Predictive significance of the overvaluation of shape/weight in obese patients with binge eating disorder: findings from a randomized controlled trial with 12-month follow-up.

BACKGROUND: Undue influence of body shape or weight on self-evaluation - referred to as overvaluation - is considered a core feature across eating disorders, but is not a diagnostic requirement for binge eating disorder (BED). This study examined the concurrent and predictive significance of overvaluation of shape/weight in obese patients with BED participating in a randomized clinical trial testing cognitive behavioral therapy (CBT) and behavioral weight loss (BWL). Method A total of 90 participants were randomly assigned to 6-month group treatments of CBT or BWL. Assessments were performed at baseline, throughout- and post-treatment, and at 6- and 12-month follow-ups after completing treatments with reliably administered semi-structured interviews and established measures. RESULTS: Participants categorized with overvaluation (n = 52, 58%) versus without overvaluation (n = 38, 42%) did not differ significantly in demographic features (age, gender and ethnicity), psychiatric co-morbidity, body mass index or binge eating frequency. The overvaluation group had significantly greater levels of eating disorder psychopathology and poorer psychological functioning (higher depression and lower self-esteem) than the non-overvaluation group. Overvaluation of shape/weight significantly predicted non-remission from binge eating and higher frequency of binge eating at the 12-month follow-up, even after adjusting for group differences in depression and self-esteem levels. CONCLUSIONS: Our findings suggest that overvaluation does not simply reflect concern commensurate with being obese or more frequent binge eating, but also is strongly associated with heightened eating-related psychopathology and psychological distress, and has negative prognostic significance for longer-term treatment outcomes. Overvaluation of shape/weight warrants consideration as a diagnostic specifier for BED as it provides important information about severity and treatment outcome.

Rapid response predicts 12-month post-treatment outcomes in binge-eating disorder: theoretical and clinical implications.

BACKGROUND: We examined rapid response in obese patients with binge-eating disorder (BED) in a clinical trial testing cognitive behavioral therapy (CBT) and behavioral weight loss (BWL). METHOD: Altogether, 90 participants were randomly assigned to CBT or BWL. Assessments were performed at baseline, throughout and post-treatment and at 6- and 12-month follow-ups. Rapid response, defined as 70% reduction in binge eating by week four, was determined by receiver operating characteristic curves and used to predict outcomes. RESULTS: Rapid response characterized 57% of participants (67% of CBT, 47% of BWL) and was unrelated to most baseline variables. Rapid response predicted greater improvements across outcomes but had different prognostic significance and distinct time courses for CBT versus BWL. Patients receiving CBT did comparably well regardless of rapid response in terms of reduced binge eating and eating disorder psychopathology but did not achieve weight loss. Among patients receiving BWL, those without rapid response failed to improve further. However, those with rapid response were significantly more likely to achieve binge-eating remission (62% v. 13%) and greater reductions in binge-eating frequency, eating disorder psychopathology and weight loss. CONCLUSIONS: Rapid response to treatment in BED has prognostic significance through 12-month follow-up, provides evidence for treatment specificity and has clinical implications for stepped-care treatment models for BED. Rapid responders who receive BWL benefit in terms of both binge eating and short-term weight loss. Collectively, these findings suggest that BWL might be a candidate for initial intervention in stepped-care models with an evaluation of progress after 1 month to identify non-rapid responders who could be advised to consider a switch to a specialized treatment.

Mind the gap: Improving the dissemination of CBT.

Empirically supported psychological treatments have been developed for a range of psychiatric disorders but there is evidence that patients are not receiving them in routine clinical care. Furthermore, even when patients do receive these treatments there is evidence that they are often not well delivered. The aim of this paper is to identify the barriers to the dissemination of evidence-based psychological treatments and then propose ways of overcoming them, hence potentially bridging the gap between research findings and clinical practice.

Health services use in eating disorders.

