Túry Ferenc, Pászthy Bea (szerk.)

Az evészavarok pszichoterpiájának aktuális kérdései

Internet multimedia programs

The programs applying Internet multimedia approach for patients with eating disorders will be summarized based on their delivery purpose in the health care spectrum.

Prevention. The majority of the interventions in prevention studies focused on the evaluation of a health promotion body image program called “Student Bodies” (SB – Winzelberg et al., 1998). The program was formerly delivered via a CDROM and later altered to be offered as an eight week education program based on cognitive behavioural approach delivered over the Internet. It included an asynchronous discussion group, moderated by a clinical psychologist that acted as a bulletin board where participants could log in at any time to read posts or post their own messages (Winzelberg et al., 2000; Celio et al., 2000; Zabinski et al., 2001a; Taylor et al., 2006).

Studies evaluating the efficacy of the SB in controlled trials yielded significant decreases in body dissatisfaction and drive for thinness or eating attitudes at the end of intervention and/or at 3 month follow up or effect sizes that suggested some positive impact of the intervention (Celio et al., 2000; Winzelberg et al., 1998, 2000; Zabinski et al., 2001a). One recent trial among 480 college aged women with high body and shape concerns at risk for an eating disorder assessed the incidence rates for clinical and subclinical onset of eating disorders as the main outcome measure and follow-up period ranged up to two years (Taylor et al., 2006). The results indicated that participants in the intervention group showed significant reductions in weight and shape concerns at post treatment and at follow-up. Although there was not an overall decrease in the onset of eating disorders, for those with baseline compensatory behaviours and elevated BMI, participation to the program was found be associated with a decrease in the onset of eating disorders

Another version of the SB program included synchronous communication components to the programme to help reduce pathology among high-risk women for eating disorders in pilot and controlled studies (Zabinski et al., 2001b; Zabinski et al., 2004, respectively). The contact with the participants took place several times during the week through e-mail contact, asynchronous message board, and synchronous chat sessions. Based on the results from the randomized controlled trial, chat-room as an additional synchronous component produced similar effects at post treatment and larger effects at the follow-up. The authors concluded that synchronous components of the program may be more effective over time than asynchronous components.

A recent online prevention program – ES[S]PRIT – adapted a stepped care approach to the prevention of eating disorders by combining several support components at various intensity (Bauer et al., 2009). As the evidence in the literature still can not give a clear answer to who will develop an eating disorder and who will not, it is advocated to offer a prevention program at low-intense support to large number of individuals and to allow access to more intense care as soon as they need it. Those who were at risk to develop an eating disorder and those who already showed mild symptoms (assessed by an online screening test) were allowed to participate as registered users and got a password protected access to the program. All the users of the program had access to the comprehensive online information material and Internet forum component of the program regardless of their participation status (i.e. independent of whether they participated as registered users or not). Registered participants automatically entered to the supportive monitoring and feedback module. Their symptoms were monitored on a weekly basis and they received automatized feedback on their symptom course. Additionally, they were invited to counseling chat sessions via the Internet. Chat sessions were provided on group and individual basis. In case that the online support was not intense enough for a particular participant, the referrals were made. The results of the pilot study showed ES[S]PRIT to be technically feasible. The program has been translated into English, Spanish, Portuguese, and French. It is currently evaluated under the support from a European Union funded project called INTACT (Individually Tailored Stepped Care for Women with Eating Disorders – http://www.intact-rtn.eu).

Self-help. A novel intervention in self-help literature for eating disordered patients has been the use of the Internet to deliver self-help materials with minimal or no therapist interaction. Internet has superiority to self-help books as feedback and advice can be generated instantly and does not require synchronicity like in the telephone guidance. Offering self-help materials online may be more entertaining for the users because of their interactive nature. Furthermore, the content of the Internet sources is easy to update and can be offered to larger samples much easily than manual-based self-help interventions.

