The Role of Regular Eating and Self-Monitoring in the Treatment of Bulimia Nervosa: A Pilot Study of an Online Guided Self-Help CBT Program.

behavioral sciences Article The Role of Regular Eating and Self-Monitoring in the Treatment of Bulimia Nervosa: A Pilot Study of an Online Guided Self-Help CBT Program Sarah Barakat 1, *, Sarah Maguire 2 , Lois Surgenor 3 , Brooke Donnelly 4 , Blagica Miceska 2 , Kirsty Fromholtz 2 , Janice Russell 5 , Phillipa Hay 6 and Stephen Touyz 1 1 2 3 4 5 6 * School of Psychology, University of Sydney, Sydney, NSW 2006, Australia; Centre for Eating and Dieting Disorders, Boden Institute, University of Sydney, Sydney, NSW 2006, Australia; (S.M.); (B.M.); (K.F.) Department of Psychological Medicine, University of Otago at Christchurch, Christchurch 8140, New Zealand; Sydney Local Health District, Sydney, NSW 2006, Australia; School of Medicine, University of Sydney, Sydney, NSW 2006, Australia; Translational Health Research Institute, School of Medicine, Western Sydney University, Sydney, NSW 2751, Australia; Correspondence: ; Tel.: +61-422-047-689 Received: 28 April 2017; Accepted: 21 June 2017; Published: 26 June 2017 Abstract: Background: Despite cognitive behavioural therapy (CBT) being regarded as the first-line treatment option for bulimia nervosa (BN), barriers such as its time-consuming and expensive nature limit patient access. In order to broaden treatment availability and affordability, the efficacy and convenience of CBT could be improved through the use of online treatments and selective emphasis on its most ‘potent’ components of which behavioural techniques form the focus. Method: Twenty-six individuals with BN were enrolled in an online CBT-based self-help programme and 17 completed four weeks of regular eating and food-monitoring using the online Food Diary tool. Participants were contacted for a weekly check-in phone call and had their bulimic symptom severity assessed at five time points (baseline and weeks 1–4). Results: There was a significant decrease in the frequency of self-reported objective binge episodes, associated loss of control and objective binge days reported between pre- and post-treatment measures. Significant improvements were also observed in most subscales of the Eating Disorder Examination-Questionnaire. Conclusion: This study provides encouraging preliminary evidence of the potential of behavioural techniques of online CBT in the treatment of BN. Online therapy with this focus is potentially a viable and practical form of treatment delivery in this illness group. These preliminary findings support the need for larger studies using control groups. Keywords: bulimia nervosa; online treatment; self-monitoring; regular eating; cognitive behavioural therapy; objective binge episodes; purging 1. Introduction Therapist-led cognitive behavioural therapy (CBT) currently forms the most empirically validated treatment for bulimia nervosa (BN), and accordingly is widely recommended as the first line treatment for adults with BN [1,2]. However, the empirical support which this “gold-standard” treatment enjoys is challenged by the statistic that on average only 23.2% of eating disorder (ED) sufferers actually access treatment [3], with this figure substantially lower in some urban and rural regions with no specialist ED services [4]. Importantly, the quality of CBT delivered in the community is inconsistent. Tobin, Banker, Weisberg and Bowers [5] report that only 6% of clinicians adhere to an evidence-based Behav. Sci. 2017, 7, 39; doi:10.3390/bs7030039 www.mdpi.com/journal/behavsci Behav. Sci. 2017, 7, 39 2 of 17 manualised version of CBT for eating disorders (EDs), concluding that therapist ‘drift’ from CBT is the norm rather than the exception [6]. Moreover, CBT for BN is a specialist treatment, which for a routine delivery costs US$6000.00 per individual case [7], with the Australian healthcare system rebating less than half of the CBT sessions for a routine case treated by a psychologist [4]. Modification of CBT-BN structure and delivery is vital to ensure treatment is accessible [8]. Broadening the format of CBT delivery beyond the current therapist-led structure to an online, self-help program will offset the shortage of ED specialist clinicians. Additionally, overcoming the lengthy nature of CBT-BN can be achieved through investigation of the most powerful therapeutic components of CBT-BN, of which behavioural techniques are a promising candidate [9]. 1.1. Treatment Delivery Formats to Increase Access In order to address barriers to accessing treatment, a number of alternative treatment formats have evolved. These are briefly reviewed. 1.1.1. Guided Self-Help Various forms of guided self-help for BN have been available for several decades now, allowing a body of research to have evolved assessing its effectiveness. People who receive professional therapeutic support throughout their self-help treatment program display superior treatment outcomes to those independently engaging in self-help, producing equivalent outcomes to therapist led CBT for one-third of BN patients [10]. Accordingly, the addition of monthly thirty-minute guidance sessions for patients’ observing Fairburn’s Overcoming Binge Eating self-help manual [11] raised symptomatic improvement from 25% for those receiving no guidance, to 36% for telephone guidance and 50% for face-to-face guidance [12]. Supervision requirements for self-help treatment options are one-fifth of that required for a complete CBT course [13], advocating for a “stepped-care” approach which allows for the appropriate allocation of therapeutic skills according to one’s clinical severity [14,15]. 1.1.2. Online Self-Help The successful application of CBT’s primary principles into recent technological advancements has been demonstrated across a range of formats including online programs [16–21], email correspondence [22,23], text messaging [24] and CD-ROM programs [25]. Pretorius et al. [19] recently evaluated a web-based CBT intervention consisting of eight 30–40 min interactive online sessions for a sample of 101 patients diagnosed with BN or eating disorder not otherwise specified (EDNOS) with bulimic features. In addition to weekly email support, completion of the eTherapy program resulted in a significant improvement in the frequency of objective binge episodes (OBEs), purge episodes and global Eating Disorder Examination (EDE) [26] maintained at the six-month follow up. Additional support for eTherapy has been provided by a study of 75 BN or EDNOS patients of whom 25.8% displayed abstinence from bulimic behaviours following engagement in an eight-session online CBT-based program [21]. These findings are comparable to the 20% and 30% post-treatment abstinence from bulimic behaviours observed following the use of manual-based CBT self-help books and face-to-face CBT treatment, respectively [10,14]. Self-monitoring via a technological device upholds numerous benefits to traditional pen and paper methods, including in-built reminders to prompt higher completion, more ecologically valid data, (...truncated)