Outpatient treatment for adults with complex eating disorders and co-morbid conditions: a decision making model and case example.

Although Cognitive Behavioral Therapy (CBT-E) for eating disorders has the most empirical support for the outpatient treatment of adult eating disorders (EDs), this model does not include a focus on intense emotion dysregulation, suicidality, and non-suicidal self-injury (NSSI). Furthermore, a subset of patients do not achieve sustained remission with CBT-E. Given that Dialectical Behavior Therapy (DBT) was designed for treatment refractory, complex patients, clinicians must be able to use assessment information to determine which type of treatment to use. The aims of this manuscript are to 1) describe a DBT-based and research-informed conceptual model for treatment decision making for an outpatient non-academic setting, 2) present a case example of a client with significant ED symptoms and complex medical and psychiatric comorbidities, using this decision making model and 3) present descriptive data from a private practice setting in which patients are referred to DBT vs. CBT-E according to this decision making model.

Predictors of current suicidal ideation in a multi-diagnostic sample of individuals with eating disorders.

BACKGROUND: Individuals with eating disorders (EDs) have high rates of suicidal ideation (SI) and attempts (SA). Fasting, body dissatisfaction, binge eating and purging have been associated with SI in non-clinical samples, individuals with anorexia nervosa or low-weight EDs, and a multi-diagnostic sample. However, few studies have examined how ED symptoms contribute to risk for SI in conjunction with other well-established risk factors, such as nonsuicidal self-injury (NSSI) and past SA. The aim of this study was to examine which ED symptoms contribute unique risk for current SI in a multi-diagnostic, clinical sample when statistically adjusting for gender, NSSI, past SA, and past SI. METHODS: We conducted a chart review of 166 individuals who presented for ED treatment at an outpatient facility and signed informed consent. Initial intake interviews were coded for the presence versus absence of fasting, fear of weight gain, binge eating, purging, excessive exercise, restriction, body checking, self-weighing, and body dissatisfaction, as well as NSSI, past SA, past SI, and current SI. RESULTS: A total of 26.5% of the sample endorsed current SI. In a logistic regression analysis, identifying as male (n = 17) or having a non-binary gender identity (n = 1), the presence of fasting, and past SI were all significantly associated with increased odds of current SI, whereas excessive exercise significantly decreased odds of current SI. Fasting was equally common across all diagnostic groups. CONCLUSIONS: Future research should establish the temporal relationship between fasting and SI to better inform intervention.

The emergence of eating pathology after bariatric surgery: a rare outcome with important clinical implications.

OBJECTIVE: The present review examines the extant literature regarding the post-operative development of eating disorders (e.g., EDNOS) in bariatric surgery patients. METHOD: Internet, PsycINFO, Pubmed, and reference lists were examined to aggregate and compare literature from January 1985 to May 2010. RESULTS: Several case studies and case series have investigated the emergence of eating disorders after bariatric surgery. Clinical considerations are outlined. DISCUSSION: The development of classical eating disorders after bariatric surgery appears to be a rare occurrence; however, eating problems are far more common. Unfortunately no typology exists to classify such eating problems. Future research should examine the incidence, risk factors, symptomatology, course, and outcome of such eating disorders and eating problems. It is highly likely that such problems are underreported.

Therapeutic factors affecting the cognitive behavioral treatment of bulimia nervosa via telemedicine versus face-to-face delivery.

OBJECTIVE: Recently, Mitchell et al. (Behav Res Ther, 46, 581-592, 2008) conducted a randomized controlled trial of an empirically supported treatment for bulimia nervosa (BN) delivered face-to-face (FTF-CBT) or via telemedicine (TV-CBT). Results suggested that the TV-CBT and FTF-CBT were generally equivalent in effectiveness. The objective of the current study was to examine ratings of therapeutic alliance factors in TV-CBT and FTF-CBT. METHOD: Data obtained from 116 adults who met criteria for BN or eating disorder-not otherwise specified with binge eating or purging weekly and six doctoral-level psychologists who delivered the therapy were used in the analyses. RESULTS: Therapists generally endorsed greater differences between the treatment delivery methods than patients. Patients tended to make significantly higher ratings of therapeutic factors than therapists. DISCUSSION: TV-CBT is an acceptable method for the delivery of BN treatment compared to FTF-CBT, and TV-CBT is more easily accepted as a treatment delivery method by patients than therapists.

Caffeine, artificial sweetener, and fluid intake in anorexia nervosa.

