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. Author manuscript; available in PMC: 2018 Jan 1.
Published in final edited form as: J Contextual Behav Sci. 2017 Jan 18;6(1):1–7. doi: 10.1016/j.jcbs.2016.12.003

A Pilot Study of an Acceptance-based Behavioral Treatment for Binge Eating Disorder

Adrienne S Juarascio 1, Stephanie M Manasse 1, Hallie M Espel 1, Leah M Schumacher 1, Stephanie Kerrigan 1, Evan M Forman 1
PMCID: PMC5618713  NIHMSID: NIHMS847547  PMID: 28966910

Abstract

While existing treatments produce remission in a relatively large percentage of individuals with binge eating disorder (BED), room for improvement remains. Interventions designed to increase emotion regulation skills and clarify one’s chosen values may be well-suited to address factors known to maintain BED. The current study examined the preliminary efficacy of a group-based treatment, Acceptance-based Behavioral Therapy (ABBT), in a small open trial (n=19), as well as the relationship between changes in hypothesized mechanisms of action and outcomes. ABBT includes the behavioral components of cognitive behavioral treatment for BED and emotion-focused strategies from acceptance and commitment therapy and dialectical behavioral therapy. Results from generalized linear multilevel modeling revealed significant fixed linear effects of time on depression, quality of life, global eating pathology, and binge frequency (all ps < .05). Global eating disorder symptoms appeared to improve rapidly from pre- to mid-treatment, and continued to improve toward post-treatment and follow-up, but at a slower rate. Binge frequency decreased rapidly from pre- to mid-treatment, followed by a slight increase at post-treatment and a reduction again by follow-up. Improvements in experiential acceptance were strongly and consistently related to decreases in overall eating pathology across several measures (rs = .35–.54). Additionally, greater access to emotion regulation strategies was strongly related to decreases in overall eating pathology (r= .67). Preliminary results support the efficacy of this novel treatment approach and indicate that additional research on ABBT for BED is warranted.

Keywords: binge eating disorder, acceptance-based treatment, group therapy

Introduction

Binge Eating Disorder

Binge eating disorder (BED) is the most common eating disorder (Hudson, Hiripi, Pope, & Kessler, 2007), and is associated with adverse health effects and impaired quality of life (Grilo, White, & Masheb, 2009). Although several treatments, such as interpersonal therapy and dialectical behavior therapy (DBT), have shown efficacy in treating BED (e.g., Safer & Jo, 2010; Telch, Agras, & Linehan, 2001; Wilfley et al., 2002), cognitive behavioral therapy (CBT) currently has the strongest research support (Vocks et al., 2010). A recent meta-analysis revealed that cognitive behavioral interventions for BED result in medium-to-large improvements in binge eating (Vocks et al., 2010). However, room for improvement remains. A significant proportion of patients continue to binge eat following treatment and some patients may lose treatment gains over time; for example, in one large trial of CBT, only 52% individuals experienced full recovery four years after treatment (Hilbert et al., 2012).

Traditional cognitive behavioral models of binge eating emphasize reducing dietary restriction as the core mechanism of action in treatment (Fairburn, Wilson, & Schleimer, 1993). However, a growing body of literature has highlighted the role of emotion regulation difficulties and negative affect in binge eating (Agras & Telch, 1998; Deaver, Miltenberger, Smyth, Meidinger, & Crosby, 2003; Munsch, Meyer, Quartier, & Wilhelm, 2012). Research suggests that negative affect may be particularly influential for a subgroup of patients (Grilo, Masheb, & Wilson, 2001; Stice et al., 2001), and that emotionally driven eating may predict treatment resistance (Ricca et al., 2010). Although newer “enhanced” cognitive behavioral treatments (e.g., CBT-E, Fairburn, 2008; Fairburn, Cooper, & Shafran, 2003) place greater emphasis on the role of negative affect in binge eating, mood intolerance is not addressed until later in treatment (i.e., after several sessions; Fairburn, 2008). Though the amount of time spent addressing emotion regulation is tailored to patient needs, the skills provided for addressing mood intolerance also are limited (Ricca et al., 2010). Additionally, while the behavioral components of CBT for BED (e.g., self-monitoring of eating behavior, regularization of eating; Fairburn, 2008; Mitchell, Devlin, de Zwaan, Crow, & Peterson, 2008) appear critical for reducing binge eating (Wilson, Fairburn, Agras, Walsh, & Kraemer, 2002; Zendegui, West, & Zandberg, 2014), many patients struggle to implement the behavioral recommendations, in part because these behaviors can initially bring on emotional discomfort and require significant time investment on the part of the patient (Wilson & Vitousek, 1999). CBT treatments provide patients with very few skills that are meant to enhance willingness to implement challenging behavioral recommendations, especially early in treatment. Increasing skills for coping with negative affect and enhancing patients’ willingness to engage in the behavioral elements of CBT for BED, despite discomfort and time investment, appear to be two key areas for improving current treatments.

