The moderating effect of impulsivity on negative affect and body checking

This study examined the moderating effects of different aspects of trait impulsivity on trajectories of negative affect prior to and following body checking in the natural environment in women with anorexia nervosa (AN). Body checking is a compulsive behavior that may maintain the cycle of eating disordered behavior through negative reinforcement. Previous studies regarding the relationship of negative affect to body checking have been inconsistent, making it unclear how negative affect functions as an antecedent to this behavior in the natural environment. We hypothesized that individual differences in trait impulsivity may influence body checking in response to negative affect. Negative urgency (NU) (the tendency to act rashly under distress) and (lack of) perseverance (the tendency to give up on goal directed behavior) may be unique facets of impulsivity that play a role in body checking. Women with AN (n = 82) completed a self-report measure of impulsivity and used ecological momentary assessment (EMA) to record negative affect and body checking for two weeks. Results indicated that women with low (lack of) perseverance experienced a greater increase in negative affect than those with high (lack of) perseverance prior to and following body checking. Overall, results indicate that individual differences in trait impulsivity moderated the relationship of negative affect to body checking in women with AN.

Patients' Perspective of Treatment in Eating Disorders: A Preliminary Study

The patient's perspective of treatment is seldom considered when psychological interventions are evaluated. Our aim was to undertake a qualitative study to assess the patients' viewpoint of what was helpful as well as harmful about the treatment they have completed. Twenty-one female referrals to an outpatient university-based eating disorders service (10 anorexia nervosa and 11 bulimia nervosa, mean age = 24.7 years, SD = 9.8) were interviewed on average one year after completion of either family counselling or cognitive-behavioural treatment. Most patients reported improvements as a result of treatment, although our formal assessment was more cautious. Patients identified psychoeducation, a supportive environment, challenging of dysfunctional beliefs, and behavioural strategies as helpful components of treatment. A significant minority felt that causes of the illness were dealt with inadequately, and that behavioural strategies were insufficient when symptoms were too overpowering. This study shows that gaining the patient's perspective of therapy could provide clinicians with helpful feedback to improve treatment for this challenging patient population.

Pre-treatment predictors of attrition in a randomised controlled trial of psychological therapy for severe and enduring anorexia nervosa

BACKGROUND

Attrition is common in the treatment of anorexia nervosa and its causes are complex and incompletely understood. In particular, its relationship with adaptive function and motivational stage of change has been little studied. This study aimed to (1) investigate and (2) compare the strength of associations between adaptive function, stage of change and other previously found factors such as illness sub-type and treatment attrition in women with severe and enduring anorexia nervosa (SE-AN).

METHODS

Participants were 63 adult women with SE-AN of at least 7 years duration who were enrolled in a multi-site randomized controlled trial conducted from July 2007 through June 2011. Treatment comprised 30 outpatient visits over 8 months of either Cognitive Behaviour Therapy for Anorexia Nervosa (CBT-AN) or Specialist Supportive Clinical Management (SSCM) both of which were modified for severe and enduring illness. Assessments were done at baseline, end of treatment, and 6 and 12 month post treatment follow-up. Demographic variables, duration of illness, specific and generic health related quality of life (QoL), eating disorder (ED) and mood disorder symptoms, social adjustment, body mass index (BMI), and motivation for change were assessed with interview and self-report questionnaires. Treatment attrition was defined as leaving therapy after either premature termination according to trial protocol or self-instigated discharge. Binary logistic regression was used to investigate relative strength of associations.

RESULTS

Those who did not complete treatment were significantly more likely to have the purging sub-type of anorexia nervosa and poorer ED related QoL. There were no significant differences between attrition and which therapy was received, educational level, and global ED psychopathology, stage of change, BMI, social adjustment, duration of illness or level of depression. The strongest predictors on multivariable analysis were ED QoL and AN-purging subtype.

CONCLUSION

This study supported previous findings of associations between attrition and purging subtype. Furthermore, we found associations between a potentially important cycle of attrition, and poorer EDQoL, which has not been previously reported. Contrary to expectations we did not find an association with BMI, severity of ED symptoms, low level of motivation to change ED features, or level of education.

