The slippery slope: prediction of successful weight maintenance in anorexia nervosa.

BACKGROUND: Previous research has found that many patients with anorexia nervosa (AN) are unable to maintain normal weight after weight restoration. The objective of this study was to identify variables that predicted successful weight maintenance among weight-restored AN patients. METHOD: Ninety-three patients with AN treated at two sites (Toronto and New York) through in-patient or partial hospitalization achieved a minimally normal weight and were then randomly assigned to receive fluoxetine or placebo along with cognitive behavioral therapy (CBT) for 1 year. Clinical, demographic and psychometric variables were assessed after weight restoration prior to randomization and putative predictors of successful weight maintenance at 6 and 12 months were examined. RESULTS: The most powerful predictors of weight maintenance at 6 and 12 months following weight restoration were pre-randomization body mass index (BMI) and the rate of weight loss in the first 28 days following randomization. Higher BMI and lower rate of weight loss were associated with greater likelihood of maintaining a normal BMI at 6 and 12 months. An additional predictor of weight maintenance was site; patients in Toronto fared better than those in New York. CONCLUSIONS: This study found that the best predictors of weight maintenance in weight-restored AN patients over 6 and 12 months were the level of weight restoration at the conclusion of acute treatment and the avoidance of weight loss immediately following intensive treatment. These results suggest that outcome might be improved by achieving a higher BMI during structured treatment programs and on preventing weight loss immediately following discharge from such programs.

Rate and prediction of relapse in bulimia nervosa.

OBJECTIVE: The purpose of this study was to provide an estimate of the rate of relapse in patients with bulimia nervosa and to attempt to identify indexes of functioning before or after treatment that predicted subsequent relapse. METHOD: The subjects were 48 female patients with bulimia nervosa who achieved symptom control while attending a specialized day hospital treatment program for eating disorders. The subjects were assessed before treatment, after treatment, and at a 2-year follow-up interview with respect to their eating symptoms and psychosocial functioning. RESULTS: A relapse rate of 31% was observed during the 2-year follow-up period, and the vast majority of relapses occurred within the first 6 months after treatment. The strongest predictors of relapse were younger age, higher vomiting frequency, and a higher score on the bulimia subscale of the 26-item Eating Attitudes Test before treatment and higher vomiting frequency and a higher score on the interpersonal distrust subscale of the Eating Disorder Inventory at the end of treatment. Measures of binge eating frequency, self-esteem, depression, and social adjustment were not significant predictors of relapse. CONCLUSIONS: Vomiting frequency, even at subthreshold levels, appears to be an important prognostic indicator and may be one of the best barometers of residual symptoms in these patients.

Comparison of cognitive-behavioral and supportive-expressive therapy for bulimia nervosa.

OBJECTIVE: The authors compared the effectiveness of 4 months (18 sessions) of cognitive-behavioral and supportive-expressive therapy for bulimia. METHOD: Sixty patients obtained from clinical referrals to an eating disorders program who met modified DSM-III-R criteria for bulimia nervosa were randomly assigned to the two conditions. Treatments were delivered in an individual format, on an outpatient basis, by experienced therapists using treatment manuals. The primary outcome measures were self-induced vomiting, binge eating, and attitudes toward body weight and shape, which were assessed by self-report and structured interview. RESULTS: Fifty patients completed treatment, 25 in each condition. Both treatments led to significant improvements in specific eating disorder symptoms and in psychosocial disturbances. Supportive-expressive therapy was just as effective as cognitive-behavioral therapy in reducing binge eating. Where treatment differences were found, they favored cognitive-behavioral therapy. Cognitive-behavioral therapy was marginally superior in reducing the frequency of self-induced vomiting; 36% of the patients who received cognitive-behavioral therapy and 12% of those who received supportive-expressive therapy abstained from vomiting in the last month of treatment. Cognitive-behavioral therapy was significantly more effective in ameloriating disturbed attitudes toward eating and weight, depression, poor self-esteem, general psychological distress, and certain personality traits. CONCLUSIONS: These results moderately favor cognitive-behavioral therapy over supportive-expressive therapy for bulimia nervosa, but follow-up is required to determine the durability of outcome with both modalities. The findings must be interpreted with caution since the selected clinical sample in this study may not represent the bulimia nervosa population.

Brief group psychoeducation for bulimia nervosa: assessing the clinical significance of change.

Forty-one women with bulimia nervosa completed a brief intervention that was designed to promote symptom management. Cutoff scores for the determination of reliable and clinically significant change were calculated for several psychometric instruments that are commonly used as outcome measures in the field of eating disorders. Using these statistical procedures to assess therapeutic change, this study documents the diversity of outcomes that individuals reported following their participation in the intervention. As expected, there was a differential reporting of clinically significant change in favor of specific eating psychopathology relative to personality features and associated psychopathology.

Depression in anorexia nervosa and bulimia nervosa: discriminating depressive symptoms and episodes.