“Third wave” acceptance-based behavioral treatments may be particularly well-suited to target patients’ difficulty coping with negative affect and increasing willingness to engage in challenging behavioral components of treatment. In particular, concepts and skills taught in Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 2011), brief behavioral activation treatment for depression (Lejuez, Hopko, Acierno, Daughters, & Pagoto, 2011), and DBT (Linehan, 1993) may hold promise for improving treatment outcomes when used in conjunction with behavioral components of CBT for BED. For example, ACT’s focus on values clarification (i.e., identifying the life domains and principles that are most important to individuals), psychological acceptance (i.e., experiencing one’s internal experiences without judgment), and committed action (i.e., developing patterns of behavior that are consistent with one’s chosen values) may provide patients with the motivation and skills needed to engage in distressing behavioral components of treatment (Hayes, Luoma, Bond, Masuda, & Lillis, 2006; Hayes et al., 2011; Manlick, Cochran, & Koon, 2013). Similarly, behavioral activation treatment emphasizes identification of valued life domains and purposeful engagement in important and/or enjoyable activities (Lejuez et al., 2011). Engagment in values-consistent activities that are important and/or enjoyable may improve patients’ overall mood, thereby reducing the frequency and intensity of negative affect and, potentially, the frequency of affect-induced binge episodes. Finally, the distress tolerance and emotion regulation skills taught in DBT (Linehan, 1993) may provide patients with numerous concrete, in-the-moment strategies for coping with negative affect without binge eating. These approaches may be particularly effective when used with the behavioral strategies emphasized in CBT to reduce dietary restriction.

Evidence for Efficacy of Third-Wave treatments for BED and Related Disorders

There is early evidence for the efficacy of third-wave interventions for binge eating. Recent meta-analyses of several third-wave approaches (e.g., mindfulness-based eating awareness training (Kristeller & Wolever, 2010), ACT, DBT) have revealed a medium-to-large effect of these interventions on binge eating (Godfrey, Gallo, & Afari, 2015; Katterman, Kleinman, Hood, Nackers, & Corsica, 2014). In particular, mindfulness-based interventions appear to increase self-efficacy and sense of control around eating, promote non-judgmental self-acceptance, and reduce frequency of binge episodes (Baer, Fischer, & Huss, 2005; Godfrey et al., 2015; Katterman et al., 2014; Kristeller, Wolever, & Sheets, 2014). One analog study found that acceptance as an emotion regulation strategy did not significantly outperform rumination on body dissatisfaction in women with binge eating, but did improve mood (Svaldi & Naumann, 2014). Research on third wave treatments for weight control has also produced favorable results (Forman, Butryn, Hoffman, & Herbert, 2009; Mantzios & Wilson, 2014; Mantzios & Wilson, 2015; Niemeier, Leahey, Reed, Brown, & Wing, 2012), indicating that the unique skills discussed in these treatments may help individuals to successfully alter eating behaviors. Additionally, a recent systematic review indicated that DBT may significantly reduce eating pathology, improve mood and affect, and enhance retention (Bankoff, Karpel, Forbes, & Pantalone, 2012). Several case series studies (e.g., Berman, Boutelle, & Crow, 2009; Hill, Masuda, Melcher, Morgan, & Twohig, 2015; Wildes & Marcus, 2011), small pilot trials (Klein, Skinner, & Hawley, 2012, 2013), and randomized controlled trials (Juarascio et al., 2013; Safer & Jo, 2010) have also all supported the efficacy of both ACT and DBT for the treatment of BED and other eating disorders. Additional emotion-focused treatments, such as Integrative Cognitive Affective Therapy (ICAT), have shown encouraging results in a sample of patients with bulimia nervosa (Wonderlich et al., 2014), and are currently under evaluation for BED.

