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.

Salivary reactivity in women with bulimia nervosa across treatment.

We examined salivary reactivity to a high-risk binge food in women with bulimia before and after cognitive-behavioral treatment. Prior to treatment, there was no change in salivation after presentation of high-risk food cues. After treatment, salivation increased significantly (p = .002) over baseline after presentation of the same foods. Salivary reactivity was negatively correlated with systolic blood pressure, but was unrelated to heart rate, self-report anxiety, or depression. Changes in salivary reactivity may be meaningful clinical index worthy of further investigation in this population.

Direction of weight change in depression.

Direction of weight change in depression has recently been reported to be mediated by Body Mass Index (BMI). The present study examined the relation between direction of weight change in unipolar depression, BMI, and clinical variables such as severity of depression, melancholia, chronicity and recurrence in 89 patients with major depression. While the BMIs of individuals who gained weight when depressed were significantly higher than individuals with no weight change, the BMIs of individuals who lost weight were not significantly lower than those with no weight change. Direction of weight change was not predicted by severity of depression, melancholia, chronicity or recurrence. Concerns regarding conceptual and methodological difficulties in research on predictors of direction of weight change in depression are discussed.

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.

Lifetime comorbidity of alcohol dependence in women with bulimia nervosa.

To determine how women with comorbid bulimia nervosa and alcohol dependence differed from those with bulimia nervosa alone, 114 women with DSM-III-R bulimia nervosa were assessed at intake for a randomized clinical trial with structure diagnostic interviews and psychometric instruments. The sample was divided on the basis of the presence (47%) or absence (53%) of lifetime alcohol dependence. Axis I and Axis II disorders, clinical features of bulimia, and personality and temperament characteristics were then compared. Women with comorbid alcohol dependence and bulimia nervosa reported a higher prevalence of suicide attempts, anxiety disorders, other substance dependence, conduct disorder and personality disorders (especially borderline and histrionic), and higher scores on novelty seeking, impulsivity, and immature defenses. There were few differences in the severity of bulimic symptoms. Findings revealed that women with comorbid bulimia nervosa and alcohol dependence bear a greater burden of Axis I and Axis II psychopathology and display greater symptoms of impulsivity and novelty seeking.

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.

Preventing the birth of infants with Down's syndrome: a cost-benefit analysis.

The costs and economical benefits of providing routine prenatal diagnosis of Down's syndrome with termination of affected pregnancies in older pregnant women in the west of Scotland were examined. The potential economic benefits would be greater than the costs for women aged 40 and over, probably about equal to costs for those aged 35 and over, but less than costs if the service were extended to women under 35.

Salivary reactivity in restrained and unrestrained eaters and women with bulimia nervosa.

Salivary and cognitive reactivity to a highly palatable food cue were examined in 19 women with bulimia nervosa, 19 restained eaters and 19 unrestrained eaters. Salivary reactivity at presentation of the palatable food varied significantly across the three groups but not baseline. Bulimic women displayed significantly less salivary reactivity than either restrained or unrestrained eaters. Bulimic women were depressed and self-reported markedly greater anxiety (SUDS) at all points during the procedure. SUDS were not significantly correlated with salivary reactivity. Depression as measured by the Beck Depression Inventory was significantly and inversely correlated with salivary reactivity. Potential cognitive and physiological explanations for decreased salivary reactivity in women with bulimia are discussed.

Self-induced abortion in a bulimic woman.

We report the case of a woman with bulimia nervosa, several personality disorders, and a past history of anorexia nervosa who deliberately induced an abortion via self-imposed starvation and vigorous exercise. Her history reveals severe obsessive-compulsive and narcissistic personality disorders as well as a lifelong pattern of denial of affect and illness.

Temperament, character, and personality disorder in bulimia nervosa.

In a sample of 76 women participating in a clinical treatment trial for bulimia nervosa, we examined the clinical differences between subjects with and without concurrent personality disorders and the ability of "self-directedness" (a character scale of Cloninger's Temperament and Character Inventory) to predict the presence of personality disorder. Sixty-three percent of the sample had at least one personality disorder diagnosis. Fifty-one percent of personality disorders were in cluster C, 41% were in cluster B, and 33% were in cluster A. The presence of personality disorder was associated with greater depressive symptoms, worse global functioning, laxative use, greater body dissatisfaction, higher harm avoidance, and lower self-directedness. As hypothesized, low self-directedness scores were associated with a markedly increased probability of a personality disorder.

The significance of a history of childhood sexual abuse in bulimia nervosa.

