Emotional and Social Mind Training: A Randomised Controlled Trial of a New Group-Based Treatment for Bulimia Nervosa

et al. (2012) Emotional and Social Mind Training: A Randomised Controlled Trial of a New Group-Based Treatment for Bulimia Nervosa. PLoS ONE 7(10): e46047. doi:10.1371/journal.pone.0046047 Emotional and Social Mind Training: A Randomised Controlled Trial of a New Group-Based Treatment for Bulimia Nervosa Anna Lavender 0 Helen Startup 0 Ulrike Naumann 0 Nelum Samarawickrema 0 Hannah DeJong 0 Martha Kenyon 0 Frederique van den Eynde 0 Ulrike Schmidt 0 James Coyne, University of Pennsylvania, United States of America 0 1 Eating Disorders Service, South London and Maudsley NHS Foundation Trust, Maudsley Hospital , London , United Kingdom , 2 Department of Biostatistics and Computing, Institute of Psychiatry, King's College London , London , United Kingdom , 3 Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, King's College London , London , United Kingdom Objective: There is a need to improve treatment for individuals with bulimic disorders. It was hypothesised that a focus in treatment on broader emotional and social/interpersonal issues underlying eating disorders would increase treatment efficacy. This study tested a novel treatment based on the above hypothesis, an Emotional and Social Mind Training Group (ESM), against a Cognitive Behavioural Therapy Group (CBT) treatment. Method: 74 participants were randomised to either ESM or CBT Group treatment programmes. All participants were offered 13 group and 4 individual sessions. The primary outcome measure was the Eating Disorder Examination (EDE) Global score. Assessments were carried out at baseline, end of treatment (four months) and follow-up (six months). Results: There were no differences in outcome between the two treatments. No moderators of treatment outcome were identified. Adherence rates were higher for participants in the ESM group. Discussion: This suggests that ESM may be a viable alternative to CBT for some individuals. Further research will be required to identify and preferentially allocate suitable individuals accordingly. Trial Registration: ISRCTN61115988 PLOS ONE | www.plosone.org - Funding: Hannah Dejong, Martha Kenyon, Ulrike Naumann and Ulrike Schmidt were supported by the National Institute for Health Research (NIHR) specialist Biomedical Research Centre for Mental Health award at South London and Maudsley NHS Foundation Trust and Institute of Psychiatry, Kings College London, and via the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research Scheme (RP-PG-0606-1043). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. Bulimia nervosa (BN) is a common and disabling disorder, particularly in young women [1,2] with a high burden on the individual, their families and society [3,4,5]. Treatment for BN has undergone significant development over the last decade. Cognitive Behaviour Therapy (CBT) for BN has proved an effective treatment for many sufferers, and a specific form of CBT (CBTBN) [6,7], is the first-line psychological treatment recommended by the National Institute for Clinical Excellence (NICE). Individual and group formats of this treatment have been tested, with comparable efficacy [8,9]. However, although promising, only 30 to 40% of people are symptom free at the end of treatment with CBT [10]. A recognition of the need to improve treatment outcomes has led to the development of a form of CBT designed to address a broader range of putative maintaining factors [11]. However a large RCT (n = 154 patients) comparing the more focused (CBTEf) version of CBT-BN with the broader (CBT-Eb) version failed to show any difference in outcome, either at the end of treatment or at five-year follow up, with half the sample retaining a level of eating disorder pathology one standard deviation above the community mean [12]. Thus, the need to develop more effective treatments for this condition remains. Exploring New Targets for Treatment of Bulimia One possibility is that CBT has over-focused on targeting the overt symptoms of BN (bingeing and compensatory behaviours) at the expense of the broader intra- and interpersonal attitudes, affects and behaviours typical of the disorder. The potential utility of focussing on interpersonal difficulties in BN has been recognised in the development of Interpersonal Psychotherapy (IPT) for BN [13], for which outcomes are comparable to those seen in CBT (e.g. [14,15]), albeit at a slower pace. IPT focuses on one of four possible domains of interpersonal difficulties for an individual. In a recent systematic review which explored factors predicting poor outcome in eating disorders, two key factors emerged for BN: poor social/interpersonal functioning and negative self-evaluation [16]. Thus while IPT does address interpersonal functioning, its focus on one particular domain for an individual means that the broader social and emotional context of these difficulties and how they relate to an individuals sense of self, are not addressed. Dialectical behaviour therapy, which does emphasise interpersonal difficulties, emotional dysregulation and distress tolerance, has recently been adapted for individuals with BN and borderline personality disorder. In a small study of this treatment, Chen et al [17], found large effects in terms of reductions in bulimic symptoms. However this treatment involves a much greater therapeutic input than is possible within most outpatient contexts, involving six months of individual therapy, six months of group therapy, and 24 hours of telephone coaching Social/interpersonal functioning in Bulimia. There is substantial evidence to suggest that many women with BN experience difficulties in the social domain during childhood [18,19]. Severe life events and chronic difficulties in the social/ interpersonal domain often trigger the onset of BN in the majority of cases [20,21]. Women with established BN often compare themselves unfavourably to other women and perceive themselves to have a lower social rank than others [22,23]. Moreover, they are more likely to have a more limited social network with fewer supportive relationships [24]. Pre-existing social difficulties may be worsened by the effects of bulimic symptoms, such as semi-starvation, bingeing or compensatory behaviours [25]. In the treatment literature, Leung et al. [26] found that amongst women treated for BN with group based CBT, it was those who held non-eating disorder-related pathological core beliefs at the outset of treatment who ended up making fewer treatment gains. These included difficulties in the realm of interpersonal functioning and low self-esteem. Thus, there is growing evidence that social functioning and social cognition are impaired in BN and may provide fruitful targets for treatment. Negative self-evaluation, shame an (...truncated)