As summarized previously, preliminary results suggest that third-wave treatments show promise for the treatment of BED. However, limited research has examined whether third-wave principles and strategies (drawn from ACT, DBT, and behavioral activation) can feasibly be integrated into a treatment that also delivers the behavioral strategies essential to CBT, whether such a treatment approach is efficacious, and whether such a treatment improves participants’ ability to regulate emotions and reduce binge eating. Our team recently developed a treatment that integrates third wave principles with the behavioral strategies of CBT and have termed this treatment acceptance-based behavioral therapy (ABBT). The ABBT that we developed targets affective triggers for binge eating while also retaining the behavioral components considered necessary to normalized daily eating patterns. Although existing treatments such as CBT-E do include a small number of ABBT techniques later in treatment, the utility of integrating ABBT techniques throughout a behavioral treatment has yet to be studied. Importantly, integrating affect regulation skills early in treatment also necessitates reducing the session time spent on fundamental skills of normalizing eating patterns and optimizing self-monitoring; this could potentially reduce treatment efficacy. On the other hand, as stated above, it is also possible that early integration of affect regulation skills may promote more rapid clinical improvement by providing greater time to practice skills that target affect triggers of binge eating. Thus, evaluation of the preliminary efficacy of this new approach through an open trial was warranted. Furthermore, because these added treatment components are designed to reduce depressive symptoms and improve overall quality of life through improved emotional coping, it was also important to evaluate the impact of the treatment on these outcomes. For an in-depth discussion of the rationale for and process of incorporating acceptance-based treatment components with the behavioral elements of CBT for BED, as well as feasibility and acceptability data related to this treatment approach, see Juarascio et al. (2016).

Finally, it was also important to determine whether an intervention utilizing third-wave treatment components for BED actually functions through the hypothesized mechanisms of action. Despite recent calls for an increased emphasis on identifying mechanisms of action and assessing whether treatments are impacting their identified clinical targets to better inform the development of new treatments (Insel, 2014; NIMH, 2014), analyses of mechanisms of action in eating disorder treatment outcome trials are rare. Third-wave treatments for BED have been hypothesized to reduce reliance on binge eating behavior as a means of coping with negative affect by providing patients with new skills (e.g., acceptance, willingness, and other emotion coping strategies) to apply when distressing emotions arise (Kristeller, et al., 2014; Wildes & Marcus, 2011; Safer & Jo, 2010). Thus, these treatments would be expected to produce improvements in acceptance of and willingness to experience distress related to eating behavior specifically and more broadly, as well as in emotional regulation abilities. By addressing emotion regulation skills more globally, these treatments are also thought to reduce other maladaptive emotional response patterns perhaps not directly tied to binge eating, such as negative urgency (i.e., the tendency to act rashly when experiencing negative affect; Whiteside, Lynam, Miller, & Reynolds, 2005) Unfortunately, however, a recent systematic review completed by our team found that third-wave treatment trials for BED and bulimia nervosa rarely assess or report on mechanisms of action (Barney et al. under review), so it is yet unclear whether these treatments function as theory suggests they would. It is possible that the benefit of new third-wave treatments is driven by the same behavioral mechanisms (i.e., self-monitoring and normalization of eating patterns) as those of standard CBT treatments, rather than improvements in processes that are uniquely addressed in third-wave treatments. Therefore, in addition to evaluating the efficacy of ABBT for BED on binge frequency and global eating disorder psychopathology, it was also important to evaluate the impact of ABBT on hypothesized mechanisms of action, specifically, emotion dysregulation, acceptance of experiential distress (related to eating and more broadly), and negative urgency.

