Target Engagement of a Novel Dissonance-Based Treatment for DSM-5 Eating Disorders R33 Phase

摘要 只有3 - 20%的饮食失调（ED）患者接受治疗，他们往往没有得到证据- 因为它们是密集和昂贵的，很少有临床医生提供它们。这些因素 阻碍了广泛的实施，这意味着对一系列ED进行简短的一线门诊治疗， 容易、廉价和广泛地实施将解决一个关键的公共卫生问题。也有有限的 关于维持ED的因素和艾德治疗的作用机制的实验数据。我们 我假设ED是通过（1）过度评价理想的瘦，这促使热量 限制和其他不健康的体重控制行为（呕吐、使用泻药/利尿剂、过度运动） 这增加了暴饮暴食的风险，（2）对高热量食物的过度评价， 吃我们建议评估一组治疗，有效地针对这2个维持因素。我们 创造了一种新的8个疗程的基于不和谐的治疗（反态度疗法; CAT），其中妇女 与任何艾德完成口头，书面和行为活动，其中他们讨论的成本，追求薄 理想和艾德的行为，他们用来追求这个理想，这pupernity创造不和谐的参与 这些行为降低了对瘦的理想和高热量的暴饮暴食的评价。在两个试点试验中， 行为评估对瘦模特和暴饮暴食的评价降低，盲态访谈者评估的艾德 症状与非标准化（d = 0.94）和标准化常规护理（d = 0.53）相比， 2-6两项试验的随访时间为一个月。效果大小与20次治疗产生的效果大小相比， ED的个体化治疗。完成了与追求目标有关的不和谐诱导活动的女性 瘦的理想表现出对瘦模型的fMRI评估的奖励区域响应的减少（Stice等人，（2015年） 提供了目标交战的进一步证据R61随机试验（N = 60）将（1）验证是否 CAT在客观fMRI评估的奖励区域对瘦模型的反应中产生更大的前后减少 和暴饮暴食（干预目标措施）与DSM-5 ED女性的等待名单对照;（2） 生成关于降低目标对艾德症状域的临床影响的初步数据， 功能（结果）;（3）测试目标和结果的减少是否显示出线性下降， 8节课或平台期更早，与更高的课程出勤率和家庭作业完成率相关， 检查剂量反应关系。如果R61确认CAT充分参与干预目标， 8个疗程的形式产生最佳反应，完全把握度的R33随机试验（N = 120）将检验 （4）CAT是否比常规护理组在两个fMRI评估目标方面产生更大的降低 治疗;（5）CAT比常规治疗更能减少艾德症状和功能障碍 治疗至6个月随访;（6）目标变化与艾德症状变化相关， 功能，并介导干预效果的结果。

ABSTRACT Only 3-20% of people with eating disorders (EDs) receive treatment, and they often do not receive evidence- based treatments because they are intensive and costly, and few clinicians deliver them. These factors have hindered broad implementation, implying that a brief frontline outpatient treatment for a range of EDs that could be easily, cheaply, and widely implemented would address a key public health problem. There are also limited experimental data regarding factors that maintain EDs and mechanisms of action for ED treatments. We hypothesize that EDs are maintained by (1) excessive valuation of the thin ideal, which prompts caloric restriction and other unhealthy weight control behaviors (vomiting, laxative/diuretic use, excessive exercise) that increase risk for binge eating, and (2) excessive valuation of high-calorie foods, which maintains binge eating. We propose to evaluate a group treatment that efficiently targets these 2 maintenance factors. We created a novel 8-session dissonance-based treatment (Counter Attitudinal Therapy; CAT) wherein women with any ED complete verbal, written, and behavioral activities in which they discuss costs of pursuing the thin ideal and the ED behaviors they use to purse this ideal, which putatively creates dissonance about engaging in these behaviors that reduces valuation of the thin ideal and high-calorie binge foods. In two pilot trials CAT reduced behaviorally-assessed valuation of thin models and binge foods, and blinded interviewer-assessed ED symptoms versus unstandardized (d=.94) and standardized usual care (d=.53), resulting in a 70% remission by 2-6 month follow-up across the two trials. Effect sizes compare favorably to those produced by 20-session individual therapies for EDs. Women who completed the dissonance-inducing activities regarding pursuit of the thin ideal showed a reduction in fMRI-assessed reward region response to thin models (Stice et al., 2015) providing further evidence of target engagement. The R61 randomized trial (N=60) will (1) validate whether CAT produces larger pre-post reductions in objective fMRI-assessed reward region response to thin models and binge foods (intervention target measures) versus waitlist controls in women with DSM-5 EDs; (2) generate preliminary data regarding the clinical effects of reducing the targets on ED symptom domains and functioning (outcomes); and (3) test whether reductions in targets and outcomes show a linear decrease over the 8 sessions or plateau earlier and correlate with greater session attendance and homework completion, to examine dose-response relations. If the R61 confirms that CAT sufficiently engages intervention targets and that the 8-session format produces optimal response, the fully-powered R33 randomized trial (N=120) will test whether (4) CAT produces greater reductions in the two fMRI-assessed targets than a usual care group treatment; (5) CAT produces greater reductions in ED symptoms and functional impairment than the usual care treatment through 6-month follow-up; and (6) change in targets correlates with change in ED symptoms and functioning, and mediates intervention effects on outcomes.