Exercise caution: over-exercise is associated with suicidality among individuals with disordered eating

We conducted four studies to examine the relationship between over-exercise and suicidality. Study 1 investigated whether over-exercise predicted suicidal behavior after controlling for other eating disorder behaviors in a patient sample of 204 women (144 with Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) Bulimia Nervosa [BN]). Study 2 tested the prospective association between over-exercise and acquired capability for suicide (ACS) in a sample of 171 college students followed for 3-4 weeks. Study 3 investigated whether pain insensitivity accounted for the relationship between over-exercise and ACS in a new sample of 467 college students. Study 4 tested whether ACS accounted for the relationship between over-exercise and suicidal behavior in a sample of 512 college students. In Study 1, after controlling for key covariates, over-exercise was the only disordered eating variable that maintained a significant relationship with suicidal behavior. In Study 2, Time 1 over-exercise was the only disordered eating behavior that was associated with Time 2 ACS. In Study 3, pain insensitivity accounted for the relationship between over-exercise and ACS. In Study 4, ACS accounted for the relationship between over-exercise and suicidal behavior. Over-exercise appears to be associated with suicidal behavior, an association accounted for by pain insensitivity and the acquired capability for suicide; notably, this association was found across a series of four studies with different populations.

A prevalence study and description of alli use by patients with eating disorders

OBJECTIVE

This study examined the frequency and characteristics of alli use among patients in eating disorder treatment facilities.

METHOD

Patients from five treatment centers completed the Survey of Eating and Related Behaviors. Diagnoses were determined from survey responses.

RESULTS

Of 417 survey respondents, 26 (6.2%) reported a history of alli use. Of those, 15 (57.7%) met criteria for an eating disorder, including one of 29 patients (3.4%) with anorexia nervosa binge-purge subtype, six of 66 patients (9.1%) with full or subthreshold bulimia nervosa, four of 49 (8.2%) with binge eating disorder, one of six (16.7%) with purging disorder, and three of 80 (3.8%) with an eating disorder not otherwise specified.

DISCUSSION

The results of this survey suggest that patients with eating disorders use alli, albeit relatively uncommonly. Therefore, it is worthwhile for clinicians to inquire about alli use when evaluating or treating these patients in any clinical setting.

A Case Series of Family-Based Therapy for Weight Restoration in Young Adults with Anorexia Nervosa

This case series aims to examine the preliminary efficacy, acceptability and feasibility of Family-Based Treatment to promote weight restoration in young adults with anorexia nervosa. Four young adults with sub/threshold anorexia nervosa were provided 11-20 sessions of Family-Based Treatment for young adults with pre-, post- and follow-up assessments. At post- and follow-up, 3/4 participants were in the normal weight range, 3/4 were in the non-clinical range on the Eating Disorders Examination and reported being not/mildly depressed. At post-treatment, 2/4 were in the good psychosocial functioning range and by follow-up, 3/4 were in this range. These results suggest that Family-Based Treatment for young adults with anorexia nervosa is a promising treatment.

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.

Affective lability and impulsivity in a clinical sample of women with bulimia nervosa: the role of affect in severely dysregulated behavior

OBJECTIVE

The primary aim of this study was to examine the role of affective lability in maladaptive behaviors in a sample of women who meet DSM criteria for current bulimia nervosa (BN).

METHOD

Participants were administered a semistructured diagnostic interview (SCID-P) and only those who currently met criteria for BN (N = 134) were included in the analyses. All other data were collected through the use of self-report questionnaires.

RESULTS

Affective lability significantly predicted the Impulsive Behavior Scale score (sr = 0.21, t = 2.64, p < .009, f(2) = 0.06) and excessive reassurance seeking (sr = 0.21, t = 2.74, p < .007, f(2) = 0.06), even when controlling for age, depressive symptoms, state and trait anxiety, and general impulsivity.

DISCUSSION

The degree to which individuals with BN experience labile emotions is associated with several indicators of dysregulated behavior such that higher levels of affective lability predict a more severely dysregulated behavioral profile.

