A randomized controlled comparison of integrative cognitive-affective therapy (ICAT) and enhanced cognitive-behavioral therapy (CBT-E) for bulimia nervosa.

BACKGROUND: The purpose of this investigation was to compare a new psychotherapy for bulimia nervosa (BN), integrative cognitive-affective therapy (ICAT), with an established treatment, 'enhanced' cognitive-behavioral therapy (CBT-E). METHOD: Eighty adults with symptoms of BN were randomized to ICAT or CBT-E for 21 sessions over 19 weeks. Bulimic symptoms, measured by the Eating Disorder Examination (EDE), were assessed at baseline, at the end of treatment (EOT) and at the 4-month follow-up. Treatment outcome, measured by binge eating frequency, purging frequency, global eating disorder severity, emotion regulation, self-oriented cognition, depression, anxiety and self-esteem, was determined using generalized estimating equations (GEEs), logistic regression and a general linear model (intent-to-treat). RESULTS: Both treatments were associated with significant improvement in bulimic symptoms and in all measures of outcome, and no statistically significant differences were observed between the two conditions at EOT or follow-up. Intent-to-treat abstinence rates for ICAT (37.5% at EOT, 32.5% at follow-up) and CBT-E (22.5% at both EOT and follow-up) were not significantly different. CONCLUSIONS: ICAT was associated with significant improvements in bulimic and associated symptoms that did not differ from those obtained with CBT-E. This initial randomized controlled trial of a new individual psychotherapy for BN suggests that targeting emotion and self-oriented cognition in the context of nutritional rehabilitation may be efficacious and worthy of further study.

A latent profile analysis of the typology of bulimic symptoms in an indigenous Pacific population: evidence of cross-cultural variation in phenomenology.

BACKGROUND: Previous efforts to derive empirically based eating disorder (ED) typologies through latent structure modeling have been limited by the ethnic and cultural homogeneity of their study populations and their reliance on DSM-IV ED signs and symptoms as indicator variables. METHOD: Ethnic Fijian schoolgirls (n=523) responded to a self-report battery assessing ED symptoms, herbal purgative use, co-morbid psychopathology, clinical impairment, cultural orientation, and peer influences. Participants who endorsed self-induced vomiting or herbal purgative use in the past 28 days (n=222) were included in a latent profile analysis (LPA) to identify unique subgroups of bulimic symptomatology. RESULTS: LPA identified a bulimia nervosa (BN)-like class (n=86) characterized by high rates of binge eating and self-induced vomiting, and a herbal purgative class (n=136) characterized primarily by the use of indigenous Fijian herbal purgatives. Both ED classes endorsed greater eating pathology and general psychopathology than non-purging participants, and the herbal purgative class endorsed greater clinical impairment than either the BN-like or non-purging participants. Cultural orientation did not differ between the two ED classes. CONCLUSIONS: Including study populations typically under-represented in mental health research and broadening the scope of relevant signs and symptoms in latent structure models may increase the generalizability of ED nosological schemes to encompass greater cultural diversity.

Examining a psychosocial interactive model of binge eating and vomiting in women with bulimia nervosa and subthreshold bulimia nervosa.

The current study tested a psychosocial interactive model of perfectionism, self-efficacy, and weight/shape concern within a sample of women with clinically significant bulimic symptoms, examining how different dimensions of perfectionism operated in the model. Individuals with bulimia nervosa (full diagnostic criteria or subthreshold) completed measures of bulimic symptoms, multidimensional perfectionism, self-efficacy, and weight/shape concern. Among those who were actively binge eating (n=180), weight/shape concern was associated with binge eating frequency in the context of high perfectionism (either maladaptive or adaptive) and low self-efficacy. Among those who were actively vomiting (n=169), weight/shape concern was associated with vomiting frequency only in the context of high adaptive perfectionism and low self-efficacy. These findings provide support for the value of this psychosocial interactive model among actively binge eating and purging samples and for the importance of considering different dimensions of perfectionism in research and treatment related to bulimia nervosa.

Depression and adrenal function in spinal cord injury.

Of 32 patients with spinal cord injury, 14 had a DSM-III diagnosis of depressive disorder: 12 had major depression (five with melancholia) and two were dysthymic. In those with major depression, a dexamethasone suppression test lacked sensitivity (30%) and specificity (50%).

Depression among amputees.