BACKGROUND: Childhood sexual abuse (CSA) is found to have occurred to a substantial minority of women with bulimia nervosa. Its clinical significance is unclear. METHOD: We studied 87 bulimic women in a clinical trial. Structured interviews determined the presence of CSA, DSM-III-R disorders, global functioning, and depressive and bulimic symptoms. RESULTS: Forty-four per cent reported a history of CSA. Bulimic women with CSA reported earlier onset of bulimia, greater depressive symptoms, worse global functioning and more suicide attempts, and were more likely to meet criteria for bipolar II disorder, alcohol and drug dependence, conduct disorder and avoidant personality disorder. CONCLUSIONS: Although those with CSA had greater comorbidity, it was not an important modifier of bulimic symptoms.

Correlates of severity in bulimia nervosa.

OBJECTIVE: We sought to clarify the correlates of severity in women with bulimia nervosa. METHOD: We studied 114 bulimic women at entry to a randomized clinical trial. We used eight definitions of severity that encompassed the DSM-III-R criteria set for bulimia nervosa (i.e., binging, purging, and body dissatisfaction in the current and worst lifetime time frames) and global functioning and symptomatology. We operationalized 28 possible correlates of severity that covered demographic, Axis I psychiatric, personality, family background, symptoms, and neuropsychological domains. We used regression techniques to investigate the associations between the correlates and severity indices. RESULTS: The regression models were all statistically significant and tended to account for a sizeable proportion of variance. In particular, earlier age of onset of bulimia and lower character scores (measured by the Temperament and Character Inventory) correlated with greater severity. Worse mean parental care (from the Parental Bonding Instrument), the absence of any lifetime anxiety disorder, and the presence of any lifetime mood disorder emerged as independent correlates in several models. CONCLUSIONS: As these were hypothesis-generating analyses, confirmation or refutation of these results awaits further study. In particular, age of onset of bulimia and personality traits related to character may be important modifiers of the severity of illness in bulimia nervosa.

Lifetime anxiety disorders in women with bulimia nervosa.

We examined the prevalence and ages at onset of additional childhood and adult psychiatric disorders in women with bulimia nervosa and evaluated the differential impact of a mood or anxiety disorder on the presentation of bulimia nervosa. One hundred fourteen women participating in a clinical trial of cognitive-behavioral therapy for bulimia nervosa were assessed at pretreatment with structured diagnostic methodology. Although mood disorders were the most frequently occurring additional psychiatric disorder (75%), 64% experienced an additional anxiety disorder. Age at onset of the anxiety disorders was markedly earlier than age at onset of bulimia nervosa or other comorbid conditions. Stratification of the sample on the presence of a mood or anxiety disorder revealed no differences in the core bulimic symptoms across groups. The presence of a mood disorder was associated with greater body dissatisfaction, lower Global Assessment of Functioning Scales (GAFS) score, more externalizing disorders of childhood, and, as expected, higher Hamilton Depression Rating Scale (HDRS) scores. The presence of an anxiety disorder was related to a history of anorexia nervosa and earlier age at onset of drug or alcohol dependence. Early-onset anxiety disorders are prevalent and may represent one potential pathway to bulimia nervosa.

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.

Initial manifestations of disordered eating behavior: dieting versus binging.

OBJECTIVE: We examined the onset of binge eating and dieting in 108 women with bulimia nervosa to determine whether (1) dieting always preceded binge eating; (2) dieting always preceded the onset of bulimia nervosa; and (3) individuals who manifested early initial binge eating differed from those whose earliest manifestation of disordered eating behavior was dieting in terms of lifetime psychopathology and temperament. METHOD: One hundred eight women were assessed at entry to a randomized clinical trial of cognitive-behavioral therapy for bulimia nervosa using structured diagnostic methodology. Retrospective recall of the onset of disordered eating behavior was used to categorize individuals as initial binge eaters or initial dieters. We then compared lifetime psychopathology and temperament across the two groups. RESULTS: Seventeen percent of women reported early binge eating prior to any dieting behavior. The mean age of onset of binging in this group was approximately 10 years. Neither the clinical picture of bulimia nervosa nor lifetime psychopathology differed between initial binge eaters and initial dieters. Individuals with early binge eating endorsed higher novelty seeking and lower harm avoidance. CONCLUSION: In a minority of women with bulimia nervosa, binge eating precedes dieting. These women display markedly higher novelty seeking and lower harm avoidance. Possible links between the dopamine system, novelty seeking, and appetitive behavior are discussed.

Changes in cue reactivity following treatment for bulimia nervosa.