Are single-parent families different from two-parent families in the treatment of adolescent bulimia nervosa using family-based treatment?

OBJECTIVE

To examine whether family-based treatment (FBT) for adolescent bulimia nervosa (BN), which emphasizes family involvement in helping to reduce binge eating and purging behaviors, is differentially efficacious in single-parent families versus two-parent families.

METHOD

Forty-one adolescents (97.6% female; 16.0 +/- 1.7 years old) with either BN (n = 18) or subthreshold BN (n = 23) were randomized to FBT as part of a larger randomized controlled trial studying treatments for adolescent BN.

RESULTS

Two-parent (n = 27; 65.9%) and single-parent (n = 14; 34.2%) families were compared on demographic variables, presence of comorbid psychiatric illnesses, and symptoms of BN at baseline, post, and 6-month follow-up. ANOVA and chi-square analyses revealed no statistically significant differences between two-parent and single-parent families on any variables with the exception of ethnicity, for which a greater proportion of Caucasians and Hispanic families had two- parent families compared with African-American families (chi(2) = 8.68, p = .01).

DISCUSSION

These findings suggest that FBT may be an appropriate and efficacious treatment for single-parent families as well as two-parent families, despite the reliance on parental intervention to reduce bulimic symptoms and normalize eating patterns.

Family-Based Treatment for Adolescent Eating Disorders: Current Status, New Applications and Future Directions

Family-based treatment (FBT) is emerging as a treatment of choice for adolescent anorexia nervosa (AN) and bulimia nervosa (BN). This paper reviews the history of FBT, core clinical and theoretical elements, and key findings from the FBT for AN and BN treatment outcome literature. In addition, we address clinical questions and controversies regarding FBT for eating disorders, including whether FBT is clinically appropriate for all adolescents (e.g., older adolescents, patients with comorbid conditions), and whether it indicated for all types of families (e.g., critical, enmeshed, and non-intact families). Finally, we outline recently manualized, innovative applications of FBT for new populations currently under early investigation, such as FBT as a preventive/early intervention for AN, FBT for young adults with eating disorders, and FBT for pediatric overweight.

Family interventions in adolescent anorexia nervosa

Although our understanding of the mechanisms of change in eating disorder treatment remain limited, the empiric evidence for the effectiveness of family therapy for adolescent Anorexia Nervosa is gaining strength. A history of family involvement in psychiatric care, current approaches to family intervention in eating disorders and evidence for their efficacy are reviewed.

Early response to treatment in adolescent bulimia nervosa

OBJECTIVE

The purpose of this study was to determine if early response predicted remission at the end of a controlled trial.

METHOD

Eighty adolescents with bulimia nervosa participated in an RCT comparing family-based treatment and individual supportive psychotherapy. Response to treatment was assessed via self-report of bingeing and purging. Remission was defined as abstinence from bingeing and purging for the last 28 days and measured by investigator-based interview, that is, the Eating Disorder Examination.

RESULTS

Receiver-operating characteristic analyses showed that, regardless of treatment, symptom reduction at session six predicted remission at posttreatment (AUC = 0.814 (p < .001)) and 6-month follow-up (AUC = 0.811 (p < .001)).

CONCLUSION

Results suggest that adolescents with BN who do not show early reductions in bulimic symptoms are unlikely to remit at posttreatment or follow-up.

Revisiting differences in individuals with bulimia nervosa with and without a history of anorexia nervosa: Eating pathology, personality, and maltreatment

OBJECTIVE

Early research in subtyping bulimia nervosa (BN) by history of anorexia nervosa (AN) generally found more similarities than differences, but recent research and limitations of the early work suggest the need to revisit this approach. We examine differences between women with BN with and without a history of AN regarding eating pathology, personality, and childhood maltreatment.

METHOD

Participants were women (aged 18-55) recruited from the community and eating disorder clinics who met DSM-IV criteria for BN; 37 had a history of AN and 101 did not. Participants completed questionnaires related to eating disorder pathology, multidimensional perfectionism, multidimensional impulsivity, and childhood maltreatment.