Results from an initial European multicentre study examining the effectiveness and feasibility of an online delivered guided self-help support program showed preliminary evidence in a pilot study (Carrard et al., 2006). The online program was based on psychoeducational and CBT concepts and consisted of seven steps that patients worked through. Recruited participants included adult females with bulimia nervosa, purging type or EDNOS and the trial lasted six months; four months for self-help treatment and two months for follow-up. Participants had three face-to-face evaluations and one e-mail contact per week during self-help period and an optional e-mail contact per week during the follow-up period. After this, in a controlled study Fernández-Aranda and colleagues (2009) analyzed the short term effectiveness of this Internet-based CBT for bulimia nervosa compared to a waiting list control group. According to the results, use of the Internet delivery approach revealed significant decrease in psychopathology levels and severity of bulimic symptomatology at the end of the treatment.

Another study assessed the efficacy of a self-help based CBT in combination with Internet support in treatment of full and sub-threshold bulimia nervosa and binge eating disorder in a waiting list randomized controlled trial (Ljotsson et al., 2007). Participants at the treatment condition received the book Overcoming Binge Eating and they had one e-mail contact via a graduate psychology student per week regarding the homework assignments of the self-help book. Participants also had access to the private discussion forum and they were asked to contact their coach once in week via e-mail and told that they could receive feedback via e-mail twice a week. According to the results, 37% (46% among completers) had no binges or purges at posttreatment. A considerable number of participants achieved clinically significant improvement on most of the other measures (restraint eating, weight, and shape concern) and on secondary outcomes such as self-esteem, depression and general life satisfaction as well. The results were maintained at the 6-month follow-up. The authors commented on the use of discussion forums in their study to have some advantages over and above the use of e-mail such as receiving validation, support, and encouragement from other people in the same situation, knowing one is not alone, working through the program together with the group, to be able to discuss the same topics in each step of the program and reduction in the feeling of being guilty.

Two recent researches focused on an Internet delivered CBT treatment program Overcoming Bulimia Online (Williams et al., 1998) which consisted of eight interactive, multi-media, web-based CBT sessions for bulimia nervosa including cognitive-behavioural, motivational, and educational strategies. Pretorius and colleagues (2009) used an adapted version of the program for adolescent population. A peer support via message boards, and e-mail support from a clinician on a weekly basis were the other two components. Significant improvements in eating disorder symptoms and service contacts from baseline to three months were reported and improvements were reported to be maintained at the sixth month. The results proved the program to be acceptable with positive program evaluations and showed potential as a first step in the treatment of adolescents with bulimic symptomatology. The second study conducted a randomized controlled trial to prove the efficacy of the program among student population with bulimia nervosa or EDNOS either assigned to the immediate Internet based CBT with e-mail support from a therapist to motivate program use over 3 months or to a waiting list control group for 3 months. Supported Internet delivered CBT was superior than waiting list group in terms of interview based Eating Disorder Examination global score, binge frequency, affective symptoms and quality of life at the end of the treatment (Sánchez-Ortiz et al., 2010).

Maintenance. Maintenance treatment of eating disorders is still in its infancy. So far, only the use of text messaging (SMS) as a strategy has been studied in pilot and feasibility studies (Bauer et al., 2003; Robinson et al., 2006, respectively). Many patients are not symptom free at the end of treatment and there is a high risk of relapse (Richard et al., 2005). The chronic nature of the illness with high relapse rates leads to direct and indirect costs (Simon et al., 2005). Offering maintenance programs using new technologies may fill the gap in service delivery and prevent relapse rates.

