Overcoming Bulimia Online

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1 Overcoming Bulimia Online This document contains research that has guided the development of the online cognitive-behavioural therapy (CBT) based intervention for those suffering from bulimia and related eating disorders, alongside outlining the Five Areas Model that forms their basis.

2 Underlying Basis of Programs: The Five Areas Assessment Model Developed by Dr. Williams; a Senior Lecturer in Psychiatry at the University of Glasgow and Honorary Consultant Psychiatrist. The Five Areas Assessment model was commissioned by the NHS to provide a CBT jargon free course which address common mental health difficulties. Over the past 10 years the Five Areas model has been applied to help for depression and anxiety, those suffering from Bulimia Nervosa and for the carers of those looking after someone with Anorexia. The Five Areas materials started out in a written format (Overcoming Anxiety and Overcoming Depression Book), to CD-ROM format to its present online format: The Five Areas model has proved highly successful and a series of articles that describe the model and its use clinically have proved to be the most downloaded series of articles ever published by the journal Advances in Psychiatric Treatment. Practice Point: All the Five Area CBT self-help materials are designed to be used as part of supported/guided self-help by a practitioner. This can include minimal therapist contact. The diverse packages allow CBT self-help to be offered in a range of ways currently including written, computer and group-based CBT. The 5 Areas approach can be helpful for summarising the impact of altered thinking, feelings, physical symptoms and behaviours and in a way that looks at the social context of a situation, relationships, practical resources and problems faced by the person. It is a very flexible approach that can be used in for long term and acute problems.

3 Williams, C. (2003). New Technologies in Self-help: Another Effective Way to Get Better? European Eating Disorders Review, 11, Summary: New technologies provide great promise for service delivery. The ability to provide tailored information in ways that meets the individual s needs is attractive. We should not however be seduced by the technology alone. The content and structure of the content will require great clinical skill. The development and piloting of such new packages should be seen as a useful therapeutic addition to go alongside older self-help treatments such as biblio-therapy. Ultimately the challenge will be in deciding how to best select patients to receive the level of input and support they require to make effective use of the resources available.

4 Research basis for Overcoming Bulimia Online (OBO) The OBO intervention also based on Dr Chris William s 5 Areas Assessment model was previously in CD-ROM format to its now online format, with contributors from Professor Ulrike Schmidt at the Institute of Psychiatry, London. Alongside Professor Janet Treasure, Director of the Eating Disorder Unit at South London and Maudsley NHS Trust and Chief Medical Officer for the Eating Disorder Association. The evidence base for the treatment of bulimia suggests that Cognitive behaviour Therapy is the most effective treatment. A key problem however is how people can access specialist services locally and rapidly. Many localities have little or no access to specialist eating disorders teams. An alternative is to provide stepped care treatments for bulimia (as suggested by NICE) so that people with milder to moderate problems can have rapid local access to low intensity interventions such as CBT selfhelp. Key reference: NICE Eating disorders review - see either the full guideline or the quick reference guide. Research on the Overcoming Bulimia CD-ROM 1. Schmidt, U., et al (2001). CD-ROM based treatment for Bulimia Nervosa reduces binge eating and use of laxatives. Available at the Royal College of Psychiatrists: Press and Parliament, at Background: Many patients with bulimia nervosa are in an age-group with high computer literacy. Moreover the shame, self-disgust and secretiveness surrounding bulimic disorders make computer-based treatment particularly appealing to sufferers at the point of first contact with services. The CD-ROM package is interactive and allows for individual tailoring of information which is likely to make it acceptable to a broader range of sufferers than other selfhelp treatment formats. Method: New out-patients with bulimia nervosa referred to two eating disorder clinics (London and Leicester) were eligible for the study. 39 patients have been offered the CD-ROM programme. Four patients failed to take up the programme and two were removed on recommendation of a clinician. Results: 67% of participants found the programme very easy or easy to use. There were significant early improvements at week 3 in terms of a reduction of bingeing (p=0.019) and laxative use (p=0.026) and similar trends at the post-treatment assessment at week 8. 93% of participants said they would recommend the programme to a friend. Conclusions: The Overcoming Bulimia CD-ROM is found to be easy to use and has reduced binge eating and the use of laxatives in the treatment of outpatients with bulimia nervosa.

