) 18 (45.0%)b

EDNOS (N 51) 21 (41.2%)b 26 (51.0%)b 22 (43.1%) 18 (35.3%)b

Note: Different superscripts denote signicant differences between groups.

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Table 3 Pre- and post-treatment scores on measures of eating and more general psychopathology. Variable Treatment completers (N 66) Pre N (%) Eating Disorder Symptoms Objective bulimic episodes Self-induced vomiting Laxative misuse Driven exercise Any of the above Absence of all of the above Cessation of all these forms of behaviour, if present at baseline EDE-Q Global Dietary Restraint Eating Concern Weight Concern Shape Concern Body Mass index DASS Depression Anxiety Stress Perfectionism Interpersonal difculties Distress Tolerance Anticipate and Distract Avoidance of Affect Accept and Manage Emotions Self-Esteem Quality of Life Note. **p < 0.001. 41 37 13 41 58 8 (62.1) (56.1) (19.7) (62.1) (87.9) (12.1) Post N (%) 15 19 1 10 28 38 29/58 (22.7)** (29.8)** (1.5)** (15.1)** (42.4)** (57.6)** (50.0) d 1.49 1.81 1.75 1.87 1.67 -0.29 1.21 1.06 1.36 0.13 1.00 0.25 0.16 0.33 1.00 1.20 Effect size All patients (N 125) Pre N (%) 79 (63.2) 69(55.2) 24 (19.2) 69 (55.2) 105 (84.0) 20 (16.0) Post N (%) 46 46 7 26 57 68 48/105 (36.8)** (36.8)** (5.60)** (20.8)** (45.6)** (54.4)** (45.7) d 0.68 0.66 0.63 0.62 0.63 -0.13 0.53 0.55 0.62 0.11 0.50 0.05 0.14 0.16 0.54 0.50 Effect size

Mean (SD) 3.89 3.64 3.30 4.23 4.50 20.20 17.43 9.94 19.16 8.10 1.50 1.64 1.31 1.71 23.17 49.84 (1.15) (1.50) (1.40) (1.28) (1.20) (3.64) (12.09) (7.21) (8.71) (5.41) (0.52) (0.64) (0.58) (0.80) (5.24) (17.63)

Mean (SD) 1.82 1.16 1.07 1.58 2.06 21.23 5.21 3.17 8.36 7.39 0.97 1.82 1.21 1.98 28.62 68.32 (1.58)** (1.21)** (1.12)** (1.53)** (1.66)** (3.46) (7.40)** (5.37)** (6.99)** (5.22) (0.53)** (0.81) (0.69) (0.81) (5.62)** (12.42)**

Mean (SD) 3.96 3.77 3.38 4.13 4.53 19.8 18.90 11.71 21.45 8.23 1.54 1.68 1.48 1.65 22.36 49.08 (1.28) (1.64) (1.48) (1.52) (1.34) (4.55) (12.60) (9.28) (9.70) (5.69) (0.60) (0.68) (0.68) (0.76) (5.17) (16.99)

Mean (SD) 3.00 2.80 2.50 3.13 3.57 20.40 (1.77)** (2.04)** (1.81)** (2.07)** (1.98)** (3.82)

13.78 (13.02)** 8.99 (9.94)** 16.93(11.45)** 7.90 (5.68) 1.33 (0.67)** 1.71 1.42 1.74 24.50 55.68 (0.74) (0.74) (0.78) (6.20)** (18.09)**

Table 4, the main point of difference between the 2 trials was the drop-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 among patients with a pre-treatment BMI  17.5) was almost exactly the same as the percentage of the total sample achieving good outcome in the Fairburn et al. trial. In addition, the percentage of the total sample (intention-to-treat) who ceased binge eating and purging was almost identical in the 2 trials for patients with a pretreatment BMI > 17.5 (although this percentage was lower for the low-weight WA patients). Discussion The aim of this study was to evaluate the effectiveness and feasibility of CBT-E as a treatment for all eating disorders, including low-weight patients, in a sample of adults presenting to a public outpatient clinic. It was expected that treatment with CBT-E would result in substantial improvements in both the specic and associated psychopathology of eating disorders and that, for patients

with a BMI > 17.5, the degree of improvement would be similar to that reported in the RCT of CBT-E (Fairburn et al., 2009). No previous published trials of CBT-E have involved patients with a BMI  17.5. In terms of effectiveness, the results did indeed support the hypothesis that CBT-E would result in signicant improvements in both 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 full remission and an additional 10.6% in partial remission) and 40% of the total sample (32% in full remission and an additional 8% in partial remission). With regard to binge eating and compensatory behaviours (self-induced vomiting, laxatives and driven exercise) it was found that, of those reporting these at baseline, 50% of treatment completers and 45.7% of the total sample had ceased all of these behaviours by the end of treatment. Substantial improvements were also found on measures of depression, anxiety, stress, interpersonal difculties, self-esteem and quality of life, for both completers and the intent-to-treat sample. The changes in scores from pre to post treatment on all of these variables were associated with medium to large effect sizes.