BACKGROUND: This study examined healthcare services used by adults diagnosed with an eating disorder (ED) in a large health maintenance organization in the Pacific Northwest. METHOD: Electronic medical records were used to collect information on all out-patient and in-patient visits and medication dispenses, from 2002 to 2004, for adults aged 18-55 years who received an ED diagnosis during 2003. Healthcare services received the year prior to, and following, the receipt of an ED diagnosis were examined. Cases were matched to five comparison health plan members who had a health plan visit close to the date of the matched case's ED diagnosis. RESULTS: Incidence of EDs (0.32% of the 104,130 females, and 0.02% of the 93,628 males) was consistent with prior research employing treatment-based databases, though less than community-based samples. Most cases (50%) were first identified during a primary-care visit and psychiatric co-morbidity was high. Health services use was significantly elevated in all service sectors among those with an ED when compared with matched controls both in the year preceding and that following the receipt of the incident ED diagnosis. Contrary to expectations, healthcare utilization was found to be similarly high across the spectrum of EDs (anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified). CONCLUSIONS: The elevation in health service use among women both before and after diagnosis suggests that EDs merit identification and treatment efforts commensurate with other mental health disorders (e.g. depression) which have similar healthcare impact.

Self-help and long-term behavior therapy for obesity.

The Trevose Behavior Modification Program, a self-help group offering continuing care for obesity, has recently been shown to produce large long-term weight losses. The present study aimed to replicate this finding across different settings and participants, assessing the weight losses and attrition rates of 128 participants in three Trevose program satellite groups that used the same treatment procedures and manual as the central Trevose group. The satellite groups' results closely paralleled those of the Central Group. Mean intent-to-treat weight loss, or final losses recorded for all participants regardless of their treatment termination date, was 13.7 +/- 0.7% of initial body weight (1.8 +/- 0.7 kg). At two years, 43.8% of participants remained in treatment, having lost a mean of 19.0 +/- 0.8% of their body weight (16.2 +/- 1.0 kg); at five years, 23.4% remained, having lost 18.4 +/- 1.1% of body weight (15.6 +/- 1.5 kg). These results demonstrate that the Trevose model of weight control, combining self-help and continuing care, can be extended and disseminated to other settings, with potentially significant public health consequences.

Different methods for assessing the features of eating disorders in patients with binge eating disorder: a replication.

OBJECTIVE: To compare different methods for assessing the features of eating disorders in patients with binge eating disorder (BED). RESEARCH METHODS AND PROCEDURES: A total of 47 participants with BED were administered the Eating Disorder Examination (EDE) Interview and completed the EDE-Questionnaire (EDE-Q) at baseline. A total of 37 participants prospectively self-monitored their eating behaviors daily for 4 weeks and then completed another EDE-Q. RESULTS: At baseline, the EDE and the EDE-Q were significantly correlated on frequencies of objective bulimic episodes (binge eating), overeating episodes, and on the dietary restraint, eating concern, weight concern, and shape concern subscales. Mean differences in the EDE and EDE-Q frequencies of objective bulimic episodes and overeating were not significant but scores on the four subscales differed significantly, with the EDE-Q yielding higher scores. At the 4-week point, the EDE-Q retrospective 28-day assessment was significantly correlated with the prospective daily self-monitoring records for frequency of objective bulimic episodes and the mean difference between the methods was not significant. The EDE-Q and self-monitoring findings for subjective bulimic episodes and objective overeating differed significantly. DISCUSSION: In patients with BED, the three assessment methods showed some areas of acceptable convergence.

Perfectionism in women with binge eating disorder.

OBJECTIVE: This study examined self-oriented (SOP), socially prescribed (SPP), and other-oriented (OOP) perfectionism in 127 obese women with binge eating disorder (BED). METHOD: Relationships between eating disorder and general psychopathology variables and SOP, SPP, and OOP were assessed. Levels of SOP, SPP, and OOP in the BED sample were compared with those of 32 normal weight women with bulimia nervosa (BN) and 60 obese non-eating-disordered individuals (NED). Structural equation modeling (SEM) was used to test models of the maintenance of BED. RESULTS: Only SPP was significantly associated with eating disorder variables related to BED. All three groups demonstrated similar levels of SPP and OOP. BN and BED groups scored significantly higher than the NED group on SOP only. SEM resulted in two models with good fits. DISCUSSION: Further research is needed on the roles of SPP and SOP in BED and on weight and shape overconcern in BED maintenance models.

A comparison of different methods for assessing the features of eating disorders in patients with binge eating disorder.