A 35% prevalence of major depressive disorder was found in a prospective study of 65 amputees evaluated in a Physical Medicine and Rehabilitation Department. The findings indicate significantly more alcohol abuse among the depressed group. Higher percentages of female than male amputees were found to be depressed and unmarried. The prevalence of smoking was significantly higher among those whose amputations were due to vascular disease rather than other causes (e.g., trauma). In addition to the physical care of amputees, their emotional needs and well-being merit serious consideration.

Long-term follow-up of patients' status after gastric bypass.

BACKGROUND: We report a long-term (13-15 year) follow-up of a cohort of 100 patients who underwent gastric bypass for morbid obesity. METHODS: Sources of information include baseline data collected before surgery and information obtained at follow-up interview including data on weight history, psychosocial functioning, and medical complications. RESULTS: Mean age at follow-up was 56.8 years. The mean weight loss at long-term follow-up was 29.5 kg (range -13.6 to 93.6 kg). Three subjects weighed more at long-term follow-up than before the operation. Overall, 74% of those interviewed indicated that the gastric bypass had benefited them in terms of their physical health. However, 68.8% reported continued problems with vomiting and 42.7% with "plugging". Eight had died. CONCLUSION: The findings in this study suggest that at long-term follow-up the majority of individuals who have undergone gastric bypass feel that the procedure benefited them, although some complications including difficulties with "plugging" and vomiting were present at long-term follow-up.

Interpretation of transference in the psychotherapy of adolescents and young adults.

There is considerable controversy in the literature surrounding the role of interpretation of transference in the expressive psychotherapy of adolescents and young adults. The authors contend that interpretation of transference is often underutilized in the psychotherapy of adolescents and that many treatments could be enriched by its inclusion. It is argued that interpretation of the transference in the immediate "here and now" of the therapeutic encounter should take precedence over genetic transference interpretation, which attempts to link current attitudes toward the therapist to archaic attitudes toward the parents. Six guidelines founded on a developmental perspective are described for exploring transference themes in this age group. While interpretation of transference is neither a panacea nor uniquely mutative with adolescents and young adults, the authors believe it has an important role to play in expressive psychotherapy if used judiciously and with foresight.

Relationship of childhood sexual abuse and eating disorders.

OBJECTIVE: To review the literature that has examined the relationship between childhood sexual abuse and the eating disorders. METHOD: Each of the five authors reviewed all identified empirical studies to be certain that inclusion/exclusion criteria were met. Two teams of raters then independently reviewed each study to determine whether it supported any of a series of six hypotheses that had been tested in this literature. RESULTS: This review indicates that childhood sexual abuse is a nonspecific risk factor for bulimia nervosa, particularly when there is psychiatric comorbidity. There is some indication that childhood sexual abuse is more strongly associated with bulimic disorders than restricting anorexia, but it does not appear to be associated with severity of the disturbance. CONCLUSION: Childhood sexual abuse is a risk factor for bulimia nervosa with significant comorbidity. Further study of the nature of this relationship is warranted.

The neglected link between eating disturbances and aggressive behavior in girls.

OBJECTIVES: Research has linked eating disturbances with behavioral impulsivity. Little is known, however, about whether eating disturbances and aggressive behavior have a tendency to co-occur in the same girls. This article assesses the eating disturbance-aggressive behavior association and then examines the extent to which these factors confer a risk on drug use and attempted suicide. METHOD: Survey data were gathered from 3,630 girls in grades 6 through 12 in the upper Midwest. Girls responded anonymously to questions regarding binge eating and purging, dietary restriction, aggressive behavior, drug use, and attempted suicide. Logistic regression analysis was used to assess the unique contribution of demographic variables, eating disturbances, and aggression on drug use and attempted suicide. RESULTS: Eating disturbances were significantly associated with aggressive behavior. Girls who endorsed binge eating and purging or dietary restriction had odds of aggressive behavior 2 to 4 times higher than girls who did not endorse these items. Logistic regression revealed that eating disturbances and aggressive behavior were significantly associated with both drug use and attempted suicide. CONCLUSIONS: Eating disturbances are significantly associated with aggressive conduct in adolescent girls. The constellation of eating disturbances and aggressive behavior is associated with a greater risk of drug use and attempted suicide.

Relationship of childhood sexual abuse and eating disturbance in children.