OBJECTIVE: To examine changes in cue reactivity following cognitive-behavior therapy (CBT) for bulimia nervosa and to evaluate whether changes are associated with treatment modality or treatment outcome. METHOD: Subjects were 135 women (17-45 years old) with a current, primary diagnosis of bulimia nervosa. They were participants in a randomized clinical trial examining the additive efficacy of exposure and nonexposure-based behavior therapy to a core of CBT. Physiological, self-report, and behavioral measures of cue reactivity to individualized high-risk binge foods were obtained at pretreatment and posttreatment. Primary, secondary, and tertiary outcome measures are reported for posttreatment. RESULTS: Bulimic patients experienced significant changes in cue reactivity following treatment. With the exception of salivary reactivity, patients experienced less reactivity at posttreatment. Changes in cue reactivity were not related to treatment modality, but were related to positive treatment outcome for self-report measures of cue reactivity. DISCUSSION: Favorable treatment outcome among bulimic women is associated with low cue reactivity on self-report measures at posttreatment.

The nutrient intake of women with bulimia nervosa.

OBJECTIVE: The objective of this study was to evaluate the meal patterns and nutrient intake of women with bulimia nervosa (BN), and to compare them to clinical variables and recommended dietary allowances (RDA). METHOD: The nutrient intake of 50 women with BN was analyzed from 14 day dietary records. The data were compared to the median intakes of a random sample of women and to the RDA. Clinical variables for the women with BN were also available. RESULTS: Compared to nonbinge episodes per day, binge eating was significantly higher in energy from sucrose, fat, saturated fatty acids (SFA), monounsaturated fatty acids (MUFA) and lower in protein. Compared to the population median, binge eating was significantly lower in percent energy from protein, and higher in percent carbohydrate (CHO), sucrose, SFA, and MUFA, while nonbinge eating was significantly lower in percent energy from fat, SFA, and MUFA. Total intakes were significantly higher in energy and percent energy sucrose compared to the population. Despite significantly lower nonbinge energy intake, calcium, vitamins A and C, iron, and folate were not significantly different to the population median. However, one half or more of the subjects had less than two-thirds the RDA for nonbinge calcium, iron, zinc and for total intake one fourth remained less than two-thirds the RDA for iron and zinc. CONCLUSION: Nonbinge eating was characterized by low energy intake and by low intake of iron, calcium, and zinc. Binge eating, characterized by high sucrose and SFA content, overcompensated for these low energy intakes. Where treatment reduces or eliminates binge eating, it should also encourage consumption of regular meals and in particular, consumption of foods rich in zinc and iron.

Effect of mood and food cues on body image in women with bulimia and controls.

OBJECTIVE: The present study evaluated body image assessment and cue reactivity in women with bulimia and controls in response to neutral, mood, and food cues in isolation, and mood and food cues in combination. METHOD: Subjects were 7 women with bulimia nervosa and 8 control women. Food cues were individualized high-risk/favorite foods. Low mood was elicited using the Musical Mood Induction Procedure. Order of cue presentation was random across subjects. Body image and cue reactivity were assessed using a computer version of the silhouette method and self-report ratings, respectively. RESULTS: Women with bulimia consistently rated their current body as being larger and their body image satisfaction as being lower than control women. In addition, women with bulimia differentially rated their current body and a picture of a healthy weight woman as being larger following exposure to food and/or mood cues. Ratings of ideal body were differentially affected by mood cues for control women. Ratings of body satisfaction were not affected by cue presentation. Mere presentation of high-risk foods in the absence of eating was sufficient to elicit urges to binge in women with bulimia. DISCUSSION: Body size estimation is not only affected by enduring characteristics (i.e., bulimia nervosa), but also more transient factors such as short-term exposure to salient food and mood cues.

The significance of a prior history of anorexia in bulimia nervosa.

OBJECTIVE: Some authors stratify women with current, normal-weight bulimia nervosa into groups defined by the presence or absence of a past history of anorexia nervosa. Unlike the distinction between current anorexia nervosa with or without bulimic symptoms, fewer studies have investigated the significance of stratifying bulimic women by a past history of anorexia. METHOD: One hundred and fourteen women with bulimia nervosa in a clinical trial were studied via structured clinical interviews covering Axis I and II disorders and measures of personality and symptomatology. Prospective, 14-day dietary analysis was available for a subset of subjects. RESULTS: Bulimic women with a past history of anorexia nervosa were significantly more likely to have a lifetime anxiety disorder, lower current body mass index, increased cooperativeness on the Temperament and Character Inventory, and increased mature and neurotic scores on the Defense Style Questionnaire. These women also reported lower scores on the bulimia subscale of the Eating Disorders Inventory, but these self-report data were not consistent with the numbers of objective binges or reported energy intake. The prevalence of other Axis I disorders, Axis II personality disorders, and bulimic symptomatology was quite similar across groups. CONCLUSIONS: Although bulimic women with a prior history of anorexia nervosa differed in limited respects from those without such a history, the differences were outweighed by the similarities. A past history of anorexia nervosa did not appear to define particularly meaningful subgroups of women with current, normal-weight bulimia nervosa.