The authors compared 3 methods for assessing the features of eating disorders in patients with binge eating disorder (BED). Participants were administered the Eating Disorder Examination (EDE) interview and completed the EDE Questionnaire (EDE-Q) at baseline. Participants prospectively self-monitored their eating behaviors daily for 4 weeks and then completed another EDE-Q. The EDE and the EDE-Q were significantly correlated on frequencies of objective bulimic episodes (binge eating) and on the Dietary Restraint, Eating Concern, Weight Concern, and Shape Concern subscales. Mean differences in the EDE and EDE-Q frequencies of objective bulimic episodes were not significant, but scores on the 4 subscales differed significantly, with the EDE-Q yielding higher scores. At 4 weeks, the EDE-Q retrospective 28-day assessment was significantly correlated with the prospective daily self-monitoring records for frequency of objective bulimic episodes, and the mean difference between methods was not significant. The EDE-Q and self-monitoring findings for subjective bulimic episodes and objective overeating differed significantly. Thus, in patients with BED, the 3 assessment methods showed some acceptable convergence, most notably for objective bulimic episodes.

Subtyping binge eating disorder.

Cluster-analytic studies of bulimia nervosa and binge eating disorder (BED) have yielded 2 subtypes (pure dietary and mixed dietary-negative affect). The authors aimed to (a) replicate the subtyping with BED, (b) consider alternative approaches to subtyping, and (c) test the stability in individual differences in the subtyping. Cluster analyses of 101 patients revealed a dietary-negative affect subtype (33%) and a pure dietary subtype (67%). The dietary-negative affect subtype was characterized by greater eating-related psychopathology and psychological disturbance. Cluster analysis produced different results from alternative subtyping approaches (by major depression or by binge eating frequency). Cluster-analytic subtyping of data at 2 time points 4 weeks apart for a subset of 73 patients demonstrated significant consistency (kappa = .55). Findings suggest that moderate dieting is characteristic of BED and that affective disturbances occur in a subset of cases that represent a more disturbed variant. The subtypes may represent reasonably stable individual differences.

Assessment of eating disorders in bariatric surgery candidates: self-report questionnaire versus interview.

OBJECTIVE: To compare the Eating Disorder Examination (EDE), an investigator-based interview for the assessment of the specific psychopathology of eating disorders, with the EDE-Q, a self-report questionnaire based directly on it. METHOD: Ninety-eight morbidly obese gastric bypass surgery candidates were administered both instruments. RESULTS: The four subscale scores (Restraint, Eating Concern, Weight Concern, and Shape Concern) generated by the EDE and EDE-Q were significantly correlated, although the questionnaire scores were significantly higher. Eating Concern and Shape Concern exhibited the lowest levels of agreement. Frequency of binges (objective bulimic episodes) as rated by the EDE and EDE-Q was significantly correlated and was not significantly different. However, variability in ratings contributed to only modest agreement with respect to classification of patients as binge eaters. DISCUSSION: Overall, there were lower levels of agreement between the EDE and EDE-Q than have been previously found in other samples.

Effective long-term treatment of obesity: a continuing care model.

BACKGROUND: Despite the well-documented success of behavioral techniques in producing temporary weight loss, treatment is typically followed by weight regain. The maintenance of treatment effects may therefore be the greatest challenge in the long-term management of obesity, and continuous care may be necessary to achieve it. OBJECTIVE: To describe the design and evaluate the effectiveness of the Trevose Behavior Modification Program, a potentially widely replicable self-help weight loss program offering continuous care. DESIGN: A description of the course of all subjects (n=171) who entered the Trevose program during 1992 and 1993. SUBJECTS: One hundred and forty-six women aged 44.1+/-11.7 y with a body mass index (BMI, kg/m2) of 33.2+/-4.4, and 25 men aged 49. 0+/-19.6 with a BMI of 35.1+/-5.2 enrolled in the Trevose program during 1992-1993. RESULTS: Mean duration of treatment was 27.1 months, with 47.4% of members still in treatment at 2 y and 21.6% at 5 y. Mean intent-to-treat weight loss was 13.7+/-0.5% of initial weight, or 12.8+/-0.5 kg. As long as they remained in treatment, almost all participants lost at least 5% of their initial weight and at least 83% lost more than 10%. Members completing 2 y of treatment lost an average of 19.3% of their initial body weight (17.9 kg); at 5 y the loss was still 17.3% (15.7 kg). After leaving the program, subjects regained weight but remained 4.7% (4.5 kg) below their pretreatment weight. CONCLUSION: A low-cost program offering treatment of indefinite duration produced large long-term weight losses and may be suitable for widespread replication.

Stepped care treatment for eating disorders.

