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.

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.

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.

Thyroid indices and treatment outcome in bulimia nervosa.

OBJECTIVE: This study examined the thyroxine (T4) and free T4 (FT4) status of women with bulimia nervosa and its value as a predictor of outcome. METHOD: A total of 135 women with bulimia nervosa underwent 12-weeks cognitive behavioral therapy treatment. Prior to and at 3-year follow-up patients completed psychiatric assessments and serumT4 and FT4 were measured. RESULTS: At 3-year follow-up, 71% had no eating disorder and 29% met criteria for any eating disorder diagnosis. Mean T4 and FT4 concentrations were within normal ranges. Pre-treatment T4 and FT4 concentrations were inversely associated with food restriction and purging frequency, respectively. Compared with women with no eating disorder, those with any eating disorder at follow-up had lower pretreatment T4 concentrations. When pre-treatment food restriction, oral contraceptive use and binge frequency where controlled for, low T4 concentration was the only predictor of eating disorder diagnosis at follow-up. CONCLUSION: Low T4 concentrations at pretreatment may be a predictor of poor outcome in bulimia nervosa.

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.

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.

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.

Interpersonal psychotherapy for anorexia nervosa.

OBJECTIVE: This paper outlines the rationale for treating individuals with anorexia nervosa using interpersonal psychotherapy. METHOD: We review theoretical, empirical, and psychotherapy literature relating to interpersonal functioning in anorexia nervosa. RESULTS: Etiological theories emphasize interpersonal and family dysfunction in the development of anorexia nervosa. Research supports the notion that families of individuals with anorexia nervosa have dysfunctional patterns of communication. The history of treatment for anorexia nervosa emphasizes the need for resolution of interpersonal dysfunction, within the traditions of psychodynamic, family therapy, and multidimensional therapies. DISCUSSION: Interpersonal psychotherapy is a time-limited psychotherapy based on the notion that regardless of etiology, interpersonal relationships are intertwined with symptomatology. The goals of the therapy are to improve interpersonal functioning and thereby decrease symptomatology. Factors identified as important in the development of anorexia nervosa are readily conceptualized within the interpersonal psychotherapy problem areas of grief, interpersonal disputes, interpersonal deficits, and role transitions.

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.

Predictors of rapid and sustained response to cognitive-behavioral therapy for bulimia nervosa.

OBJECTIVE: To examine characteristics of individuals who show a rapid and sustained response to cognitive-behavioral therapy (CBT) for bulimia nervosa (BN). METHOD: As part of a randomized clinical trial designed to dismantle CBT for BN, we compared 19 individuals who exhibited complete abstinence from binging and purging after only eight sessions of CBT and maintained abstinence throughout the duration of treatment and the 1-year follow-up interval, to 79 individuals who had a more variable response to treatment. Demographics, baseline clinical characteristics, lifetime comorbidity, and personality disorder symptoms and profiles from the Temperament and Character Inventory were examined. RESULTS: In univariate analyses, frequency of binging and purging at baseline, low scores on the Eating Disorders Inventory (EDI) Bulimia subscale, lower harm avoidance, and higher self-directedness were associated with rapid response. In multiple regression analyses, frequency of binging at baseline (OR = 0.87; 95% CI 0.77-0.98) and self-directedness (OR = 1.12; 95% CI 1.04-1.21) independently predicted rapid and sustained treatment response. CONCLUSION: Frequency of binging and the character quality of self-directedness may be useful predictors of those individuals who are likely to respond positively to a brief course of CBT for BN.

Body weight in bulimia nervosa.