Aims of the current study

The current study aimed to assess the preliminary efficacy of ABBT for BED in reducing binge frequency and improving eating pathology, depressive symptoms, and overall quality of life. Additionally, we sought to understand whether changes in hypothesized mechanisms of ABBT are related to outcome. We hypothesized that patients who received ABBT would experience clinically significant reductions in binge episodes, eating pathology, psychiatric comorbidity and improvements in quality of life. We also hypothesized that changes in the hypothesized mechanisms of action would be associated with symptom improvements.

Methods

Participants

Adult females (n = 19) were recruited via distribution of flyers, targeted emails sent out to our university, and posting in online forums. Participants were eligible if they were between the ages of 18 and 65 and endorsed at least 12 objective binge episodes in the past 3 months, consistent with DSM-5 criteria. Exclusion criteria included severe psychiatric comorbidity (e.g., psychosis) and previous cognitive behavioral or acceptance-based treatment for BED.

A total of 198 potential participants were screened over the phone to assess for preliminary eligibility. Thirty-seven individuals were invited to come to the lab for a full diagnostic interview, of whom 13 were excluded because they: were currently engaging in compensatory behaviors (n = 3); failed to meet binge frequency or loss-of-control criteria for BED (n = 6); exhibited cognitive impairment that interfered with ability to benefit from treatment (n = 1); had recent bariatric surgery (1); or failed to come in for an assessment (n =2). Excluded participants were provided appropriate referrals.

Though males were considered eligible for the study, the final sample consisted only of female participants, whose ages ranged from 20 to 63 years (M = 38.26; SD = 14.41). A majority of participants were overweight or obese, and average body mass index was 32.80 kg/m2 (SD = 8.98). Participants were predominantly Caucasian (n=13); the remainder of the sample identified as Hispanic (n=2), Asian-American (n=2), and African-American (n=2). All participants who enrolled in treatment are included in the analyses.

Measures

Eating Disorders Examination Interview 16.0 (EDE)

The EDE (Cooper & Fairburn, 1987) is a semi-structured diagnostic interview for eating disorders. Inter-rater reliability between trained interviewers and test-retest reliability is high (Rizvi, Peterson, Crow, & Agras, 2000) and the measure has good internal consistency among eating disorder samples (Cooper, Cooper, & Fairburn, 1989). Global scores represent average symptom severity across the four subscales/dimensions.

Mini International Neuropsychiatric Interview (MINI)

The MINI is a brief structured interview used to assess for comorbid psychopathology (Sheehan & Lecrubier, 2010). The MINI has demonstrated high clinical validity and reliability, while maintaining efficiency and reducing participant burden (Lecrubier et al., 1997; Sheehan & Lecrubier, 2010).

Quality of Life Inventory (QOLI)

The QOLI assesses an individual’s life satisfaction in each of sixteen areas identified as important to him/her (Frisch, 1994). It has demonstrated adequate validity, reliability, and consistency (Frisch, Cornell, Villanueva, & Retzlaff, 1992).

Beck Depression Inventory-II (BDI-II)

The BDI-II assesses depressive symptoms. The measure has high internal consistency and validity among psychiatric outpatients (Beck, Steer, & Brown, 1996).

Difficulties in Emotion Regulation Scale (DERS)

The DERS assesses difficulty with identifying and regulating aversive emotional experience across six domains, i.e., Nonacceptance of Emotional Responses, Difficulties Engaging in Goal-Directed Behavior, Impulse Control Difficulties, Lack of Emotional Awareness, Limited Access to Emotion Regulation Strategies, and Lack of Emotional Clarity. The DERS has strong internal consistency and test-retest reliability (Gratz & Roemer, 2004). Higher scores on all subscales represent greater difficulty with identifying and regulating aversive emotions.