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 BMI  17.5 N Drop-out rate (%) Good outcome total sample (%) Good outcome completers (%) Cessation of binge eating and purging if present at baseline (ITT) (%) 125 40 54 (42.4) 44/66 (66.7) 37/93 (39.8) 40 54.3 18 (45.0) 11/16 (68.8) 6/20 (30.0) BMI > 17.5 85 38.3 35 (41.2) 33/50 (66.0) 31/73 (42.5) Fairburn et al. Trial Total sample (all BMI > 17.5) 149 22.1 79 (53.0) 77/116 (66.4) 55/130 (42.30)

Note. Good outcome was dened 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 patients with a pre-treatment BMI > 17.5, good outcome (dened as having a post-treatment global EDE score < 1 SD above community norms), was achieved by 66.4% of treatment completers and 51.3% of the total sample. Using an equivalent denition (having a global EDE-Q score < 1 SD above Australian community norms) among participants in the WA trial with a BMI > 17.5, good outcome was achieved by 66.0% of treatment completers and 41.2% of the total sample. 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 total sample reported no episodes of binge eating or purging over the previous 28 days. Thus, the outcome for CBT-E with these patients appears to be positive and similar regardless of whether it is conducted in an outpatient clinic setting or in the context of a RCT. The current study is the rst to report treatment outcome for CBT-E with low-weight AN patients. In this study, full or partial remission was achieved by 50.0% of AN patients (6/12) who completed treatment, compared to 66.7% of BN patients (16/24) and 73.3% of EDNOS patients (22/30). When good outcome was dened according to post-treatment global EDE-Q score, the percentage of AN patients achieving good outcome was 66.7% for treatment completers. When the total sample was considered, however, the outcomes for AN were poorer than those for BN and EDNOS due to the high drop-out rate among the AN patients (50% vs 35% and 37.3% respectively). Thus, overall, the results do appear to indicate that CBT-E may be less effective for AN than for the other eating disorders. While Fairburn et al. have not yet published outcome data regarding the use of CBT-E with AN patients, preliminary results of a multi-site RCT have indicated that CBT-E is appropriate for about 60% 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 provides an appropriate comparison for the current WA study in that they have involved outpatient psychological treatments, an adult sample, 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 (not meeting DSM-IV criteria for any eating disorder) of 30% at the end of a 1-year treatment period, and 33% 3 years later. Dare, Eisler, Russell, Treasure, and Dodge (2001) reported good outcome (recovered or signicantly improved) in 32.3% of a sample of adults with AN (BMI < 17.5) after 1 year of treatment with cognitive analytic therapy, focal psychotherapy or family therapy. The overall drop-out rate was 37%. McIntosh et al. (2005) compared 3 outpatient treatments for patients with a BMI of 15e19 kg/m2 (CBT, Interpersonal Therapy and Non-specic Supportive Clinical Management). Good outcome across the 3 treatment conditions was observed in 45% of treatment completers and 30% of the total sample, and there was a 38% drop-out rate. Therefore the outcome for CBT-E with the AN patients in our WA study is comparable to that reported in these studies, except for our higher drop-out rate. Indeed, overall attrition rate is an important point of difference between 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 total sample) was not outside the realm of drop-out rates reported for outpatient trials of eating disorders (29e73%; Fassino, Piero, Tomba, & Abbate-Daga, 2009), it is much higher than the dropout 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 the therapeutic alliance very positively. The high drop-out rate in the WA study may be partly due to the fact that the sample consisted of patients attending an inner-city public clinic offering free treatment, where commitment to treatment may be more limited than in a research trial. However, both sites in the Fairburn et al. trial (Oxford and Leicester) were providing the main outpatient eating disorder services locally, and both also offered free treatment. It is also notable that the majority (70%) of patients assessed for eligibility at the W.A. site actually entered the trial, compared to less than half (42.7%) of those assessed in the Fairburn et al. trial; and the prevalence of co-morbid depression 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 may include the waiting time for treatment, the experience level of the therapists and staff turnover. While in RCTs there is generally no waiting list, in the W.A. trial, on average, patients were on a waiting list for treatment for over 5 months, and the waiting time was almost twice as long for drop outs (around 6.5 months) than for treatment completers (around 3.5 months). As the period of time between referral and the start of treatment increases, it is possible that patients level of motivation may diminish or that their circumstances may change in such a way as to affect their commitment to, or desire for, treatment. The majority of the therapists in the W.A. trial was relatively inexperienced and had not received the same amount of formal training and supervision in CBT-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 in the future. Interestingly, in the current study, there was no overall improvement noted on measures of perfectionism or mood intolerance at the end of treatment. These constructs are 2 of the additional purported maintaining mechanisms which have been included in the transdiagnostic model (Fairburn et al., 2003) and which are specically targeted in CBT-E, if relevant, during the third stage of treatment. The lack of change in these variables overall may reect the fact that only a subset of patients (those for whom perfectionism or mood intolerance were particularly problematic) received these treatment modules. Additional analyses were conducted with patients classied into high (above the mean for eating disorder patients) and low groups on pre-treatment measures of perfectionism and mood intolerance. For perfectionism, there was a signicant group by time (pre to post treatment) interaction F (1,59) 8.63, p < 0.01, h .12, such that patients initially high on perfectionism did show a signicant decrease in perfectionism over treatment, t(1,31) 2.51, p < .01, whereas those initially low on perfectionism, as would be expected, did not. Thus, it appears that perfectionism did improve signicantly in patients for whom perfectionism was a problem. This was not the case for mood intolerance. Patients scoring highly on the DTS pre-treatment did not show improvement on this measure over treatment. One explanation for this may relate to our previous observation that current measures of mood intolerance are less than adequate (Raykos, Byrne, & Watson, 2009). Alternatively, the mood intolerance treatment module in CBT-E may not be potent enough to fully address this complex construct. In terms of feasibility, the current study offers evidence that CBT-E can be effectively delivered in a community clinic by therapists with little experience in treating eating disordered patients without extensive training or time-consuming supervision. The amount of training and the degree of supervision required for the therapists involved in this study were considered to be appropriate and realistic for a public outpatient clinic.

