Maintenance treatment for anorexia nervosa: a comparison of cognitive behavior therapy and treatment as usual.

OBJECTIVE: The aim of this study was to compare two maintenance treatment conditions for weight-restored anorexia nervosa (AN): individual cognitive behavior therapy (CBT) and maintenance treatment as usual (MTAU). METHOD: This study was a nonrandomized clinical trial. The participants were 88 patients with AN who had achieved a minimum body mass index (BMI) of 19.5 and control of binge eating and purging symptoms after completing a specialized hospital-based program. Forty-six patients received 1 year of manualized individual CBT and 42 were in an assessment-only control condition (i.e., MTAU) for 1 year. This condition was intended to mirror follow-up care as usual. Participants in both the conditions were assessed at 3-month intervals during the 1-year study. The main outcome variable was time to relapse. RESULTS: When relapse was defined as a BMI

Illness intrusiveness in anorexia nervosa.

OBJECTIVE: "Illness intrusiveness" refers to illness-induced lifestyle disruptions. The primary aim of the current study was to compare the level of illness intrusiveness in anorexia nervosa (AN) to that reported in a variety of other chronic medical and psychiatric conditions. A secondary aim was to compare the two subtypes of AN (binge/purge vs. restricting) in terms of the nature and extent of illness intrusiveness. A final goal was to examine changes in the level of illness intrusiveness in AN following successful completion of specialized inpatient treatment. METHODS: The participants were a consecutive series of 121 female inpatients with AN who were admitted to a specialized inpatient unit for treatment of the eating disorder. Assessments took place before and after inpatient treatment and at 3-month follow-up. RESULTS: At baseline, illness intrusiveness scores for AN patients were significantly higher than those reported by women in the medical and psychiatric comparison groups. Overall, illness intrusiveness scores decreased (i.e., improved) significantly following successful completion of inpatient treatment. Among patients with the restricting subtype, scores continued to improve during follow-up, whereas this was not the case among patients with the binge-purge subtype of AN, whose scores did not change significantly during follow-up. CONCLUSION: Despite being notoriously ambivalent about change, these findings suggest that AN patients perceive their illness to be highly disruptive to a variety of life domains, even more so than patients with other chronic medical and psychiatric conditions.

Readiness to change mediates the impact of eating disorder symptomatology on treatment outcome in anorexia nervosa.

OBJECTIVE: The aim of the present study was to determine if readiness to change eating and weight was predictive of anorexia nervosa (AN) inpatient treatment outcome, and whether it mediates the relationships between AN treatment outcome and other known predictors of outcome. METHOD: Participants were 127 patients with AN who were consecutively admitted to an intensive in-patient treatment program. They completed the Eating Disorder Inventory at admission and a measure of readiness to change after 4 weeks of treatment. RESULTS: Readiness to change significantly predicted treatment outcome, even after controlling for level of eating disorder symptomatology at admission and AN subtype. It was also found to fully mediate the relationship between eating disorder symptomatology at admission and later treatment outcome. CONCLUSION: These findings suggest not only that readiness to make changes is an important indicator of future inpatient treatment outcome, but that it is the mechanism by which eating disorder symptomatology predicts success in a treatment program.

The impact of childhood sexual abuse in anorexia nervosa.

OBJECTIVE: The aim of this study was to examine the impact of childhood sexual abuse (CSA) on clinical characteristics and premature termination of treatment in anorexia nervosa (AN). METHOD: The participants were 77 consecutive patients with AN admitted to an inpatient eating disorders unit. The patients were assessed in terms of eating disorder symptoms, general psychopathology, and CSA history at admission to hospital. RESULTS: Thirty-seven patients (48%) reported a history of CSA before the onset of the eating disorder. Individuals with a history of CSA reported significantly greater psychiatric comorbidity, including higher levels of depression and anxiety, lower self-esteem, more interpersonal problems, and more severe obsessive-compulsive symptoms. Patients with the binge-purge subtype of AN (AN-BP) were significantly more likely to report a history of CSA prior to the onset of the eating disorder as compared with patients with the restricting subtype (AN-R) of the illness (65% of the AN-BP patients vs. 37% of the AN-R patients; p<.02). Contrary to our predictions, abused patients were not significantly more likely to dropout of treatment overall. However, patients of the binge-purge subtype (AN-BP) with a history of CSA were significantly more likely to terminate treatment prematurely as compared with the other patients. CONCLUSIONS: Consistent with previous findings, the present results indicate that the prevalence of CSA is high among individuals seeking inpatient treatment for AN. A history of CSA was associated with greater psychiatric disturbance overall and a higher rate of dropout for patients of the binge-purge subtype.

Decision-making deficits and overeating: a risk model for obesity.

OBJECTIVE: To demonstrate that human overeating is not just a passive response to salient environmental triggers and powerful physiological drives; it is also about making choices. The ventromedial prefrontal cortex has been strongly implicated in the neural circuitry necessary for making advantageous decisions when various options for action are available. Decision-making deficits have been found in patients with ventromedial prefrontal cortex lesions and in those with substance dependence--impairments that reflect an inability to advantageously assess future consequences. That is, they choose immediate rewards in the face of future long-term negative consequences. RESEARCH METHODS AND PROCEDURES: We extended this research to the study of overeating and overweight, testing a regression model that predicted that poor decision making (as assessed by a validated computerized gambling task) and a tendency to overeat under stress would correlate with higher BMI in a group of healthy adult women (N = 41) representing a broad range of body weights. RESULTS: We found statistically significant main effects for both independent variables in the predicted direction (p < 0.05; R2 = 0.35). Indeed, the decision-making impairments across the 100 trials of the computer task were greater in those with high BMI than in previous studies with drug addicts. DISCUSSION: Findings suggested that cortical and subcortical processes, which regulate one's ability to inhibit short-term rewards when the long-term consequences are deleterious, may also influence eating behaviors in a culture dominated by so many, and such varied, sources of palatable and calorically dense sources of energy.