Following the need for the maintenance treatment of eating disorders, our group developed an Internet-based support program called EDINA (Evési Rendellenességek Internetre Adaptált Utókezelése; www.e-mental-health.eu/edina) with various support channels that can be tailored by patients with bulimic symptomatology according to their individual needs (Figure 2 and Figure 3). Treatment outcome for eating disorders is heterogeneous ranging from recovery or remission to chronic course with recurring relapses (see Kordy et al., 2002 for definitions of the concepts). It is hypothesized that an online support program with many components (both synchronous and asynchronous) designed to deliver help for patients with bulimia nervosa and bulimic symptoms would be an adequate tool to maintain therapeutic relationship and provide social support after treatment termination in a step-down strategy. The program offers participants an information and communication platform as well as online professional consultation both on individual and group basis. Some of the modules are offered continuously while the others can be voluntarily taken up according to the individual needs of the participants. Continuous support channels include online weekly monitoring of the symptoms that patients receive supportive feedback on their symptom course and weekly group consultation chats moderated by an online counselor. Voluntary support channels include information resources, a forum and individual chat sessions. The efficacy of the program is currently evaluated in a randomized controlled trial in Hungary under the funding from a European funded Project called INTACT (Individually Tailored Stepped Care for Women with Eating Disorders – http://www.intact-rtn.eu).

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Figure 2: Illustration of the EDINA program

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Figure 3: Illustration of the EDINA program

Az evészavarok pszichoterpiájának aktuális kérdései

Tartalomjegyzék

Kiadó: Semmelweis Kiadó

Online megjelenés éve: 2026

ISBN: 978 963 331 725 9

A jelenlegi összeállítás 13 fejezetben taglalja az evészavarok pszichoterápiájának legkülönbözőbb kérdéseit. Természetesen nincs szó arról, hogy teljességre törekedtünk, annyira sokszínűvé vált a pszichoterápia alkalmazása e krónikus pszichoszomatikus zavarokban. A fejezetek különböző terápiás lehetőségeket, gyakorlati ötleteket nyújtanak, s egy-egy új irányt is kijelölnek a pszichoterápiás kutatások alapján. Az első fejezet Walter Vandereycken professzor írása a betegségtagadásról – ő a nemzetközi evészavar-kutatás egyik vezéralakja (mellesleg a Magyar Pszichiátriai Társaság tiszteletbeli tagja). A téma a betegségtudattal nem rendelkező anorexiások megértésében és kezelésében alapvető. A második fejezet szintén elméleti jellegű, s a pszichoterápiás folyamat során jelentkező ellenállást tekinti át. A harmadik fejezet is nagy gyakorlati fontosságú, az elhízás kognitív terápiáját mutatja be. A negyedik fejezet egy hazánkban még kevéssé ismert pszichoterápiás eljárást ismertet, az interperszonális pszichoterápiát. Ezután az ötödik fejezetben a családterápia gyakorlati vonatkozásainak, a lehetséges csapdáknak az áttekintését találja az olvasó. Az új információs technológiák pszichoterápiás alkalmazásáról szól a hatodik, angol nyelvű fejezet. Mivel az angol nyelv használata közkeletűvé vált a hazai szakmai színtéren is, a fejezetet nem fordítottuk le (egy EU-projekt kapcsán hazánkban kutató szakemberek írásáról van szó). A hetedik fejezet az izomdiszmorfia terápiáját foglalja össze, a nyolcadik pedig egy hasonlóan új keletű evészavartípust, az orthorexiát veszi szemügyre. E két új zavar a közeljövőben feltehetőn egyre nagyobb figyelmet kap. A kilencedik, szintén angol nyelvű írás a pszichoterápiás folyamat időbeli sajátosságainak összegzése. A tizedik fejezet a pszichoterápiás hatékonyságvizsgálatok főbb adatait summázza, így a bizonyítékokra alapozott orvoslás jegyében igyekszik háttértudást szolgáltatni. A kötet második része három esettanulmányt tartalmaz. Ezek egy-egy érdekes részterületet dolgoznak fel: a súlyos, életveszélyes anorexia kezelését, az anorexia by proxy nevű érdekes altípust, valamint az evészavarokban szenvedő ikrek terápiáját. Bízunk benne, hogy az olvasó hasznos gyakorlati szempontokkal gyarapodik a kötet olvastán. Az összeállítást elsősorban pszichológusoknak, pszichiátereknek szántuk, de haszonnal forgathatják az evészavarok pszichoterápiájában érdekelt más szakemberek is.

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