OBJECTIVE: To test the hypothesis that childhood sexual abuse increases the risk of eating disturbance in children. METHOD: Data obtained from 20 sexually abused children were compared with data obtained from 20 nonabused control children. All subjects were female and between the ages of 10 and 15 years. Subjects completed a battery of tests assessing eating disorder behaviors, body image concern, and childhood trauma history. RESULTS: Comparison of the 2 groups revealed that the abused children had higher levels of weight dissatisfaction and purging and dieting behavior. Furthermore, abused children reported eating less than control children when they felt emotionally upset. Abused children were less likely than control children to exhibit perfectionistic tendencies, but more likely to desire thinner body types. CONCLUSIONS: This is the first controlled study to examine the relationship between childhood sexual abuse and eating disturbance which relied on children as subjects. The results support previous findings with adult subjects which indicate that a history of childhood sexual abuse is associated with weight and body dissatisfaction, along with purging and dietary restriction.

Social perceptions and borderline personality disorder: the relation to mood disorders.

We used the Structural Analysis of Social Behavior (SASB) to compare the social perceptions of borderline, unipolar, and bipolar-depressed inpatients. As predicted, borderline subjects differed from bipolar-depressed and unipolar subjects in their social perceptions. Borderline subjects viewed their relationships to their mother, hospital staff, and other patients as more hostile and autonomous than did mood disordered subjects. The results are discussed in terms of an integrative theory of borderline personality that considers the psychobiology of interpersonal relationships and attachment disruptions.

Perceptions of parental relationships in the eating disorders: the relevance of depressed mood.

Recent studies have suggested that subtypes of eating-disordered persons differ in their perceptions of their family environments. This study used Benjamin's (1983) Structural Analysis of Social Behavior to examine how depressed mood influenced eating-disordered subjects' ratings of their parental relationships. The results indicated that when level of mood disturbance was statistically controlled, there were no significant differences in parent ratings among restricting anorexics, bulimic-anorexics, bulimics, and normal control subjects. The results are discussed in terms of the possible relations of mood, eating disorder, and perception of family relationships.

Self-concept correlates of the personality disorders.

This study investigated the extent to which the DSM personality disorder dimensions are associated with discrete patterns of self-concept. Participants were 366 men and women who were receiving mental health services and who completed the Wisconsin Personality Disorders Inventory to assess the personality disorders and Benjamin's INTREX questionnaire to describe their "typical" self-concepts. Although there was some overlap between categories, most were associated with fairly distinct patterns of self-concept. The disorders also clustered together in meaningful ways along the major axes of Benjamin's interpersonal model of the self-concept.

Sexual trauma and personality: developmental vulnerability and additive effects.

Two types of sexual trauma, sexual abuse in childhood and rape in adulthood, were investigated in terms of possible effects on personality. Four groups of participants were studied: women who had experienced sexual abuse in childhood, women who had experienced rape as adults, women who had experienced both of these sexual traumas, and a control group of women who had experienced no sexual trauma. Personality functioning was assessed using the Dimensional Assessment of Personality Pathology. Groups who had experienced childhood sexual abuse displayed the highest degree of personality disturbance; however, the additive effects of repeated sexual trauma were limited. These findings may reflect the outcome of specific adversity in childhood on the psychobiological constructs underlying personality.

Hypnosis and behavioral treatment in a worksite smoking cessation program.

In the initial study, 48 subjects of the total (N = 63) ultimately used, were assigned to one of three treatments: four hypnotic sessions with a booster, two hypnotic sessions, or two hypnotic and two behavioral sessions with a booster. A follow-up group was later recruited composed of 15 subjects who received four hypnotic sessions and a booster session with less time between sessions. The results indicated no difference in smoking cessation 6 months after treatment regardless of the frequency, length between sessions, or addition of behavioral methods. Successful subjects were more educated, less able to utilize their imagination, and had fewer smokers at home.

Sexual victimization and adolescent weight regulation practices: a test across three community based samples.

OBJECTIVE: This study had four objectives: 1) to examine the association between sexual victimization and weight regulation across three samples of adolescent girls, 2) to assess whether sexual victimization is associated with more extreme forms of weight regulation in girls, 3) to discern whether sexual victimization has implications for the use of multiple forms of weight regulation, and 4) to address the role of physical victimization in explaining these relationships. METHOD: Data from three separate samples of 9th-12th graders were used to test these hypotheses. Girls from the upper Midwest responded to survey questions related to victimization and weight regulation in a largely urban sample (N = 2,086), a rural sample (N = 2,629), and a statewide sample (N = 966). RESULTS: Logistic regression revealed that sexual victimization was consistently associated with weight regulation in adolescent girls, independent of the effects of physical victimization. In the urban sample, being sexually victimized was associated with an increase in the probability of purging by 18% relative to not being sexually victimized. Sexual victimization was associated more strongly with extreme forms of weight regulation and significantly discriminated whether girls would choose multiple weight regulation forms. CONCLUSIONS: Sexual victimization contributes unique variance to the probability that girls will practice weight regulation techniques. Data from three independent samples confirms that being violated sexually places girls at risk for various health compromising eating behaviors.