Acceptance and Action Questionnaires—General and Food-Specific

Acceptance of general internal experiences was measured using the Acceptance and Action Questionnaire-II (AAQ-II), which is a 7-item, single factor self-report measure that is used transdiagnostically in acceptance-based treatments (Bond et al., 2011). The Food Craving Acceptance and Action Questionnaire (FAAQ; Juarascio, Forman, Timko, Butryn, & Goodwin, 2011) was used to assess acceptance of internal experiences specifically related to eating behavior, and has two subscales: acceptance and willingness. Both the AAQ-II and the FAAQ have strong psychometric properties. Higher scores on both measures reflect greater acceptance.

UPPS Impulsive Behavior Scale—Negative Urgency subscale

The 12-item Negative Urgency subscale of the UPPS Impulsive Behavior Scale (Whiteside et al., 2005) was used to measure the tendency to act rashly under negative affective states. The full scale has demonstrated sound psychometric properties (Whiteside et al., 2005). Higher scores indicate greater negative urgency.

Treatment

The group-based ABBT treatment was delivered over 10 weekly sessions to three groups (five to seven participants each). The first two sessions were 120 minutes each; remaining sessions were 90 minutes. Each group was co-led by two therapists, who were licensed clinical psychologists or advanced doctoral students in clinical psychology supervised by a Ph.D.-level psychologist.

Each session followed a general format, which included individual participant check-ins, review of skills from the previous session, introduction of new skills and concepts, and assignment of homework. Core behavioral elements of traditional CBT for binge eating were included as essential foundational principles of the treatment, including weekly self-weighing, normalization of eating patterns, and daily self-monitoring of food intake and emotions. However, the treatment expanded upon traditional CBT by incorporating several acceptance-based psychological strategies in lieu of traditional cognitive strategies (which were not included in ABBT). The inclusion of these strategies was intended to help participants overcome common barriers (e.g., low motivation, distress related to treatment components) to engaging in recommended behaviors, and to improve tolerance of distress and negative affect. Participants were encouraged to clarify their personal values, and to draw a connection between the behavioral strategies introduced in treatment and these values. Specific psychological strategies that were added to help facilitate this valued action included both acceptance- and change-strategies, such as cognitive defusion, urge surfing, distress tolerance skills, willingness, and emotional awareness. Participants were also provided with emotion regulation strategies drawn from DBT, and were instructed to engage in values-based behavioral activation in order to improve overall mood. For more information regarding the development and implementation of ABBT for BED, see Juarascio (2016).

Assessment Procedures

Participants underwent a 20-minute phone screen to determine initial study eligibility. Eligible participants provided informed consent and completed an in-person interview, which included administration of the EDE 16.0 and the MINI 6.0 by a trained diagnostician and the self-report measures listed above.

Mid-treatment (5 weeks) and post-treatment (10 weeks) assessments included the EDE (assessing binge eating for only one month prior, as three months would overlap with the pre-treatment time period) and self-report measures. Follow-up (3 months after treatment) assessment included the EDE, self-report measures, and qualitative interview.

Data Analyses

Analyses evaluating symptom improvement over time were performed in R version 3.1.2 using the “lme4” (Bates, Maechler, Bolker, & Walker, 2014) package for generalized linear mixed/multilevel modeling. For all models, observations of the outcome variables across time (Level 1) were nested within individual participants (Level 2). Linear, quadratic, and cubic fixed effects of time were tested for each of the outcome variables (binge frequency and EDE Global, BDI-II, and QOLI scores). Logarithmic transformation was applied to binge frequency data to normalize the distribution. Likelihood ratio tests (LRT) were conducted to determine whether random linear and quadratic effects contributed significantly to model fit, using the criterion p ≤ .05 for the χ2 statistic. Descriptive and correlational analyses were performed in SPSS version 23. Because we anticipated large improvements in both process and outcome measures by the mid-treatment assessment point, formal mediation analyses were not possible. We thus elected to evaluate the correlations between pre- to post-treatment change in both process measures and EDE Global score. Because our small sample did not provide adequate power for formal significance testing, we noted whether correlations reached a medium effect size (i.e., r ≤.3). Correlations between pre- to post-treatment change in process measures and pre- to post-treatment change in binge frequency were not examined, as it was determined that these evaluations would largely reflect differences in baseline values since the vast majority of participants experienced no or rare binge eating at post-treatment assessment.