RESULTS

Women with BN and a history of AN had higher levels of dietary restraint and purging and lower body mass indices as well as higher levels of all forms of childhood neglect and abuse. In contrast, no group differences were found for perfectionism or impulsivity dimensions.

CONCLUSION

The group differences in terms of eating pathology and maltreatment have clinical implications. Further research is needed regarding if and how a history of AN among those with BN may reflect different etiological pathways and predict different outcomes.

How do adolescents with bulimia nervosa rate the acceptability and therapeutic relationship in family-based treatment?

OBJECTIVE

To describe therapeutic alliance and treatment acceptability ratings of adolescents with bulimia nervosa (BN) participating in family-based treatment (FBT-BN) and to explore how participant characteristics relate to these constructs.

METHOD

Adolescents with BN (n = 80) in a randomized controlled trial comparing FBT-BN and individual supportive psychotherapy (SPT), completed the Eating Disorder Examination, Rosenberg Self-esteem Scale, and Beck Depression Inventory prior to treatment. The Helping Relationship Questionnaire, patient expectancy for treatment, treatment suitability, and self-reported estimates of improvement ratings were obtained at multiple points throughout treatment.

RESULTS

Therapeutic alliance and treatment acceptability ratings were positive in both treatments and generally did not differ. Within FBT-BN, more severe eating disorder symptomatology pretreatment was related to lower alliance ratings mid-treatment (p < .05). However, reductions in binge and purge behaviors over the course of treatment were not related to alliance or acceptability for participants in FBT-BN (all p's > .10).

CONCLUSION

Contrary to expectations of FBT-BN, adolescents receiving both treatments develop a strong alliance with the therapist.

Why patients seek bariatric surgery: a qualitative and quantitative analysis of patient motivation

BACKGROUND

Bariatric surgery is becoming a common procedure to control the obesity problem in the United States. However, despite the prevalence of the surgery, little is known regarding the motivation of patients who seek out these procedures. This present study aims to qualitatively and quantitatively examine in a moderate-sized sample of bariatric seeking patients their reported reasons for wanting surgery.

METHODS

109 severely obese patients (mean BMI 49.9) seeking either the duodenal switch or gastric bypass surgery between 1999 and 2002 were surveyed as to their motivations for seeking weight loss surgery. Their responses were coded into psychological, medical and quality of life categories for analysis. Depression and Quality of Life data was also obtained.

RESULTS

Descriptive analysis of the data indicated the vast majority (73.4%) of respondents endorsed current medical ailments as their primary reason for seeking weight loss surgery. Patients who responded with a secondary reason for desiring surgery reported primarily psychological and quality of life reasons. Scores on depression and quality of life measures did not impact their endorsed reasons for seeking surgery.

CONCLUSIONS

Patients in the present sample appear motivated for surgery primarily to control current medical problems. However, a significant portion of patients do endorse psychological and quality of life factors as important in their decision to seek weight loss surgery.

Comorbidity and high-risk behaviors in treatment-seeking adolescents with bulimia nervosa

OBJECTIVE

The purpose of this brief report is to describe the comorbid diagnoses and high-risk behaviors in a sample of adolescents with bulimia nervosa (BN).

METHOD

Eighty adolescents enrolled in a RCT for BN that compared family-based therapy with individual-supportive psychotherapy completed the Eating Disorder Examination and the Schedule for Affective Disorder and Schizophrenia for School Age Children (K-SADS).

RESULTS

A total of 62.5% of the sample had a comorbid diagnosis as determined by the K-SADS. The majority of these presented with a major mood disorder. In addition, 25% of the sample had previously attempted suicide or self-harmed, 65.8% had consumed alcohol, and 30% had used illegal drugs. Suicidal behavior, drug use, and presence of a comorbid diagnosis were not related to diagnosis (full BN vs. subthreshold BN) or age.

CONCLUSION

Comorbidity and high-risk health behaviors in adolescents with BN mirror those of adults with BN although not at similar rates.