A stepped care approach would link different patient needs to therapeutic modalities that range from simple advice to intensive inpatient care. Brief methods, including self-help and psychoeducation, may be effective for a subset of patients with bulimia nervosa and binge eating disorder. Identifying this subset remains a challenge. It is unclear how patients who fail to respond to evidence-based, first-line treatments should be treated. Given the absence of data on effective treatment of anorexia nervosa (AN), discussion of a stepped care approach is speculative. Because AN typically demands expert and sustained treatment, the lower levels of stepped care models are inapplicable for these patients. A stepped care approach poses methodological challenges for clinical research and raises important clinical issues, such as when to switch from 1 level of treatment to another.

Outcome predictors for the cognitive behavior treatment of bulimia nervosa: data from a multisite study.

OBJECTIVE: The aim of this study was to discover clinically useful predictors of attrition and outcome in the treatment of bulimia nervosa with cognitive behavior therapy. METHOD: Pretreatment, course of treatment, and outcome data were gathered on 194 women meeting the DSM-III-R criteria for bulimia nervosa who were treated with 18 sessions of manual-based cognitive behavior therapy in a three-site study. Differences between dropouts and nondropouts and between recovered and nonrecovered participants were first examined descriptively, and signal detection analyses were then used to determine clinically significant cutoff points predicting attrition and abstinence. RESULTS: The dropouts were characterized by more severe bulimic cognitions and greater impulsivity, but it was not possible to identify clinically useful predictors. The participants with treatment failures were characterized by poor social adjustment and a lower body mass index, presumably indicating greater dietary restriction. However, early progress in therapy best predicted outcome. Signal detection analyses revealed that poor outcome was predicted by a reduction in purging of less than 70% by treatment session 6, allowing identification of a substantial proportion of prospective failures. CONCLUSIONS: A cutoff point based on reduction of purging by session 6 usefully differentiates patients who will and will not respond to cognitive behavior therapy for bulimia nervosa, potentially allowing early use of a second therapy.

Fluoxetine for bulimia nervosa following poor response to psychotherapy.

OBJECTIVE: This was an investigation of whether treatment with fluoxetine is useful for individuals with bulimia nervosa who do not respond to psychotherapy or relapse afterward. METHOD: Twenty-two patients with bulimia nervosa who had not responded to, or had relapsed following, a course of cognitive behavior therapy or interpersonal psychotherapy were randomly assigned to receive placebo (N=9) or fluoxetine (60 mg/day, N=13) for 8 weeks. RESULTS: The median frequency of binge eating in the previous 28 days declined from 22 to four episodes in the fluoxetine group but increased from 15 to 18 episodes in the placebo group. Similarly, purging frequency in the previous 28 days declined from 30 to six episodes in the fluoxetine group but increased from 15 to 38 episodes in the placebo group. CONCLUSIONS: Fluoxetine may be a useful intervention for patients with bulimia nervosa who have not responded adequately to psychological treatment.

Obesity: what mental health professionals need to know.

OBJECTIVE: Obesity is a highly prevalent condition with significant health implications. This report summarizes recent clinically relevant findings concerning the pathogenesis and treatment of obesity and considers their implications for psychiatric diagnosis and management. METHOD: The authors conducted selective reviews of the literature from the last 10 years. Topics included the biological and behavioral factors that contribute to the onset and maintenance of obesity, the relationship between obesity and psychiatric illness and treatment, and the questions of whether and how obesity should be treated. RESULTS: Genetic effects, some mediated by eating behavior, contribute importantly to the potential for obesity, the expression of which is promoted by environmental factors that increase the availability of calorically dense foods and discourage activity. There appear to be behaviorally distinct subsets of obese persons who display particular patterns of disordered eating and elevated rates of psychopathology. Treatment with psychotropic medications may contribute to obesity in ways that are only partly understood. Although successful obesity treatment is associated with clear health benefits and available treatments offer benefit to some, relapse remains the rule. CONCLUSIONS: Although the presence or development of obesity is a daunting problem, it should not be ignored by mental health professionals. Treatment should address not only obesity per se, but also its effects on self-esteem in a hostile cultural climate. Ongoing developments in basic and clinical research are likely to increase the range, efficacy, and acceptability of treatment options in the years ahead.

A multicenter comparison of cognitive-behavioral therapy and interpersonal psychotherapy for bulimia nervosa.