Prevalence and risk factors for childhood sexual abuse in women: national survey findings.

OBJECTIVE: We interviewed a U.S. national sample of women, aged 18 years and older to determine the prevalence and characteristics of childhood sexual abuse. We also examined which family and background variables were predictive of CSA in this sample. METHOD: The study employed a series of detailed descriptive questions regarding childhood sexual experiences that were administered in a highly structured format by trained female interviewers. CSA prevalence rates were calculated using two definitions of CSA, one of which was slightly more inclusive. RESULTS: Prevalence rates for the more inclusive CSA definition ranged from 21% to 32%, depending on how respondents who provided incomplete information about their sexual experiences were classified. The less inclusive CSA definition resulted in prevalence rates ranging from 15% to 26%. Additional information about the types of abuse experienced, perpetrator characteristics, age at first abuse, and physical and affective consequences of the abusive experiences are reported. The risk of CSA was related to higher scores on a measure of father's rejection, and the interaction between parental drinking status and whether the respondent had lived with both parents during childhood. Further analysis of this interaction suggests that when respondents reported living with both biological parents, they were most at risk for CSA when their father was a nondrinker and their mother was a drinker.

An assessment of the recidivism rates of substantiated and unsubstantiated maltreatment cases.

OBJECTIVE: This study assembles information about the large number of maltreatment reports that are determined by social services to be unsubstantiated. Specifically, we assess whether the status of a maltreatment case (substantiated vs. unsubstantiated) has implications for recidivism. Recidivism rates for substantiated and unsubstantiated maltreated juveniles were also compared to juvenile offenders. METHOD: Juvenile court records for 15,812 juveniles were assessed over a 3 year period. The data included 2558 maltreatment cases. Fifty-four percent of these cases were unsubstantiated. Logistic regression analysis was employed to assess the probability of recidivism based on time one referral status. RESULTS: Youth whose maltreatment allegations were unsubstantiated had significantly lower odds of recidivating than abused youth. Having a case recorded as unsubstantiated lowered a youth's odds of subsequent offending by 55% relative to being abused. The probability of recidivating was highest for juvenile offenders, followed in order by maltreated youth and youth whose reports were unsubstantiated. DISCUSSION: This is one of the first studies to examine the court histories of substantiated and unsubstantiated maltreatment cases. If the subsequent outcomes following maltreatment investigations are used as an indicator of seriousness, our results suggest that assessment caseworkers are successfully sorting out the serious from the less serious cases.

Smoking and weight control in adolescent females.

This paper examines the association between smoking and various weight control techniques among adolescent girls in two school-based samples. Previous studies have relied heavily on clinical trials of adults and have focused mainly on dietary restraint rather than purging behavior. This study seeks to determine whether purging is associated with smoking and if purging and dietary restraint effects upon smoking are additive or synergistic. Data from adolescent girls were gathered from two school-based surveys conducted in the upper Midwest. Assessments were conducted for smoking, dietary restraint, diet pill use, and purging. Logistic regression was used to test for main and interaction effects. Analysis revealed significant associations between smoking and weight control. Purging was more highly associated with smoking than dietary restraint or diet pill use. The form of these associations was interactive rather than additive in both data sets. Nonpurging girls were significantly more likely to smoke if they were dieting or using diet pills than if they were not practicing dieting behavior. Thus, the effect of dieting and diet pill use on smoking is dependent on purging behavior. Weight control is associated with smoking behavior in adolescent girls but the form of these associations may be more complex than originally thought. Future research is needed to determine if there are two subtypes of smoking-weight control girls.

The integrity of independent variables in behavior analysis.

Establishing a functional relationship between the independent and the dependent variable is the primary focus of applied behavior analysis. Accurate and reliable description and observation of both the independent and dependent variables are necessary to achieve this goal. Although considerable attention has been focused on ensuring the integrity of the dependent variable in the operant literature, similar effort has not been directed at ensuring the integrity of the independent variable. Inaccurate descriptions of the application of the independent variable may threaten the reliability and validity of operant research data. A survey of articles in the Journal of Applied Behavior Analysis demonstrated that the majority of articles published do not use any assessment of the actual occurrence of the independent variable and a sizable minority do not provide operational definitions of the independent variable. The feasibility and utility of ensuring the integrity of the independent variable is described.