A randomised controlled trial of three psychological treatments for anorexia nervosa.

BACKGROUND: There is a lack of evidence pointing to the efficacy of any specific psychotherapy for adults with anorexia nervosa (AN). The aim of this study was to compare three psychological treatments for AN: Specialist Supportive Clinical Management, Maudsley Model Anorexia Nervosa Treatment for Adults and Enhanced Cognitive Behavioural Therapy. METHOD: A multi-centre randomised controlled trial was conducted with outcomes assessed at pre-, mid- and post-treatment, and 6- and 12-month follow-up by researchers blind to treatment allocation. All analyses were intention-to-treat. One hundred and twenty individuals meeting diagnostic criteria for AN were recruited from outpatient treatment settings in three Australian cities and offered 25-40 sessions over a 10-month period. Primary outcomes were body mass index (BMI) and eating disorder psychopathology. Secondary outcomes included depression, anxiety, stress and psychosocial impairment. RESULTS: Treatment was completed by 60% of participants and 52.5% of the total sample completed 12-month follow-up. Completion rates did not differ between treatments. There were no significant differences between treatments on continuous outcomes; all resulted in clinically significant improvements in BMI, eating disorder psychopathology, general psychopathology and psychosocial impairment that were maintained over follow-up. There were no significant differences between treatments with regard to the achievement of a healthy weight (mean = 50%) or remission (mean = 28.3%) at 12-month follow-up. CONCLUSION: The findings add to the evidence base for these three psychological treatments for adults with AN, but the results underscore the need for continued efforts to improve outpatient treatments for this disorder. Trial Registration Australian New Zealand Clinical Trials Registry (ACTRN 12611000725965) http://www.anzctr.org.au/.

No change in neuropsychological dysfunction or emotional processing during treatment of major depression with cognitive-behaviour therapy or schema therapy.

BACKGROUND: Impaired neuropsychological functioning is a feature of major depression. Previous studies have suggested that at least some aspects of neuropsychological functioning improve with successful treatment of major depression. The extent to which medications may affect the degree of normalization of these functions is unclear. The aim of the current study was to examine the course of neuropsychological functioning during treatment of major depression with cognitive-behaviour therapy (CBT) or schema therapy (ST). METHOD: A total of 69 out-patients with a primary diagnosis of major depression and 58 healthy controls completed mood ratings, neuropsychological measures, and measures of emotional processing at baseline and after 16 weeks. Participants were randomized after baseline assessment to a year-long course of CBT or ST. Patients reassessed at 16 weeks were medication-free throughout the study. RESULTS: Significant neuropsychological impairment was evident at baseline in depressed participants compared with healthy controls. After 16 weeks of psychotherapy, mean depression rating scores fell more than 50%. However, no neuropsychological measures showed convincing evidence of significant improvement and emotional processing did not change. CONCLUSIONS: Persisting impairment in neuropsychological functioning after the first 16 weeks of CBT or ST suggests a need to modify psychological treatments to include components targeting cognitive functioning.

Five-year outcome of cognitive behavioral therapy and exposure with response prevention for bulimia nervosa.

BACKGROUND: Few data exist examining the longer-term outcome of bulimia nervosa (BN) following treatment with cognitive behavioral therapy (CBT) and exposure with response prevention (ERP). METHOD: One hundred and thirty-five women with purging BN received eight sessions of individual CBT and were then randomly assigned to either relaxation training (RELAX) or one of two ERP treatments, pre-binge (B-ERP) or pre-purge cues (P-ERP). Participants were assessed yearly following treatment and follow-up data were recorded. RESULTS: Eighty-one per cent of the total sample attended long-term follow-up. At 5 years, abstinence rates from binging were significantly higher for the two exposure treatments (43% and 54%) than for relaxation (27%), with no difference between the two forms of exposure. Over 5 years, the frequency of purging was lower for the exposure treatments than for relaxation training. Rates of recovery varied according to definition of recovery. Recovery continued to increase to 5 years. At 5 years, 83% no longer met DSM-III-R criteria for BN, 65% received no eating disorder diagnosis, but only 36% had been abstinent from bulimic behaviors for the past year. CONCLUSIONS: This study provides possible evidence of a conditioned inoculation from exposure treatment compared with relaxation training in long-term abstinence from binge eating at 5 years, and the frequency of purging over 5 years, but not for other features of BN. Differences among the groups were not found prior to 5 years. CBT is effective for BN, yet a substantial group remains unwell in the long term. Definition of recovery impacts markedly on recovery rates.

Menstrual cycle irregularity in bulimia nervosa. Associated factors and changes with treatment.