OBJECTIVES: The objectives of this study were to determine: 1) factors associated with body mass index (BMI) in women with bulimia nervosa prior to treatment; 2) changes in BMI during cognitive behavioral therapy (CBT) for bulimia nervosa; and 3) predictors of weight change during CBT treatment. METHODS: Participants were 94 women with DSM-III-R bulimia nervosa enrolled in a randomized clinical trial of CBT. Eating disorder symptomatology, past and current psychopathology, and BMI were measured prior to treatment and after twelve weeks of treatment. RESULTS: A significantly lower BMI prior to treatment was independently associated with a history of anorexia nervosa, substance use, cigarette smoking, and a high frequency of vomiting. Reductions in binge eating, purging, and food restriction after treatment did not result in significant changes in BMI. Increasing age, higher maximum lifetime body weight, and a high frequency of binge eating at baseline predicted weight gain during treatment. Weight loss during treatment was predicted by a high frequency of vomiting, and elevated levels of body dissatisfaction prior to treatment. DISCUSSION: Patients hesitant to engage in treatment for fear of weight gain upon cessation of their bulimic behaviors should be reassured that CBT is not usually accompanied by substantial weight gain. Identification of women at risk of significant weight gain or loss during CBT may enable therapists to focus on its aspects that help to prevent excessive body weight changes.

Predictors of 1-year treatment outcome in bulimia nervosa.

We examined predictors of outcome 1 year after completion of a randomized clinical trial assessing the additive efficacy of two forms of exposure with response prevention to a core of cognitive-behavioral therapy (CBT) for bulimia nervosa (BN). One hundred one women who met DSM-III-R criteria for BN, and who completed the clinical trial, were available for follow-up at 1 year. Predictor variables were assessed prospectively and partitioned temporally to reflect lifetime history (including personality), pretreatment clinical status, and posttreatment clinical status. Outcome was based on the frequency of binging and purging in the 3 months before assessment based on carefully constructed lifechart interviews. A series of stepwise logistic regressions were performed to determine independent predictors of 1-year outcome while controlling for treatment received. Demographic variables were unrelated to treatment outcome. A history of obesity was predictive of poor outcome, whereas a history of alcohol dependence decreased the odds of poor outcome. High self-directedness on the Temperament and Character Inventory (TCI) predicted favorable outcome at 1 year, whereas personality disorder symptoms were not predictive. Pretreatment global functioning, bulimia scores on the Eating Disorders Inventory (EDI), and the presence of major depression predicted poor outcome. Posttreatment binging, food restriction, and urges to binge on a cue reactivity assessment predicted poor outcome at 1 year. The character trait of self-directedness is a strong predictor of good outcome for CBT, and methods to enhance this trait may be worthy of investigation. Low global functioning and the presence of major depression at presentation may require additional treatment than focused CBT for BN. Our results argue for treatment goals that include abstinence from binging and restricting and decreases in urges to binge in response to high-risk cues.

The role of exposure with response prevention in the cognitive-behavioural therapy for bulimia nervosa.

BACKGROUND: One hundred and thirty-five women with bulimia nervosa participated in a randomized clinical trial designed to determine whether the addition of exposure with response prevention to a core of cognitive-behavioural therapy (CBT) leads to greater clinical improvement and lower risk of relapse. We present results from the end of treatment and 6- and 12-month follow-up. METHODS: Participants received eight sessions of CBT and were then randomized to either exposure to pre-binge cues (B-ERP), exposure to pre-purge cues (P-ERP), or a relaxation training control condition (RELAX). RESULTS: CBT produced significant clinical change. At the end of the behavioural treatments, there were no significant differences across the three groups on abstinence (66% in B-ERP, 45% in P-ERP and 47% in RELAX), or frequency of bingeing and purging. B-ERP, but not P-ERP, significantly reduced anxiety on the cue reactivity assessment, food restriction, body dissatisfaction and depression. These differences were not maintained at 6-month follow-up. At 12-months, B-ERP was independently associated with lower food restriction and better global functioning. CONCLUSIONS: CBT is a highly effective treatment for bulimia nervosa. B-ERP was modestly superior to P-ERP at post-treatment; however, the advantage did not remain throughout the follow-up interval. ERP for bulimia nervosa is an expensive and logistically complicated treatment that does not appear to offer any significant additive benefits that are proportional to the amount of effort required to implement the treatment.

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.