In a clinical sample of 198 female patients with anorexia nervosa (N = 83) and bulimia nervosa (N = 115), 43% met criteria for major depression using the Structured Clinical Interview for DSMIII-R. This group had a mean score of 30.9 +/- 8.7 on the Beck Depression Inventory (BDI) which was significantly higher than the BDI mean score of 20.5 +/- 8.9 among the remainder of the sample (p < 0.0001). A score of 26 yielded the highest levels of sensitivity and specificity, while five items from the BDI (loss of satisfaction, discouragement, weight loss, suicidal ideation and decision-making) correctly classified approximately 80% of subjects into "depression-positive" or "depression-negative" categories. Detection of co-morbid depression in patients with eating disorders may have practical implications for treatment.

Efficacy of a brief group psychoeducational intervention for bulimia nervosa.

This study compared a brief group treatment that was designed to be purely educational (ED) with a longer course of individual cognitive-behavioural (CB) therapy intended to represent more standard clinical care. Participants were 65 women who sought treatment at Toronto General Hospital, met DSM-III criteria for bulimia nervosa at a normal weight and reported vomiting at least twice weekly. Results indicated that the CB treatment, as expected, was generally more effective than the ED intervention, but on several important outcome indices both treatments appeared to be equally effective for the healthiest 25-45% of the sample. The more intensive individual CB treatment was associated with greater improvement in patients who were more severely symptomatic. However, the ED intervention proved significantly more cost-effective and it was suggested that a sequential treatment program might achieve the superior benefits associated with the longer individual CB treatment at a reduced cost.

A randomized controlled trial of fluoxetine and cognitive behavioral therapy for bulimia nervosa: short-term outcome.

This study compared and combined fluoxetine and individual cognitive behavioral therapy in the treatment of bulimia nervosa. Participants were 76 women who sought treatment at the Eating Disorders Program of the Toronto Hospital and who met DSM-III-R criteria for bulimia nervosa. Subjects were randomly assigned to receive fluoxetine alone, cognitive behavior therapy alone, or the two in combination and were treated over 16 weeks. Short-term outcome revealed that all three treatment conditions were associated with clinical improvement across a wide range of parameters. The combination of pharmacotherapy and psychotherapy was superior to pharmacotherapy alone on specific parameters and there was no statistically significant advantage to the combination over psychotherapy alone. Limitations to the study include the absence of a placebo pill group and a waiting list control group as well as a substantial dropout rate across all three treatment conditions.

Characterization of the "seasonal" bulimic patient.

OBJECTIVE: To determine whether bulimia nervosa (BN) patients who experience marked fall/winter worsening in eating behavior and/or mood are otherwise distinct from nonseasonal BN patients. METHODS: We empirically identified "seasonal" and "nonseasonal" groups from a sample of 208 consecutive BN patients completing the Seasonal Pattern Assessment Questionnaire (SPAQ). t Tests were performed to determine if seasonal patients differed from nonseasonal patients with respect to demographic and weight variables, age of onset of symptoms, illness severity, and attitudes and beliefs. RESULTS: Seasonal BN patients exhibited a greater discrepancy between maximum lifetime and current weight, an earlier age of onset of binging, and a higher current monthly binge frequency than did the nonseasonal group. Seasonal patients also scored significantly higher on the Bulimia and Interoceptive Awareness (reflecting lower self-awareness) subscales of the Eating Disorders Inventory (EDI). DISCUSSION: The results suggest that seasonal BN patients may represent a distinct subgroup characterized by a low threshold for binging behavior, greater preoccupation with bulimic behaviors, poor awareness of moods and feelings, and a unique course of illness. More research is needed to confirm these initial findings and to further assess the effectiveness of light therapy for these patients.

A prospective study of eating disturbances in the ballet.

A group of 35 ballet students was assessed and then retested between 2 and 4 years later to determine the persistence of eating symptoms and to identify factors which predict eating disorders. Of those interviewed at follow-up, 25.7% had anorexia nervosa and 14.2% had either bulimia nervosa or a 'partial syndrome'. 'Drive for thinness' and 'body dissatisfaction' scales of the Eating Disorder Inventory were the only measures which predicted development of eating disorders at follow-up. The finding that most cases of anorexia nervosa gained weight at follow-up was similar to an earlier report; however, the view that these disorders were benign adaptations to the ballet subculture was challenged by the observation that many continued to experience significant eating disorder symptoms at follow-up. Findings indicate that vulnerable adolescents may be identified early using economical self-report measures as the initial step in a two-stage screening process.

Assessment of personality disorders in anorexia nervosa and bulimia nervosa. A comparison of self-report and structured interview methods.

Interest in assessing Personality Disorders (PDs) in association with anorexia nervosa (AN) and bulimia nervosa (BN) has been accompanied by the development of several structured interview and self-report measures. In an attempt to see how the self-report Millon Clinical Multiaxial Inventory (MCMI-II) compared with the Structured Clinical Interview for DSM-III-R (SCID-II) in the assessment of PDs, we gave both instruments to 43 inpatients with a diagnosis of AN or BN. Correlation coefficient values for both categorical and dimensional comparisons were generally less than .4. Although comparable rates of positive PDs occurred for each of the three clusters (A: 30.2% vs. 34.9%, B: 25.6% vs. 18.6%, and C: 62.8% vs. 81.4% for SCID-II vs. MCMI-II), agreement for individual diagnosis and individual subjects was poor. In conclusion, the MCMI-II did not prove to be a reliable instrument for assessing axis II PDs in patients with AN and BN when compared with the SCID-II.