Considerations for the use of the Beck Depression Inventory in the assessment of weight-loss surgery seeking patients

BACKGROUND

The Beck Depression Inventory (BDI) is an assessment frequently used in pre-surgical evaluation for patients seeking bariatric surgery. Items on the BDI reflect both cognitive and somatic symptoms associated with depression. However, many patients seeking bariatric surgery have medical symptomatology and health concerns independent of the syndrome of depression, and thus scores on the BDI may inflate their actual level of depression. With depression viewed by some clinicians as contraindicated for bariatric surgery, clarification of the BDI items is necessary.

METHODS

Pre-surgical BDIs of 259 bariatric patients were reviewed. An exploratory factor analysis was conducted to examine the factor structure of the BDI in this population. Independent sample t-tests compared the means of the cognitive and somatic items.

RESULTS

A clear two-factor solution emerged on the BDI, indicating items mapped on to either a cognitive or a somatic domain. The patients in the present sample also were more likely to endorse somatic and health-related symptoms on the BDI.

CONCLUSIONS

The factor structure of the BDI in this population is similar to that in other non weight-loss surgery populations. However, this population is more likely to endorse somatic complaints that may not be indicative of depression, rather an acknowledgement of actual medical complaints. Thus, assessors should be mindful of specific symptom endorsement, rather than a total depression score when utilizing the BDI to help determine surgery suitability.

What can dropouts teach us about retention in eating disorder treatment studies?

OBJECTIVE

To describe strategies used to retain adolescents with bulimia nervosa (BN) in a randomized clinical trial, and to compare treatment completers and dropouts on baseline demographic and symptom severity information.

METHOD

Adolescents with BN (N = 80) completed a demographic questionnaire, the Eating Disorder Examination, Rosenberg Self-esteem Scale, Family Adaptability and Cohesion Evaluation Scales, and Beck Depression Inventory prior to beginning treatment.

RESULTS

Several strategies were used to promote treatment retention (e.g., encouraging parental involvement in treatment, prompt rescheduling of cancelled appointments). Six participants (7.50%) voluntarily dropped out of treatment and three additional participants (3.75%) were asked to terminate treatment for medical/psychiatric reasons. Compared with treatment completers, noncompleters reported significantly longer duration of illness (p < .01). Sixty-two percent of treatment completers and only 22% of dropouts were from intact families.

CONCLUSION

Examining factors related to retention in adolescent treatment trials is important, and could be utilized to improve retention in adult studies where drop out rates are higher.

Latent profile analysis of a cohort of patients with eating disorders not otherwise specified

OBJECTIVE

This article examined possible ways of classifying eating disorders not otherwise specified (EDNOS) using latent profile analysis (LPA).

METHOD

Of 687 patients being seen for an evaluation for an eating disorder, 284 were classified as having anorexia nervosa (AN) or bulimia nervosa (BN). LPA was performed on the remaining 403 cases (EDNOS).

RESULTS

Five clusters were identified that characterized individuals who appeared to be: (1) subsyndromal restrictor AN patients that denied a great deal of eating disorder (ED) psychopathology; (2) subsyndromal ED patients, some but not all of whom were low weight; (3) subsyndromal BN with higher rates of vomiting than binge-eating; (4) primarily overweight individuals with low levels of ED pathology; or (5) overweight patients who most resembled binge eating disorder (BED).

CONCLUSION

Most EDNOS cases resembled AN, BN, or BED cases and can be conceptualized several ways, one of which is to see them as existing on a continuum with the DSM-IV ED.

A randomized controlled comparison of family-based treatment and supportive psychotherapy for adolescent bulimia nervosa

CONTEXT

Evidenced-based treatment trials for adolescents with bulimia nervosa are largely absent.

OBJECTIVE

To evaluate the relative efficacy of family-based treatment (FBT) and supportive psychotherapy (SPT) for adolescents with bulimia nervosa.

DESIGN

Randomized controlled trial.

SETTING

The University of Chicago from April 1, 2001, through June 30, 2006.

PARTICIPANTS

Eighty patients, aged 12 to 19 years, with a DSM-IV diagnosis of bulimia nervosa or a strict definition of partial bulimia nervosa.