Results

Symptom Improvement Over Time

A majority of participants experienced early remission of binge eating symptoms, which was maintained through the follow-up period. At mid-treatment, ten of eighteen participants (56%) were abstinent from objective binge eating in the four weeks prior to assessment. This rate remained relatively consistent at subsequent assessments, with 59% abstinent at end-of-treatment (10/17) and 60% abstinent at 3-month follow-up (9/15).

Results from LRT indicated that inclusion of random slopes did not significantly improve model fit for any of the outcome variables (ps ≥ .37 for Wald’s χ2 statistics). All models therefore include random intercepts but only fixed effects of time. Results from final optimized models are presented in Table 1. Results from generalized linear multilevel modeling revealed significant fixed linear effects of time on BDI-II, QOLI, and EDE Global scores, and binge frequency. Quadratic effects of time on BDI-II and EDE Global scores and binge frequency were also detected; in particular, global eating disorder symptoms appeared to improve rapidly from pre- to mid-treatment, and continued to improve toward post-treatment and follow-up, but at a slower rate (See Table 1 for descriptives). Significant cubic time effects were present for only binge frequency, indicating that participants experienced a temporary increase in binge frequency after initial improvement had already been made. Examination of mean binge frequency data at each assessment point is consistent with this combined cubic/quadratic model, in that participants experienced the greatest average reduction in binge frequency during the first five weeks of treatment, but also experienced a relative increase between five and ten weeks that resolved by the end of the follow-up period (Table 1).

Table 1.

Change in Eating Disorder Symptoms, Depression, and Quality of Life During Treatment

Outcome Measure Pre-Treatment Mid-Treatment Post-Treatment 3-Month Follow-Up Fixed Effects
Model Term M (SD) (n = 19) M (SD) (n = 18) M (SD) (n = 17) M (SD) (n = 15) b (SEb)
 EDE Global 2.64 (0.84) 1.86 (0.71) 1.60 (0.63) 1.58 (0.98)
Time −0.16 (.03)***
Time2 0.01 (.00)***
 Binge frequencya 16.82 (8.62) 1.35 (2.00) 3.29 (7.90) 1.33 (2.47)
Time −0.77 (.12)***
Time2 0.08 (.02)***
Time3 −0.002 (<.01)***
 BDI-II 20.37 (11.60) 13.11 (12.21) 11.25 (13.72) 10.33 (10.26)
Time −1.26 (.35)***
Time2 0.04 (.01)**
 QOLI −0.23 (2.00) -- 1.18 (1.89) 1.14 (1.85)
Time 0.06 (.03)*
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*

p < .05;

**

p < .01;

***

p < .001.

Notes. b-values represent average change in each outcome variable per week. BDI-II = Beck Depression Inventory-II. QOLI = Quality of Life Inventory.

a

Binge frequency regression weights were calculated after log-transformation; Ms and SDs represent untransformed values from raw participant data.

Process Measures and Associations with Symptom Change

Medium-to-large improvements were observed across most process measures, with the exception of the Goals, Awareness, and Clarity subscales of the DERS (see Table 2). Associations between pre- and post-treatment changes in process measures and pre- to post-treatment changes in EDE Global score are presented in Table 2. Decreases in EDE Global scores were related to improvements in the Nonacceptance and Strategies subscales of the DERS, the Acceptance subscale of the FAAQ, and to AAQ-II scores. Decreases in EDE Global scores were also related to worsening in the Clarity and Awareness subscales of the DERS. All of these relationships were at least medium in effect size.

Table 2.