5 2. Murray, K., et al (2003). Factors Determining Uptake of a CD-ROM-based CBT Self-help Treatment for Bulimia: Patient Characteristics and Subjective appraisals of Self-help Treatment. European Eating Disorders Review, 11, Background: Cognitive-behavioural self-help treatments are widely advocated as the first step in the management of bulimia nervosa. Very little is known about the characteristics and attitudes of patients who are able to utilize self-help treatments. Aims: The aim of this study was to identify whether there are any pre-treatment differences in patient characteristics and patients expectations about computerized self-help between those who do or do not take up this type of treatment. Method: 81 patients who were offered a CD-ROM-based self-help treatment for bulimia nervosa completed baseline assessments including a questionnaire assessing their attitudes to and past experiences with self-help, confidence in using a computer and knowledge about and ability to manage aspects of their eating disorder. Results: Patients who did not take up the CD-ROM-based treatment had a significantly lower expectation of the usefulness of self-help for themselves but not for others. There were no baseline differences between groups in terms of mean BMI and symptom severity; in particular there were no differences in previous utilization of self-help or attitudes to previous self-help, or differences in confidence in using a computer. Qualitative comments of participants who failed to take up the package highlighted a diverse range of concerns and anxieties about computer treatment, some of which were based on misunderstandings about this treatment. Conclusions: These findings show that patients views about self-help need to be carefully explored and misconceptions corrected if self-help treatment is to be considered by a subgroup of patients.

6 3. Bara-Carril, N., et al (2004). A Preliminary Investigation into the Feasibility and Efficacy of a CD-ROM Based Cognitive-Behavioural Self-Help Intervention for Bulimia Nervosa. International Journal of Eating Disorders, 35 (4), Background: Many patients with bulimia nervosa find it hard to access evidencebased treatment such as cognitive-behavioural therapy (CBT). The aim of the current study was to evaluate the feasibility and efficacy of a novel CD-ROM based cognitive-behavioural multimedia self-help intervention for the treatment of bulimia nervosa. Method: Patients with bulimia nervosa referred to a catchment area-based eating disorder service were offered eight sessions of a novel CD-ROM cognitivebehavioural self-help treatment without any added therapist input. We report here the take-up and drop-out rates and efficacy of this intervention. Results: Of 60 participants who were offered the intervention, 47 took it up. At follow-up, there were significant reductions in binging and compensatory behaviours, most clearly in self-induced vomiting. Conclusions: This intervention has potential as a first step in the treatment of bulimia nervosa and for dissemination to non-specialist settings.

7 4. Murray, K., et al (2007). Does therapist guidance improve uptake, adherence and outcome from a CD-ROM based cognitive-behavioural intervention for the treatment of bulimia nervosa? Computers in Human Behaviour, 23, Background: We recently demonstrated the efficacy and feasibility of a novel CD- ROM based cognitive-behavioural multi-media self-help intervention for the treatment of bulimia nervosa. What is not known in CD-ROM treatments is how to best to deliver and support such packages in clinical practice. In particular, it is of great importance to identify to what extent such packages can be offered stand alone, and to what extent additional support from a practitioner is required. Aim: The aim of the present study was to examine whether the addition of therapist support to the CD-ROM intervention would improve treatment uptake, adherence and outcome. Method: Two cohorts of patients with full or partial bulimia nervosa referred to a catchment area based eating disorder service were offered an eight-session CD- ROM-based cognitive- behavioural self-help treatment ( Overcoming Bulimia ). The first cohort received minimal guidance only and the second cohort was offered three brief focused support sessions with a therapist. The two cohorts were compared on treatment uptake, adherence and outcome. Results: Patients in both groups improved significantly. There were no significant differences between the two groups in terms of treatment uptake, adherence or outcome, except that the therapist guidance group more often achieved remission from excessive exercise at follow-up. Conclusions: These findings provide further support for the acceptability and efficacy of the CD-ROM intervention for bulimia nervosa. Brief focused therapist guidance did not confer any significant additional benefits. This result has important implications for the widespread adoption of such approaches.