Rapid responders to intensive treatment of bulimia nervosa.

OBJECTIVE: The purpose of the study was to examine patterns of response to treatment in bulimia nervosa and to consider the utility of differentiating rapid from slower responders. METHOD: Participants were 166 female patients with bulimia nervosa who received specialized day hospital treatment for their eating disorder and provided complete data on symptom frequencies over the course of treatment. Symptoms and psychological functioning were assessed at the beginning and end of treatment and 2-year follow-up information was available for a subsample of 57 patients. RESULTS: A large subgroup (41%) of patients responded rapidly to treatment (i.e., symptom frequencies of three or less during the first 4 weeks of treatment) and a smaller subgroup (31%) were considered slower responders (i.e., symptom frequencies of four or more over the first 4 weeks of treatment and three or less over the last 4 weeks of treatment). The remaining patients were either partial responders (18%) or nonresponders (10%). Rapid responders tended to be older, less symptomatic, and less preoccupied with binging before treatment (all ps < .05), but the differences were not strong. Rapid responders also had better symptom control at the end of treatment (p < .00001), were less likely to receive antidepressant/antibulimic medication during the program (p < .04), and were significantly less likely to relapse within 2 years of attending the program (p < .005). DISCUSSION: These findings demonstrate that a significant subgroup of severely ill bulimia nervosa patients had a rapid, strong, and enduring response to intensive treatment, but could not be well identified with the available measures before treatment.

Sequencing of cognitive-behavioral treatments for bulimia nervosa.

OBJECTIVE: This study investigated the efficacy of a stepped-care trial of brief group psychoeducation (PE) followed by individual cognitive-behavioral therapy (CBT) in the treatment of bulimia nervosa. METHOD: Fifty-six subjects first completed PE and were then randomly assigned to either a 16-week trial of CBT (PE + CBT) or to no further treatment follow-up (PE-alone). RESULTS: Compared to PE-alone, PE + CBT produced significantly greater reductions in the specific eating symptoms of binging and purging and significantly higher remission rates that were maintained over a 16-week follow-up. However, there were no differential treatment effects on measures of nonspecific psychopathology. Among PE + CBT subjects, remission in specific eating symptoms was associated with greatest improvements in non-specific psychopathology. The outcome of nonremitted PE + CBT subjects and PE-alone subjects was no different at posttreatment or follow-up. DISCUSSION: These results provide limited support for offering individual CBT to subjects once they have completed an initial trial of group PE.

Group psychoeducation for bulimia nervosa with and without additional psychotherapy process sessions.

OBJECTIVE: The present study examined whether additional sessions of group psychotherapy process (PP) would incrementally benefit bulimia nervosa (BN) subjects over and above that which is achieved through a course of brief group psychoeducation (PE). METHOD: Utilizing a quasi-experimental design, the first cohort of 40 BN subjects completed five-session PE-alone groups that were highly didactic and explicitly devoid of group process work. The second cohort of 41 BN subjects completed 12-session PE + PP groups that integrated PE with more conventional cognitive-behavioral group process interventions. RESULTS: Both treatments were associated with comparable levels of change on measures of specific and nonspecific psychopathology. Furthermore, the two treatments did not differ in rates of premature termination, in rates of remission in eating symptoms, in rates of normalization of scores on psychometric measures, or in consumer evaluation of the treatments. DISCUSSION: While subjects value the opportunity to engage in psychotherapy process with other group members, the addition of seven such sessions offers no enhanced therapeutic benefit over five sessions of group PE.

Psychological impact of screening for familial ovarian cancer: reactions to initial assessment.

OBJECTIVES: To assess the psychological impact on women attending a familial ovarian cancer screening clinic. STUDY METHODS: 157 women referred for screening completed an investigator designed questionnaire, the Spielberger State Trait Anxiety Scale and the Centre for Epidemiological Studies Depression Scale prior to the screening interview and an eight-item questionnaire post-assessment. RESULTS: 95.4% saw the screening as valuable. Thirty-one point four percent of all patients scored about the cutoff point for depression. Sixteen percent exhibited high levels of anxiety. Fifty-six point four percent of patients accurately perceived their risk. Twenty-one point five percent of those who accurately perceived themselves as being at high risk had high anxiety and 40.6% reported significant depressive symptoms. Of the 26.5% of patients who overestimated their risks, 40.0% reported significant depressive symptoms and 22.6% were anxious. Of the 17.1% who minimized their risk, none were anxious (0.0%), and only 15.8% were depressed. CONCLUSION: Attendees at a familial ovarian cancer screening clinic may have high levels of depression and anxiety.