WHAT DOES EVIDENCE-BASED TREATMENT MEAN FOR REALITY-BASED PRACTICE?

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2 WHAT DOES EVIDENCE-BASED TREATMENT MEAN FOR REALITY-BASED PRACTICE?

3 Miss Information

4 Miss Behaviour Guess what i think of evidencebased treatment!

5 Miss Behaviour Psychologists in clinical practice are not using empirically validated treatments because such treatments provide little guidance for dealing with the issues and comorbid problems that their clients with ED often have. Haas & Clopton, 2003

6 Miss Behaviour 28% of psychologists had trained in EBT (Haas & Clopton, 2003) 4% of primary care physicians use best practice guidelines for ED. (Currin et al, 2007) 51% of patients reported receiving nationally recommended CBT (Serpell et al, 2013)

7 i said calm the F#CK down! Miss Nomer

8 Miss Nomer We are taught to believe that: EBT is above all other treatment. EBT is the most effective treatment there is It is immoral not to use EBT This is very understandable, since we would like to have a guarantee that patients are treated effectively and in the best possible manner. We hear a lot about treatment that patients have experienced as harmful this we need to avoid.

9 Miss Nomer In reality no treatments for ED that qualify as EBT For AN there is really nothing that can be called Evidence Based Problems with the N of subjects / study design. E.g. randomising patients in in- & outpatient setting is difficult. CBT for BN comes as close to EBT as it gets, but it has ca 50% recovery rate Other methods, such as integrative cognitive affective therapy have been found to be just as effective

10 Miss Nomer AN: 46.9% recovered, 33.5% improved, 20.8% chronic, 5% dead Steinhausen 2002 (Meta analysis of 119 studies, 5590 subj) AN pt s with good outcome after CBT = 44% Pike & al. 2003

11 BN: Miss Nomer CBT-E resulted in 51,3 % recovery rate (i.e. ED features less than one standard deviation above community mean) Fairburn, et al ICAT (integrative cognitive-affective therapy) vs. CBT-E. Both treatments were equally effective. Abstinence rates for ICAT 37,5% at EOT and 32,5% at follow-up. Abstinence rates for CBT-E 22,5% at EOT and follow-up. Wonderlich, et al. 2014

12 Miss Nomer Overall 80% of individuals with ED do not receive treatment, which is only effective for 40 50% of patients. Shaw & Stice (2016)

13 Miss Nomer EBT puts clinicians in a difficult position. They need to understand the psychology of ED and the mechanisms of the illness in order to provide the best possible treatment. Clinicians have to find out what might work for whom. Clinicians need to use scientific evidence as an indication of what might work but not what definitely will work.

14 Miss Treatment who wants their dose of evidence-based treatment?

15 Miss Treatment Are treatment manuals the solution or part of the problem? Is adherence to manuals part of the solution or part of the problem? Do we need better recipes or better cooks?

16 Miss Treatment Manualised treatments: put the therapist in charge, not the patient (i.e. the patient is there for the therapist!) pre-determined value-laden built from the therapists perspective (i.e. not necessarily based on the patient s needs) can be inherently self-destructive by relying on the therapist s motivation puts the patient in complacency mode But manuals can also give a sense of direction, achieving goals, conveying important material and information to work with between sessions.

17 Miss Treatment

18 Miss Representation Let s get real, baby!

19 Miss Representation Comorbidity in Stepwise: 6919 female patients Ulfvebrand, Juhlin, Högdahl & Birgegård (2015) Diagnos ANR ANBP BN EDNOS BED TOTAL Any Axis 1 61% 73% 74% 71% 75% 71% Any Mood 33% 49% 46% 42% 45% 43% Any Anxiety 45% 56% 54% 54% 55% 53% Any Substance 4% 11% 13% 9% 9% 10%

20 Miss Representation Trauma in Stepwise: 4524 adult patients 18.6% had experienced trauma % of all trauma % resulted in PTSD Sexual abuse 34% 28% Physical abuse 21% 34% Disease/death 17% 19% Accident/disaster 9% 12% Backholm, Isomaa & Birgegård (2013). Backholm & Birgegård (2015).

21 Miss Representation Clientele of therapists and subjects in RCTs (Haas & Compton, 2003) % Clinical % RCT Males 6,4% 0,7% AN 41,9% 16,9% BN 40,3% 81,2% EDNOS 17,7% 1,3% Comorbidity 72,2%% 0,0%

22 Miss Representation Personality Disorder? Ca 20-80% of ED patients depending on population and assessment method. Neuropsychological problems? 27% av tonårsflickor med ASD har stört ätande (Kalvya, 2009) 23% vuxna AN med ASD (Wentz, 2005) ADHD koppling till BN

23 hope they don t look inside Miss Classification

24 Miss Classification DSM-5 AN BN BED OSFED TOTAL AN 100% % BN - 100% <1% - 26% DSM-IV EDNOS 6% 18% 6% 69% 55% N = 2584 TOTAL 22% 36% 4% 38% 100% Birgegård, A., Norring, C. & Clinton, D. (2012). DSM-IV vs. DSM-5: Implementation of proposed DSM-5 criteria in a large naturalistic database. IJED., 45:

25 Miss Classification 80% 60% år år 18 år DSM-IV DSM-5 40% 20% 0% AN BN BED OSFED AN BN BED OSFED AN BN BED OSFED

26 Miss Classification Taxometric analysis of the latent structure of eating disorder symptoms Birgegård, Broman-Fulks, Norring, Clinton & Olatunji N = 6358

27 Miss Classification ED categories based on semi-structured diagnostic interview (DSM-IV and DSM-5) Indicators derived from EDEQ Planned contrasts, for both DSM-IV and 5, focusing on theoretically important subdivisions: N = 6358 DSM-IV ANR vs. ANBP BN-P vs. BN-nonP AN vs. BN AN/BN vs. EDNOS AN/BN vs. BED EDNOS vs. BED DSM-5 AN vs. BN AN/BN vs. OSFED AN/BN vs. BED OSFED vs. BED PD vs. AN PD vs. BN PD vs. OSFED

28 Miss Classification DSM- IV Diagnosis Mean CCFI ANR vs ANBP.35 BN- Purging vs BN- NP.32 AN vs. BN.36 AN/BN vs. EDNOS.35 AN/BN vs. BED.42 EDNOS vs. BED.43 DSM- 5 Diagnosis AN vs BN.34 ANBN vs OSFED.46 ANBN vs. BED.37 OSFED vs. BED.38 PD vs. AN.36 PD vs. BN.35 PD vs. OSFED.54 Plots showing simulated categorical and dimensional data in relation to actual data Comparison Curve Fit Index (CCFI): à CCFI <.45 suggests dimensionality (comparison plots are distinct) à CCFI >.55 suggest taxonicity (comparison plots are distinct) à CCFI are ambiguous (comparison plots are similar)

29 Miss Classification Ouch!

30 Miss Use one size fits all!!

31 Miss Use Guidelines are recommended for the treatment of ALL patients with the same ED diagnosis. This means clinicians are left without guidelines for a large number of (especially complicated) patients. We are great at helping patients to spontaneously remit! This isn t talked about!

32 Miss Use

33 Miss Conception everyone s a winner!

34 Miss Conception all have won! and all must have prizes!! Th e D t c i d r e o do V

35 Miss Conception Relationship between allegiance and outcome: r =.85! Meta-analysis of meta-analysis: Uncorrected d =.21 Corrected d =.14

36 Miss Conception Rather than determinedly sticking to the view that my treatment is superior to yours, why is it not possible to be interested in the findings, seek replication and wonder which patients may benefit from which treatment? Bryan Lask, 2013.

37 Miss Take what do you mean you haven t done your workshop!!

38 Miss Take How do we create good ED therapists? What do therapists need? How important is training, supervision and experience?

39 Miss Take Patients who reported having received EBT therapies (CBT and IPT) did not differ in their estimate of treatment gains from those who received non- EBTs. Serpell, Stobie, Fairburn, van Schaick (2013)

40 Miss Understanding It s my way or no way!

41 Miss Understanding Ambivalence about recovery is a central feature of AN Resistance to recovery is common in ED <50% of AN patients who present for treatment are ready for change (Blake et al 1996) Treatment dropout for ED is 30%-50% even when best EBT is offered (Mahon, 2000)

42 Miss Understanding Stein et al 2012 N=149 Attrition rate = 81% (72%) N=69 N=80 Demographic and ED variables not important for predicting attrition, but changes in beliefs about the self and ED symptoms appeared to be important. after 12 months N=16 N=13

43 Miss Perception just another perceptive scientist!

44 Miss Perception What do patients find helpful? Treatment at specialised ED centres, self-help groups, and treatment with a partner. Beneficial components of ED centres: communication skills of professionals working alliance contact with peers focus of treatment on both ED symptoms and underlying issues De la Rie & al, 2006

45 Miss Perception Strongest satisfaction with: Individual therapy (79.3 %) Group psychotherapy (62.1 %) Drug therapy (59,6%) Weakest satisfaction with family therapy 45,9% 31,3% experienced family therapy as making the situation worse De la Rie & al, 2006

46 Miss Perception Lambert s pie

47 Miss Perception What do patients think if you ask them? Preferred therapist characteristics in AN: Acceptance Vitality Challenge Expertise Gulliksen et al, 2012

48 Miss Perception Factors impacting recovery in AN Being understood 76% Hope (possibility of life after AN) 73% Self-acceptance 69% Hope (possibility of change) 68% Engagement with therapist or treatment provider 67% Improved self-esteem 59% Self-discovery 47% (Fogarty & Ramjan 2016)

49 Miss De Meanour just a minute while i take care of those follow-ups

50 Miss De Meanour Year 1-year follow-ups in Swedish Stepwise/Riksät database N new cases previous year Percent followed-up range ,3% 0-100% ,3% 0-100% ,9% 0-100% Total ,4% 0-100%

51 Miss De Meanour EVERY TIME I HEAR THE WORD FOLLOW-UP I REACH FOR MY makarov!

52 Miss Trust believe me!! I will tear down the wall between science and practice!

53 Miss Trust

54 Miss Trust An example of problematic implementation of EBT for adolescents Hutsebaut et al, 2012

55 Miss Match together? work?

56 Miss Match

57 Miss Information? who s the winner?

58 Miss Information?

59 NEDS 2016