OBJECTIVE: This article provides an analysis of the use of artificial sweeteners, caffeine, and excess fluids in patients diagnosed with anorexia nervosa (AN). METHOD: Seventy participants with AN were recruited to participate in an ecologic momentary assessment study which included nutritional analysis using the Nutrition Data Systems for Research, a computer based dietary recall system. RESULTS: When subtypes were compared, participants with AN-restricting subtype (AN-R) and participants with AN-Binge-Purge (AN-B/P) did not differ in quantity of aspartame, caffeine, or water consumed. Daily water consumption was related to daily vomiting frequency in AN-B/P but not to daily exercise frequency in either participants with AN-R or AN-B/P. DISCUSSION: Caffeine, water, and aspartame consumption can be variable in patients with AN and the consumption of these substances seems to be only modestly related to purging behavior.

The desire for body contouring surgery after bariatric surgery.

BACKGROUND: Obesity has become far more prevalent over the last few decades. In parallel, bariatric surgery has been increasingly utilized as a method of treatment. This appears to be having an impact on the rate of body contouring surgery for hanging redundant skin after the massive weight loss that usually results from bariatric surgery. Little literature is available addressing how frequently patients who have undergone bariatric surgery receive or desire body contouring surgery or regarding how satisfied these patients are with the hanging skin in certain body areas. METHODS: Seventy individuals (out of 250 who were mailed the questionnaire) who had undergone Roux-en-Y gastric bypass surgery 6-10 years previously completed a questionnaire, which obtained information regarding their experiences with as well as their desire for body contouring surgery and more general body area satisfaction. RESULTS: Thirty three of the seventy patients reported having undergone a total of 38 body contouring procedures. The most common were abdominoplasties (24.3%), breast lifts (8.6%), and thigh lifts (7.1%). However, subjects were not uniformly satisfied with body areas that had undergone body contouring surgery; some found the areas unattractive. The majority of patients, at least to some extent, desired body contouring surgery, often in several areas, most notably the waist/abdomen, rear/buttock, upper arms, and chest/breast. CONCLUSION: Paralleling the increasing use of bariatric surgery is an increasing desire for body contouring surgery. Most patients desire body contouring surgery after bariatric surgery. However, third party payors usually do not reimburse for such procedures.

Alcohol abuse and dependence before and after bariatric surgery: a review of the literature and report of a new data set.

BACKGROUND: To review the published data on alcohol abuse and alcohol dependence after bariatric surgery and to assess the prevalence of alcohol abuse and alcohol dependence in a sample of bariatric surgery patients, both before and after surgery. All participant data were collected from patients who had undergone gastric bypass at a Midwestern hospital. METHODS: The participants were contacted by mail 6-10 years after surgery and asked to complete the Post-Bariatric Surgery Appearance Questionnaire. RESULTS: The results of the analysis indicated that a small percentage of the sample appeared to spontaneously develop alcohol abuse or dependence after bariatric surgery. CONCLUSION: The results of the present study will be useful in understanding the likelihood of bariatric surgery patients developing alcohol abuse and dependence after surgery. However, additional research is needed to fully understand the risk of this outcome.

Inhibiting irrelevant information in adult children of people with alcoholism.

Adult children of people with alcoholism (ACAs; n = 21) and adults with no family history of alcoholism (non-ACAs; n = 24) completed a task designed to test inhibitory ability using a reaction-time based negative priming task. Although participants in the ACA group responded more slowly overall, they did not differ on this task as compared with participants in the non-ACA group. This pattern of results suggests that inhibitory ability is preserved in ACAs, at least within the context of the current negative priming task. The authors discuss study limitations and inconsistencies in the ACA literature.

Effects of acute alcohol intoxication on verbal memory in young men as a function of time of day.

This experiment examined whether the time of day of alcohol administration influences alcohol metabolism and the impact of alcohol on verbal memory. It was hypothesized that circadian fluctuations in endogenous levels of testosterone in young men would differentially affect blood alcohol levels, which would consequently impair their memory performance to a different degree. Participants were administered alcohol or placebo drinks either at 8am or 6pm and recall of 4 prose passages was examined. The results indicated that recall declined for subjects administered alcohol but time of day did not moderate these effects. Nevertheless, generally alcohol breath levels changed in the predicted direction as a function of the time of the day with higher levels recorded in the morning and lower levels in the afternoon. The results suggested that observed differences in breath alcohol levels may be influenced by differences in endogenous levels of testosterone, but the effect of this presumed interaction on verbal memory appears inconclusive.