Overall Change in Process Measures and Association with Treatment Outcome

Pre-Treatment Mid-Treatment Post-Treatment F ηp2 Correlation with EDE Global changea
M (SD) (n = 19) M (SD) (n = 18) M (SD) (n = 17)
EDE – Restraint 1.98 (1.23) 1.22 (1.51) 1.24 (0.86) 5.33* .25 .22
EDE – Eating Concern 1.31 (.88) 1.60 (0.72) 0.52 (0.54) 6.71* .30 .81**
EDE – Shape Concern 3.76 (1.00) 2.97 (0.97) 2.42 (1.08) 18.19** .53 .69**
EDE – Weight Concern 3.54 (1.27) 2.52 (1.16) 2.24 (0.99) 12.24** .43 .89**
BDI – II 20.37 (11.60) 13.11 (12.21) 11.25 (13.72) 5.18* .26 .39
DERS – Nonacceptance 18.06 (4.00) 15.63 (3.10) 16.63 (4.75) 3.52* .19 .54*
DERS - Goals 12.06 (2.41) 12.19 (2.76) 12.25 (3.66) .03 <.01 .16
DERS – Impulse 17.25 (3.55) 15.44 (2.71) 16.44 (4.37) 1.73 .10 .19
DERS – Awareness 18.06 (4.48) 18.75 (3.30) 17.75 (5.26) .38 .03 −.39
DERS – Strategies 20.63 (4.57) 18.25 (2.67) 19.56 (5.29) 2.09 .12 .67**
DERS – Clarity 11.88 (2.58) 12.81 (2.86) 13.06 (3.19) 1.35 .08 −.37
DERS – Total 100.21 (10.40) 95.39 (9.46) 95.69 (13.85) 1.46 .09 .34
FAAQ – Willingness 15.22 (6.20) 21.89 (6.09) 23.22 (6.46) 7.52** .48 −.26
FAAQ – Acceptance 14.00 (6.16) 15.89 (5.16) 15.89 (5.13) 2.09 .21 −.35
AAQ-II 26.75 (9.89) 29.19 (6.46) 32.19 (9.48) 3.40* .19 −.41
UPPS – Urgency 2.52 (.64) 2.49 (.47) 2.09 (.57) 3.87* .22 −.29
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Note.

**

p < .01;

*

p < .05;

a

Pre-post-treatment change correlated with pre-post-treatment change in EDE Global score.

Discussion

These findings support the preliminary efficacy of ABBT for BED. Although the current pilot study did not compare ABBT to an existing treatment approach (CBT or another third-wave approach), the magnitude of the improvements observed were similar to those of other treatments for BED (e.g., Godfrey et al., 2015) and demonstrated the promise of this novel treatment approach. Participants experienced rapid decreases in binge frequency early in treatment, and although some participants experienced a slight uptick between mid-treatment and post-treatment, 3-month follow-up results again showed a reduction to very low rates of binge eating. Importantly, the change from mid- to post-treatment appeared to be driven primarily by a marked increase in binge frequency experienced by two participants at post-treatment, which resolved by follow-up. Thus, it appears that these participants initially struggled to maintain the momentum of their early symptom improvements, but that they eventually stabilized (perhaps with continued practice of skills taught in treatment after the program ended). We can only conjecture as to the cause of this temporary difficulty, but possibilities include situational life stressors or motivational factors.

Interestingly, temporary post-treatment increases were not observed for other outcome variables. Overall eating pathology showed steep improvement from pre- to mid-treatment and then a continuing, though less rapid, improvement at both post-treatment and follow-up. Mood symptoms demonstrated a similar pattern of results, with the average participant moving from the moderate to minimal range for depressive symptoms on the BDI-II by post-treatment. This result was sustained, and even slightly improved, by follow-up. Lastly, quality of life showed substantial improvements by post-treatment and this improvement was sustained at 3-month follow-up. Overall, the results from our pilot trial thus demonstrate clear and sustained improvement in both eating disorder-specific symptoms and other relevant outcomes.

