Self-induced vomiting in eating disorders: Associated features and treatment outcome

Self-induced vomiting is adopted by people with a variety of eating disorders (ED) to control body shape and weight. We tested the prevalence, the associated features and the role on treatment outcome of self-induced vomiting in 152 ED patients consecutively admitted to an inpatient cognitive-behavioral treatment (CBT), based on the transdiagnostic CBT for ED. The Eating Disorder Examination, together with the Beck Depression Inventory, the State-Trait Anxiety Inventory and the Temperament and Character Inventory were recorded at entry and at end of treatment. Self-induced vomiting was reported in 35.5% of cases, and 21.1% had multiple purging with vomiting. Individuals with vomiting and those with multiple purging had significantly higher BMI and a higher frequency of bulimic episodes, but individuals with multiple purging were also characterized by higher levels of depression, longer ED duration, more severe ED psychopathology and lower self-directness. Individuals with vomiting had higher eating concern and novelty seeking compared with those without purging behaviors. However, the three groups had similar dropout rates and outcomes in response to inpatient CBT, in keeping with the transdiagnostic theory of EDs.     

Family perception of interpersonal behavior as a predictor in eating disorders: a prospective, six-year followup study

This study assessed family perception patterns of interpersonal behavior in families with a daughter diagnosed with an eating disorder 6 years after treatment that used a prospective design. Family perception patterns of patients found to have a poor outcome at followup (n = 15) were compared with patients with a good outcome (n = 23), as well as a control group (n = 36). Using the system of multiple level observation of groups (SYMLOG), all 238 family members evaluated themselves and each other. The index patients with a poor outcome perceived themselves as friendlier and more positive than they were perceived by their families. In comparison to parents of daughters with a good outcome and the control group, parents of daughters in the poor outcome group perceived themselves to be less friendly than their partners perceived them to be. A rigid polarization of the perception of the index patient by family members and a discrepancy in this perception between the index patient and the rest of the family were found to be indicative of a poor prognosis. Implications for treatment based on family perception patterns of interpersonal behavior are discussed.     

Psychological treatment of eating disorders

Significant progress has been achieved in the development and evaluation of evidence-based psychological treatments for eating disorders over the past 25 years. Cognitive behavioral therapy is currently the treatment of choice for bulimia nervosa and binge-eating disorder, and existing evidence supports the use of a specific form of family therapy for adolescents with anorexia nervosa. Important challenges remain. Even the most effective interventions for bulimia nervosa and binge-eating disorder fail to help a substantial number of patients. A priority must be the extension and adaptation of these treatments to a broader range of eating disorders (eating disorder not otherwise specified), to adolescents, who have been largely overlooked in clinical research, and to chronic, treatment-resistant cases of anorexia nervosa. The article highlights current conceptual and clinical innovations designed to improve on existing therapeutic efficacy. The problems of increasing the dissemination of evidence-based treatments that are unavailable in most clinical service settings are discussed.     

Anxiety in eating disorders: a comparative study

Scientific literature shows that anxiety is an important factor in eating disorders. The aim of this case-control study was to compare the anxiety manifestations obtained by means of the Anxiety Situations and Responses Inventory of in a clinical sample of 74 females (46, anorexia nervosa; 28, bulimia) to those obtained by a control group (130 girls without disorders). The between-group ANOVA results showed higher anxiety scores in the clinical group with a medium effect size for the anxiety trait, finding a flat profile (within-group ANOVA) for the three response systems (cognitive, physiological and motor) and the four specific anxiety traits (test, interpersonal, phobic, and daily life situations). Moreover, high scores in anxiety involved a greater risk of being diagnosed with an eating disorder in the 8 bivariate comparisons. The estimations were more precise for cognitive anxiety and for the specific interpersonal anxiety trait.     

Binge eating and outcome of behavioral treatment of obesity: a preliminary report

A survey was carried out of binge-eating behavior in a group of 44 patients who had completed group behavioral treatment for obesity. Obese binge eaters, defined by DSM-III criteria for bulimia, lost significantly less weight immediatedly posttreatment and at 6-month follow-up than non-binge eaters.     

Cognitive behaviour therapy for eating disorders: a "transdiagnostic" theory and treatment

This paper is concerned with the psychopathological processes that account for the persistence of severe eating disorders. Two separate but interrelated lines of argument are developed. One is that the leading evidence-based theory of the maintenance of eating disorders, the cognitive behavioural theory of bulimia nervosa, should be extended in its focus to embrace four additional maintaining mechanisms. Specifically, we propose that in certain patients one or more of four additional maintaining processes interact with the core eating disorder maintaining mechanisms and that when this occurs it is an obstacle to change. The additional maintaining processes concern the influence of clinical perfectionism, core low self-esteem, mood intolerance and interpersonal difficulties. The second line of argument is that in the case of eating disorders shared, but distinctive, clinical features tend to be maintained by similar psychopathological processes. Accordingly, we suggest that common mechanisms are involved in the persistence of bulimia nervosa, anorexia nervosa and the atypical eating disorders. Together, these two lines of argument lead us to propose a new transdiagnostic theory of the maintenance of the full range of eating disorders, a theory which embraces a broader range of maintaining mechanisms than the current theory concerning bulimia nervosa. In the final sections of the paper we describe a transdiagnostic treatment derived from the new theory, and we consider in principle the broader relevance of transdiagnostic theories of maintenance.     