INTERVENTIONS

Twenty outpatient visits over 6 months of FBT or SPT. Participants were followed up at 6 months posttreatment.

MAIN OUTCOME MEASURES

Abstinence from binge-and-purge episodes as measured by the Eating Disorder Examination. Secondary outcome measures were Eating Disorder Examination binge-and-purge frequency and Eating Disorder Examination subscale scores.

RESULTS

Forty-one patients were assigned to FBT and 39 to SPT. Categorical outcomes at posttreatment demonstrated that significantly more patients receiving FBT (16 [39%]) were binge-and-purge abstinent compared with those receiving SPT (7 [18%]) (P = .049). Somewhat fewer patients were abstinent at the 6-month follow-up; however, the difference was statistically in favor of FBT vs SPT (12 patients [29%] vs 4 patients [10%]; P = .05). Secondary outcome assessment, based on random regression analysis, revealed main effects in favor of FBT on all measures of eating pathological features (P = .003 to P = .03 for all).

CONCLUSIONS

Family-based treatment showed a clinical and statistical advantage over SPT at posttreatment and at 6-month follow-up. Reduction in core bulimic symptoms was also more immediate for patients receiving FBT vs SPT.

Family interaction among white and ethnic minority adolescents with bulimia nervosa and their parents

OBJECTIVE

To examine family adaptability, cohesion and satisfaction among white and ethnic minority families of adolescents seeking treatment for BN.

METHOD

Families completed the Family Adaptability and Cohesion Evaluation Scales (FACES III) as part of their baseline assessment.

RESULTS

No differences were found between white and ethnic minority patients' perceived and ideal levels of family cohesion and adaptability or level of satisfaction with family functioning, nor were differences found between white and ethnic minority parents on these measures. Both white and ethnic minority patients perceived their families to be less cohesive than did their fathers and their mothers, and their ideal levels of cohesion were lower than that of their fathers and their mothers.

CONCLUSION

These findings are consistent with a growing literature on eating disorders among ethnic minorities, which suggests that there may be fewer differences and more similarities among ethnic groups than previously thought.

Open trial of family-based treatment for full and partial anorexia nervosa in adolescence: evidence of successful dissemination

OBJECTIVE

There is a paucity of evidence-based interventions for anorexia nervosa (AN). An innovative family-based treatment (FBT), developed at the Maudsley Hospital and recently put in manual form, has shown great promise for adolescents with AN. Unlike traditional treatment approaches, which promote sustained autonomy around food, FBT temporarily places the parents in charge of weight restoration. This aim of this open trial was to investigate the feasibility and effectiveness of delivering FBT at a site beyond the treatment's origin and manualization.

METHOD

Twenty adolescents (ages 12-17) with AN or subthreshold AN were treated with up to 1 year of FBT using the published treatment manual. Outcome indices included the percentage of ideal body weight, menstrual status, the Eating Disorder Examination (EDE) subscales scores, and the Children's Depression Rating Scale-Revised score.

RESULTS

Of the 20 patients recruited, 15 (75%) completed a full course of treatment. Intent-to-treat analyses showed significant improvement over time in the percentage of ideal body weight (t = -4.46, p =.000), menstrual status (p =.002), EDE Restraint (z = -3.02, p =.003), EDE Eating Concern (z = -2.10, p =.04), but not in EDE Shape Concern or Weight Concern subscales or Children's Depression Rating Scale-Revised score.

CONCLUSIONS

This open trial provides evidence that FBT can be successfully disseminated, replicating the high retention rates and significant improvement in the psychopathology of adolescent AN seen at the original sites.

Emotional Eating in a Morbidly Obese Bariatric Surgery-Seeking Population

BACKGROUND

The impact of presurgical eating patterns on postoperative outcomes is poorly understood. The results of previous studies are mixed regarding the impact of presurgical binge eating on weight loss after surgery. However, many patients describe other maladaptive eating patterns prior to surgery, such as eating in response to emotions. The goals of this study were to describe presurgical emotional eating patterns in morbidly obese individuals, determine whether these individuals were binge eaters, and assess the effect of this eating behavior on weight loss after surgery.