Although we were under-powered to utilize standard tests of mediation, simple comparisons of change scores lend initial support to our theoretical model. Medium-to-large improvements were observed in experiential acceptance (both generally and of food-related internal experiences), negative urgency, and in several domains of emotion regulation. Improvements in experiential acceptance were strongly related to decreases in overall eating pathology across several measures. Additionally, greater perceived access to emotion regulation strategies was strongly related to decreases in overall eating pathology. If replicated, these results provide support for the notion that ABBT functions through its hypothesized mechanisms. Of note, increases in awareness and clarity of emotional experiences were related to lesser improvements in overall eating pathology. While surprising in some respects, this finding is consistent with previous reports (Cardaciotto, Herbert, Forman, Moitra, & Farrow, 2008), and has been interpreted as indicating that awareness in and of itself may actually increase focus on negative internal experiences, particularly if the individual is not accepting of those experiences.

The current study featured several notable strengths. First, this study was the first to develop and evaluate a values-based emotion-focused treatment for BED that directly attempted to integrate acceptance-based skills into existing cognitive behavioral treatments. We utilized multiple assessment points, including a 3-month follow-up, which allowed assessment of changes in process and outcome measures during and after the treatment process. We also used statistical procedures that maximized power given our small sample.

However, several limitations should also be noted. The study was an open pilot trial and did not have a comparison condition; we therefore cannot conclude that the treatment yielded results on primary outcomes or mechanisms that are superior to those that would have been obtained in CBT. We were also unable to evaluate the extent to which BED symptom improvements were attributable to the unique components of ABBT. While examination of change scores in hypothesized mechanisms of action were related to outcome, we were not able to conduct full mediation analyses due to the small sample size. To balance concerns with type 1 and type 2 error, we chose to focus on effect size rather than statistical significance, which limits the confidence we can place in this set of exploratory analyses. Future studies would benefit from a larger sample size and use of formal mediation analyses to investigate the causal link between change in process variables and change in outcomes. Additionally, the follow-up period was relatively short, and due to the chronic nature of BED, longer follow-up periods are necessary to assess for relapse. Finally, given the paucity of research in this area and the already small sample size, we did not control for experiment-wise error. Caution is thus warranted when interpreting results.

The current pilot study suggests that ABBT is worthy of future study as a treatment alternative for patients with BED. Although several third-wave treatments have been developed for treating BED, ABBT has several unique elements that distinguish it from existing treatment, including integration of both acceptance- and change-based strategies for responding to emotions, integration of important behavioral skills that target dietary restriction with skills that seek to increase patients’ abilities to cope with negative affect, and a strong emphasis on values (including on how values and other emotion focused skills can be used to facilitate engagement in behavioral recommendations). Future research should thus compare ABBT to CBT-E and other third-wave approaches in randomized controlled trials to assess whether ABBT improves outcomes beyond that achieved by these treatment approaches. Future research with larger samples should also assess for moderating variables, as it is quite possible that certain subsets of patients (e.g. individuals with deficits in emotion regulation and high dietary restraint) may do particularly well in ABBT. Recent research on integrative cognitive-affective therapy (ICAT) suggests that although ICAT performs similarly to CBT-E across individuals with bulimia nervosa (Wonderlich et al., 2014), ICAT may be more effective for certain individuals (e.g., those high in affective lability and stimulus seeking; Accurso et al., 2016). Such findings support the continued investigation of ABBT for BED even if initial results suggest that ABBT may perform similarly to other treatments when examined across individuals, as important moderators may emerge with further investigation with larger samples. Additionally, research should examine whether the current treatment holds promise for a broader spectrum of individuals with binge eating pathology. Lastly, although participants in our trial exhibited large reductions in binge eating episodes that were well maintained at 3-month follow-up, longer follow-up periods are needed to determine the long-term effects of ABBT. Although a great deal of future research is necessary, we believe this pilot study highlights a promising venue for future treatment development for eating disorders.

Highlights.

  • Room improvement remains in treatment for binge eating disorder

  • This study tested a novel acceptance-based behavioral treatment (ABBT) for BED

  • Results support the preliminary efficacy of ABBT for BED

Acknowledgments

This work was funded by two awards from the National Institutes of Mental Health (K23MH105680 and F31MH108279) to Dr. Juarascio and Ms. Manasse, respectively, and a research grant from the Innovation Lab (EMF 041013).

Footnotes

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