Towards effective treatment of eating disorders: nothing is as practical as a good theory

There is much room for improvement in the treatment of eating disorders, anorexia nervosa in particular. It is argued that for more effective treatment a radical change in thinking and doing is needed. First, the wide-spread multicausal model of eating disorders must be abandoned and replaced by (a) fundamental strategic research into the most parsimonious explanation of eating disorders and (b) interventions solely directed on the specific maintaining mechanisms. Second, evidence-based working is needed in mental health care. In daily practice, two of three psychotherapists do not treat their eating disordered patients with the best treatment available, i.e. cognitive behaviour therapy. The Dutch Ministry of Health, Welfare and Sport tried to improve the care for eating disorder patients by the nomination of several specialist hospital units. These units are, however, not selected for their treatment quality or the use of evidence-based treatment protocols. It is argued that this ministerial operation will not increase the supply of effective treatment. The Minister obviously should have done two other things to improve the amount and quality of treatment supply for eating disorders: First, she better could invest in a broad array of workshops, training and supervision programs in cognitive behaviour therapy for all psychotherapists working with eating disorders. Second, since nothing is so practical as a good theory, the facilitation of research into parsimonious models of the relevant mechanisms as well as the experimental tests of interventions on these mechanisms would have been a promising move to effective treatment.     

Post-traumatic feeding disorders in infancy: Behaviors predicting treatment outcome

The purpose of this study was to examine whether specific problem feeding behaviors exhibited by infants with post-traumatic feeding disorders (PTFD) predict treatment outcome. In this case series, 24 infants aged 7 weeks to 34 months received a three-component intervention for the treatment of their PTFD. The three components of the interventions included (1) physiological and environmental changes to regularize hunger-satiety cycles and promote good eating habits and routines; (2) nutritional monitoring; and (3) behavior therapy (flooding). Infants with PTFD who exhibited passive refusal to swallow food placed in their mouths and did not chew/suck/move food placed in their mouths for more than 5 sec were significantly less likely to respond to treatment, compared to infants with PTFD who did not exhibit these behaviors. Further, compared with infants with PTFD who responded to treatment, more infants with PTFD who did not respond had anatomical/mechanical problems of their upper airway such as tracheoesophageal fistula or lung disease such as bronchopulmonary dysplagia. The findings have direct implications for the assessment and treatment of PTFD in infancy.     

Neuropeptides in eating disorders

The past decade has witnessed a dramatic acceleration in research on the role of the neuropeptides in the regulation of eating behavior and body weight homeostasis. This expanding research focus has been driven in part by increasing public health concerns related to obesity and the eating disorders anorexia nervosa (AN) and bulimia nervosa (BN). Preclinical advances have been facilitated by the development of new molecular and behavioral research methodologies. With a focus on clinical investigations in AN and BN, this article reviews research on selected hypothalamic and gut-related peptide systems with prominent effects on eating behavior. Studies of the orexigenic peptides neuropeptide Y and the opioid peptides have shown state-related abnormalities in patients with eating disorders. With respect to gut-related peptides, there appears to be substantial evidence for blunting in the meal-related release of the satiety promoting peptide cholecystokinin in BN. Fasting plasma levels of the orexigenic peptide ghrelin have been found to be elevated in patients with AN. As discussed in this review, additional studies will be needed to assess the role of nutritional and body weight changes in neuropeptide alterations observed in symptomatic eating disorder patients, and to identify stable trait-related abnormalities in neuropeptide regulation that persist in individuals who have recovered from an eating disorder.     

MMPI-2 profiles of women with eating disorders in a Dutch day treatment sample

In this study, we examined the MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) profiles of 324 Dutch patients with eating disorders at an eating disorder day treatment program. We studied the MMPI-2 profiles in 5 diagnostic eating disorder groups. All diagnostic subgroups showed high mean elevations of the T scores on the same 6 or 7 scales. Remarkable similarities existed between the mean profile configurations. The MMPI-2 distinguished especially in that patients with restricting anorexia nervosa scored lower on one Validity scale (F), two Clinical scales (1 and 2) and several Supplementary and Content scales of the MMPI-2 compared to the other groups. Only on the validity Scale L did they score higher. The MMPI-2 also distinguished patients with the bulimia nervosa purging type who scored higher on Scale 9 and different on several Content and Supplementary scales. We discuss results with regard to other studies of MMPI (Hathaway & McKinley, 1983) and MMPI-2 profiles of women with anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified in inpatient and outpatient settings.     

Multi-family groups in the treatment of young adults with eating disorders

Multi-family group therapy is a variant of family therapy in which members are able to gain insight and learn from each other, provide support and encouragement, alleviate their sense of isolation and improve communication and social functioning. This study describes a series of multi-family groups conducted within the eating disorder service of a large London NHS Hospital. Ratings made by participants indicated that families viewed the treatment favourably.     

Weight suppression is a robust predictor of outcome in the cognitive-behavioral treatment of bulimia nervosa

This study examined weight suppression (difference between highest premorbid weight and pretreatment weight) as a predictor of outcome in 188 outpatients with bulimia nervosa enrolled in a cognitive-behavioral therapy intervention. Participants who dropped out of treatment had significantly higher levels of weight suppression than treatment completers. Of participants who completed treatment, those who continued to engage in binge eating or purging had significantly higher levels of weight suppression than those who were abstinent from bingeing and purging. Results did not change when body mass index, dietary restraint, weight and shape concerns, or other relevant variables were controlled. Relinquishing bulimic behaviors and adopting normal eating patterns may be most feasible for patients who are closest to their highest premorbid weights.