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S.M. Byrne et al. / Behaviour Research and Therapy 49 (2011) 219e226 Fairburn, C. G., Cooper, Z., & Shafran, R. (2003). Cognitive behaviour therapy for eating disorders: a transdiagnostic theory and treatment. Behaviour Research and Therapy, 41, 509e528. Fairburn, C. G., Cooper, Z., Shafran, R., Bohn, K., Hawker, D. M., Murphy, R., et al. (2008). Enhanced cognitive behaviour therapy for eating disorders: the core protocol. In C. G. Fairburn (Ed.), Cognitive behavior therapy and eating disorders. New York: Guildford Press. Fairburn, C. G., Marcus, M. D., & Wilson, G. T. (1993). Cognitive-behavioural therapy for binge eating and bulimia nervosa: a comprehensive treatment manual. In C. G. Fairburn, & G. T. Wilson (Eds.), Binge eating: Nature, assessment and treatment (pp. 361e404). New York: Guilford Press. Fassino, S., Piero, A., Tomba, E., & Abbate-Daga, G. (2009). Factors associated with dropout from treatment for eating disorders: a comprehensive literature review. 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A major strength of this study was that it was able to evaluate a newly-devised treatment (CBT-E) in an open trial in a public outpatient setting. In addition, the range of standardised measures used in this study allowed for a comparison of the ndings with the only previous RCT of CBT-E. Limitations of the study are those that are commonly associated with a naturalistic effectiveness trial, such as lengthy waiting lists, high staff turnover, high attrition rates and lack of follow-up data. At this stage, we are in the process of collecting follow-up data for the sample described in this study, and we hope to have these data available for a subsequent publication. However, in contrast to formal RCTs where participants commit to completing post-treatment assessments and attending follow-up assessment sessions, to date we have had limited success in getting participants to attend follow-up sessions or to respond to written or telephone requests to provide follow-up data. An additional limitation was the fact that therapist adherence to the treatment protocol was not directly measured. Rather, adherence was monitored via weekly supervision and team meetings with SB and AF which included reviewing video recordings of a random selection of treatment sessions. In conclusion, this study represented the rst effectiveness trial of CBT-E for all eating disorders including AN patients with a BMI < 17.5. Overall, CBT-E was found to result in signicant improvements in both eating disorder and general psychopathology. With regard to eating disorder features, CBT-E was shown to be highly effective for about 40% of patients who entered treatment, and for over two thirds of patients who completed treatment. These results compare favourably in many respects to those reported in the only RCT of CBTE, with one exception being the considerably higher drop-out rate in the WA study. The ndings provide strong evidence that CBT-E, as conducted in a RCT, is generalisable to treatment conducted in a real world clinical setting and feasible as a treatment conducted by therapists with a range of clinical experience.

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