Self‐regulation deficits moderate treatment outcomes in a clinical trial evaluating just‐in‐time adaptive interventions as an augmentation to cognitive‐behavioral therapy for bulimia‐spectrum eating disorders

Abstract

Objective Just‐in‐time adaptive interventions (JITAIs), momentary interventions delivered at identified times of risk, may improve skill utilization during cognitive‐behavioral therapy (CBT‐E) for bulimia‐spectrum eating disorders (BN‐EDs). JITAIs may be especially helpful for individuals with self‐regulation deficits, including emotion regulation deficits and elevated impulsivity. Method Participants (N = 55 with BN‐EDs) received 16 sessions of CBT‐E with electronic self‐monitoring and were randomized to receive JITAIs (JITAIs‐On) or not receive JITAIs (JITAIs‐Off). Baseline Difficulties in Emotion Regulation Scale (DERS) and UPPS‐P Impulsive Behavior Scale (UPPS‐P) total scores were examined as moderators of baseline to post‐treatment change in binge episodes, compensatory behaviors, and Eating Disorder Examination (EDE) global score using repeated measures ANOVAs. Results Emotion regulation difficulties significantly moderated compensatory behavior change (F[1, 51] = 4.31, p = .04, ηp2 = 0.08) such that individuals with emotion regulation deficits demonstrated greater improvements in the JITAIs‐On condition. Impulsivity moderated change in binge episodes (F[1, 51] = 8.94, p = .004, ηp2 = 0.15) and compensatory behaviors (F[1, 51] = 7.83, p = .007, ηp2 = 0.13), such that individuals with high impulsivity showed greater improvement in the JITAIs‐On condition. Neither DERS nor UPPS‐P scores moderated EDE global score change. Discussion JITAIs appear particularly beneficial for facilitating skill use during treatment for BN‐EDs for individuals with self‐regulation deficits, yielding improved treatment outcomes. Public Significance Statement Reminders to use therapy skills that are delivered via smartphone as an individual goes about their daily life may improve treatment response among individuals with bulimia nervosa who have difficulty coping with emotions or who tend to act impulsively. Results from this study indicate that individuals with these difficulties benefitted more from cognitive‐behavioral therapy when it was accompanied by in‐the‐moment reminders to use therapeutic skills, which may facilitate long‐term recovery. Clinical Trials.gov Registration Number NCT03673540.

Optimizing digital health technologies to improve therapeutic skill use and acquisition alongside enhanced cognitive‐behavior therapy for binge‐spectrum eating disorders: Protocol for a randomized controlled trial

“…It is also possible that the optimal complexity level for improving skill use is different for different patients. As described previously, our pilot trial found that individuals with self‐regulation deficits benefitted more from JITAIs during CBT‐E than individuals without these difficulties (Presseller et al, 2022). This moderating effect may have been the result of JITAIs (triggered by elevated distress) increasing the capacity for individuals with difficulties in emotion regulation and elevated impulsivity to identify and implement appropriate coping skills, which in turn promoted abstinence from ED behaviors.…”

“…Impulsivity and emotion dysregulation have been identified as aspects of self-regulation that are highly relevant for individuals with eating pathology (Lavender et al, 2015) and were predictive of individuals who responded particularly well to JITAIs in our pilot trial (Presseller et al, 2022); these two constructs will be used as markers of selfregulation deficits at baseline.…”

“…JITAIs may be more effective than automated interventions as they are delivered at times of actual patient risk (i.e., times at which it is most important for patients to implement therapeutic skills). Consistent with this hypothesis, a recent JITAI system for EDs showed particular promise for improving skill use among individuals with self‐regulation deficits (i.e., emotion regulation deficits and elevated impulsivity), which may contribute to difficulty practicing treatment skills at times of risk (Presseller et al, 2022). However, JITAIs also typically involve more user burden related to inputting data and therefore may be associated with poorer user adherence.…”

Acute Augmentations to Psychological Therapies in Eating Disorders: A Systematic Review and Meta-Analysis

“…A nal 29 studies met inclusion criteria and were included in the systematic review [19,. Of these, 17 randomised trials that had eating disorder outcomes were included in the meta-analysis [19,[26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41].…”

Attention Deficit Hyperactivity Disorder and Dysregulated Eating

“…Self-regulation requires self-Janice Arsenault BSc, RN, MN-NP and Kathryn Weaver BN, RN, MN, PhD awareness (acknowledgment of what is occurring in the present situation), inhibition (ability to restrain from acting on impulse and to evaluate the circumstances, options, and consequences), and both immediate and long-term strategies to attain the appropriate goal [18]. Self-regulation deficits, including deficits in emotion regulation and impulsivity, are similarly implicated in the maintenance of the eating disorder Bulimia Nervosa [Table 1] as individuals engage in binge eating or compensatory behaviors without considering long-term consequences [19] [20]. Greater deficits in self-regulation have been associated with greater eating pathology of more frequent binge eating and use of compensatory behaviours [21].…”