BACKGROUND: Research suggests that cognitive-behavioral therapy (CBT) is the most effective psychotherapeutic treatment for bulimia nervosa. One exception was a study that suggested that interpersonal psychotherapy (IPT) might be as effective as CBT, although slower to achieve its effects. The present study is designed to repeat this important comparison. METHOD: Two hundred twenty patients meeting DSM-III-R criteria for bulimia nervosa were allocated at random to 19 sessions of either CBT or IPT conducted over a 20-week period and evaluated for 1 year after treatment in a multisite study. RESULTS: Cognitive-behavioral therapy was significantly superior to IPT at the end of treatment in the percentage of participants recovered (29% [n=32] vs 6% [n=71), the percentage remitted (48% [n=53] vs 28% [n = 31]), and the percentage meeting community norms for eating attitudes and behaviors (41% [n=45] vs 27% [n=30]). For treatment completers, the percentage recovered was 45% (n= 29) for CBT and 8% (n= 5) for IPT. However, at follow-up, there were no significant differences between the 2 treatments: 26 (40%) CBT completers had recovered at follow-up compared with 17 (27%) IPT completers. CONCLUSIONS: Cognitive-behavioral therapy was significantly more rapid in engendering improvement in patients with bulimia nervosa than IPT. This suggests that CBT should be considered the preferred psychotherapeutic treatment for bulimia nervosa.

Long-term maintenance of weight loss: current status.

Intervention strategies for promoting long-term weight loss are examined empirically and conceptually. Weight control research over the last 20 years has dramatically improved short-term treatment efficacy but has been less successful in improving long-term success. Interventions in preadolescent children show greater long-term efficacy than in adults. Extending treatment length and putting more emphasis on energy expenditure have modestly improved long-term weight loss in adults. Fresh ideas are needed to push the field forward. Suggested research priorities are patient retention, natural history, assessment of intake and expenditure, obesity phenotypes, adolescence at a critical period, behavioral preference-reinforcement value, physical activity and social support, better linkage of new conceptual models to behavioral treatments, and the interface between pharmacological and behavioral methods.

Guided and unguided self-help for binge eating.

This study compared the relative short- and longer-term efficacy of therapist-guided and unguided use of a cognitive behavioral self-help manual for binge eating [Fairburn, C. G. (1995). Overcome binge eating. New York: The Guilford Press.] Forty women (82.5% with binge eating disorder) were randomized to one of the two treatment levels. Results indicate that both conditions represent viable means of treating binge eating. Overall, patients improved their eating behavior, eliminated any inappropriate compensatory behaviors, reduced their shape concern, weight concern, and other symptoms of eating-related psychopathology, and improved their general psychological functioning. The guided self-help condition was notably superior in reducing the occurrence of binge eating and its associated symptomatology, as well as lowering interpersonal sensitivity. A high degree of general psychopathology was a negative prognostic indicator. The implications for a stepped-care approach to treating binge eating are discussed.

Cognitive-behavioral therapy and nutritional counseling in the treatment of bulimia nervosa and binge eating.

The goals of manual-based cognitive-behavioral therapy (CBT) and nutritional counseling for eating disorders are similar, namely, eliminating dysfunctional patterns of eating. Modifying these behaviors requires specific therapeutic expertise in the principles and procedures of behavior change that is not typically part of the training of nutritionists and dieticians or mental health professionals without specific expertise. We discuss ways in which principles of behavior change can be applied to eating disorders by non-CBT experts. Specific nutritional rehabilitation programs have the potential to augment CBT in addressing the array of appetitive abnormalities present in eating disorder patients. The dysfunctional appetitive, hedonic, and metabolic characteristics of patients with bulimia nervosa (BN) and binge eating disorder are reviewed. These abnormalities constitute potential target areas that might be more fully addressed by nutritional interventions designed to restore normal appetitive function.

Psychological versus pharmacological treatments of bulimia nervosa: predictors and processes of change.

This article extends the acute outcome findings from a study comparing psychological and pharmacological interventions for bulimia nervosa (B.T. Walsh et al., 1997) by examining 3 additional domains: predictive factors, therapeutic alliance, and time course of change. One hundred twenty women were randomized to cognitive-behavioral therapy (CBT), supportive psychotherapy (SPT) plus antidepressant medication or a placebo, or a medication-alone condition. Results indicate that high baseline frequencies of binge eating and vomiting, as well as a positive history of substance abuse or dependence, are negative prognostic indicators. Although a greater overall therapeutic alliance may increase the likelihood of remission, symptom change over the course of treatment may have as much of an impact on patient ratings of alliance as the reverse. CBT was significantly more rapid than SPT in reducing binge eating and vomiting frequencies.