8 5. Schmidt, U,. et al (2008). Randomised controlled trial of CD ROM-based cognitive behavioural self-care for bulimia nervosa. British Journal of Psychiatry, 193, Background: Cognitive behavioural self-care is advocated as a first step in the treatment of bulimia nervosa. Aims: To examine the effectiveness of a CD ROM-based cognitive behavioural intervention in bulimia nervosa and eating disorder not otherwise specified (NOS) (bulimic type) in a routine setting. Method: Ninety-seven people with bulimia nervosa or eating disorder NOS were randomised to either CD ROM without support for 3 months followed by a flexible number of therapist sessions or to a 3-month waiting list followed by 15 sessions of therapist cognitive behavioural therapy (CBT). Clinical symptoms were assessed at pre-treatment, 3 months and 7 months. Results: Only two-thirds of participants started treatment. Although there were significant group x time interactions for bingeing and vomiting, favouring the CD ROM group at 3 months and the waiting-list group at 7 months, post hoc group comparisons at 3 and 7 months found no significant differences for bingeing or vomiting. CD ROM-based delivery of this intervention, without support from a clinician, may not be the best way of exploiting its benefits.

9 Research on Overcoming Bulimia Online 1. Munro, C., et al (2008). A randomised controlled trial of Internet-based CBT for Bulimia Nervosa in a student population: identifying and treating the iceberg of unmet need. Academy of Eating Disorders Annual Conference; Seattle, USA. Background: Female students are at high risk of bulimic type eating disorders, yet the majority do not access effective treatment. Computerised Cognitive Behaviour Therapy (CBT) may be able to bridge this gap. The aim of this clinical trial was to evaluate the efficacy of an internet-based CBT (icbt) treatment, Overcoming Bulimia Online, supplemented with support. Method: Seventy-six students with DSM IV bulimia nervosa (BN) or an eating disorder not otherwise specified (EDNOS) were recruited via . Participants were randomly assigned to an immediate icbt group with support over 3 months or a 3-month waiting list group followed by icbt (delayed treatment control: DTC). Eating disorder outcomes were assessed with the Eating Disorder Examination (EDE) at baseline, 3 months and 6 months. Primary outcomes were the EDE-global score, bingeing and vomiting. Other outcomes included EDE-subscales, depression, anxiety and quality of life. Results: The majority of participants (72%) had not had any prior psychological treatment. Students who had received immediate icbt showed significantly greater improvements at 3 months than those on the waiting list on the primary and secondary outcomes: EDE-global score, binge eating, all EDE-subscale scores, depression, anxiety and quality of life. At 6 months, improvements in the immediate icbt group were maintained and remained superior to the DTC group. Conclusions: Students with largely untreated BN or EDNOS can be identified and engaged immediately in icbt treatment with support, resulting in substantial improvements in eating symptoms, affective symptoms and quality of life.

10 2. Pretorius, N., et al (2009). Cognitive-behavioural therapy for adolescents with bulimia syptomatology: The acceptability and effectiveness of internet-based delivery. Behaviour Research and Therapy 1-8. Background: The evidence base for the treatment of adolescents with bulimia nervosa (BN) is limited. Aims: To assess the feasibility, acceptability, and clinical outcomes of a web-based cognitive-behavioural (CBT) intervention for adolescents with bulimic symptomatology. Method: 101 participants were recruited from eating disorders clinics or from beat, a UK-wide eating disorders charity. The programme consisted of online CBT sessions ( Overcoming Bulimia Online ), peer support via message boards, and support from a clinician. Participants bulimic symptomatology and service utilisation were assessed by interview at baseline and at three and six months. Participants views of the treatment package were also determined. Results: There were significant improvements in eating disorder symptoms and service contacts from baseline to three months, which were maintained at six months. Participants views of the intervention were positive. Conclusions: The intervention has the potential for use as a first step in the treatment of adolescents with bulimic symptomatology.

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