OBJECTIVES: This study determined the clinical and nutritional variables associated with menstrual disturbance in women with bulimia nervosa (BN). METHODS: Eighty-two women with DSM-IV BN underwent psychiatric, nutritional and menstrual related assessments prior to an outpatient treatment programme and at 12 months follow-up. RESULTS: Forty-five percent reported a current irregular menstrual cycle. A high frequency of vomiting, low thyroxine concentrations and low dietary fat intake were independently associated with irregular menses at pretreatment. At 12 months follow-up, 30.5% reported irregular menstrual cycles. A greater difference between past maximum and minimum body weight, smoking and depression were associated with menstrual irregularity at 12 months follow-up. Of those with irregular menstrual cycles at pretreatment, 56.8% became regular at 12 months follow-up. CONCLUSION: Menstrual irregularity in BN is associated with indices of nutritional restriction that are not reflected by low body weight or energy intake. Depression, cigarette smoking and fluctuations in body weight may act as metabolic stresses that contribute to the perpetuation of menstrual disturbances.

Abstention during cue reactivity assessment is associated with better outcome among women with bulimia nervosa.

OBJECTIVE: To compare women with bulimia nervosa who abstained from eating during pretreatment cue reactivity assessment with those who ate. METHOD: 135 participants in a randomized clinical trial completed an assessment of cue reactivity to individualized high-risk binge foods prior to treatment. A broad range of physiological, self-report, and behavioral measures of cue reactivity was assessed. Primary, secondary, and tertiary outcome measures of eating disorder symptomatology were evaluated at pretreatment, midtreatment, posttreatment, and 6-month follow-up. RESULTS: As expected, women who abstained from eating during pretreatment cue reactivity assessment exhibited less cue reactivity than women who ate. This was especially evident for self-report measures of cue reactivity. Surprisingly, women who abstained from eating during pretreatment cue reactivity assessment also had significantly less eating disorder symptomatology at 6-month follow-up. DISCUSSION: Possible psychological mechanisms contributing to the superior outcome of women who abstained from eating during the cue reactivity assessment and implications for the assessment of cue reactivity are discussed.

Cosmetic breast augmentation and eating disorders.

AIMS: To comment on the relation between eating disorders and requests for cosmetic surgery in some women. METHODS: We report two cases of women who were accepted for cosmetic breast augmentation while suffering from current anorexia and bulimia nervosa. RESULTS: For both women, the motivation for seeking cosmetic surgery was directly related to the body image distortion and dissatisfaction which were an inherent part of the eating disorder. CONCLUSION: It is our contention that women with eating disorders require treatment to address the distortion in body image, and the belief that cosmetic surgery will result in satisfaction with their bodies. Screening for eating disorders and body image disturbance should be a routine part of assessment for cosmetic surgery.

The process of change in psychotherapy for depression: helping clients to reformulate the problem.

There is increasing interest in mental health nurses delivering structured short-term evidence-based psychotherapies such as cognitive behavioural therapy (CBT) and interpersonal psychotherapy (IPT); however, while there is evidence of the efficacy of psychotherapy for depression, there is limited understanding of the treatment processes. Data were drawn from audio tapes of CBT and IPT sessions for treatment of depression. The transcripts of the initial, middle and final psychotherapy sessions of 40 clients were analysed. A thematic analysis was conducted to identify what was occurring in the sessions, how the client was describing psychotherapy and how the client was describing improvement or lack of improvement in depressive symptoms. There were differences in descriptions of therapy and the experience of depression between clients who responded and those who did not respond to therapy that were related to improvement in symptoms but not to the specific therapy. These differences were in the client's engagement with the language of therapy, sense of optimism about the particular model of psychotherapy, ability to examine their own role in the problem and desire to engage with new ways of being in their lives. Clients who responded to CBT or IPT had flexibility to develop new ways of thinking and acting, the ability to accept responsibility for their role in the identified problem and were willing to risk change.

Changes on the stroop test following treatment: relation to word type, treatment condition, and treatment outcome among women with bulimia nervosa.

OBJECTIVE: To examine changes in speed of information processing on a modification of the Stroop color-naming task following cognitive-behavior therapy (CBT) and to evaluate whether changes are associated with word type, treatment condition, or treatment response. METHOD: Subjects were 98 women aged between 17 and 45 years with a current primary diagnosis of bulimia nervosa who were participating in a randomized clinical trial evaluating CBT. Data were available on all relevant variables for 98 women. Speed of information processing was assessed at pretreatment and posttreatment using a modification of the Stroop color-naming paradigm. RESULTS: Significant main effects were found for the factors time (pretreatment vs. posttreatment) and word type (food/body words vs. color words, food/body words vs. control words). Predicted interactions between time and word type were not identified. DISCUSSION: Changes in information processing speed over treatment were not specifically associated with word type, treatment condition, or treatment response. Consequently, the utility of the modified Stroop paradigm as a measure of change over time for bulimia nervosa is questioned.