METHODS

Prior to surgery, 144 Roux-en-Y gastric bypass (RYGBP) patients completed the Questionnaire of Eating and Weight Patterns (QEWP) or QEWP-Revised (QEWP-R) and the Emotional Eating Scale to assess eating patterns prior to surgery. Their eating behavior, levels of depression, and weight were assessed after surgery.

RESULTS

High emotional eaters tended to have higher levels of depression, binge eating, and eating in response to external cues than low emotional eaters prior to surgery. However, there appeared to be a distinct group of individuals who were high emotional eaters but who did not engage in binge eating. At a mean of 8 months after surgery, High Emotional Eaters and Low Emotional Eaters were indistinguishable on these subscales and there were no differences in weight lost.

CONCLUSIONS

RYGBP has an equally positive impact on eating behavior and weight loss for both High Emotional Eaters and Low Emotional Eaters. Further replication is needed with longer follow-up times and larger samples.

Psychometric properties of the eating disorder examination-questionnaire: factor structure and internal consistency

OBJECTIVE

The purpose of this investigation was to evaluate the factor structure and the internal consistency of the Eating Disorder Examination-Questionnaire (EDE-Q).

METHOD

The EDE-Q was administered to 203 women with bulimic symptoms, who were recruited from five Midwestern communities.

RESULTS

Acceptable levels of internal consistency were observed for the EDE-Q total score (alpha = .90) and subscales: Restraint (alpha = .70), Eating Concern (alpha = 0.73), Shape Concern (alpha = 0.83) and Weight Concern (alpha = 0.72). Exploratory factor loadings using Principal Axis Analysis supported the Eating Concern and Restraint subscales. Most of the Shape Concern and Weight Concern items loaded on one factor, with the exception of the items focusing on the importance of weight and shape in self-evaluation and preoccupation with shape and weight.

CONCLUSION

The results of this study provide support for the internal consistency of the EDE-Q and indicate a need for further examination of the factor structure of this instrument.

Pre-surgery binge eating status: effect on eating behavior and weight outcome after gastric bypass

BACKGROUND

The impact of pre-surgical binge eating on postoperative outcomes is poorly understood. Previous studies have found marked preoperative differences between binge eaters (BE) and non-binge eaters (NBE) in hunger and disinhibition using the Three-Factor Eating Questionnaire (TFEQ). Short-term prospective data are mixed regarding whether these differences persist after surgery and if preoperative binge eating impacts postoperative weight outcomes. The purpose of the present study was to compare self-reported eating behavior and weight outcomes between BE and NBE after the first postoperative year.

METHODS

Prior to surgery, 72 Roux-en-Y gastric bypass (RYGBP) patients completed the Questionnaire of Eating and Weight Patterns (QEWP) or QEWP-Revised (QEWP-R), to assess binge eating status which was defined as one objective binge episode per week over the past 6 months. Subjects also completed the TFEQ prior to surgery and again > or = 12 months after surgery.

RESULTS

For BE, higher scores were found for both hunger and disinhibition prior to surgery. At a mean of 18 months after surgery, BE and NBE were indistinguishable on these subscales and there were no differences in weight lost.

CONCLUSIONS

RYGBP surgery has an equally positive impact on eating behavior and weight loss for both BE and NBE. Within a multidisciplinary clinic, preoperative BE status does not appear to be a negative prognostic indicator for RYGBP surgery in the domains of weight loss and disinhibition. Further replication is needed with longer follow-up times and larger samples.

Psychosocial and physical impairment in overweight adolescents at high risk for eating disorders

OBJECTIVE

Many overweight adolescents display elevated risk for the development of eating disorders, as seen in higher rates of weight/shape concerns and disordered eating behaviors, but the extent of impairment in this subset of high-risk adolescents has not been explored.

RESEARCH METHODS AND PROCEDURES

Eighty-one overweight adolescents (63% girls) presenting for an Internet-based weight loss program were assessed at baseline using the Eating Disorder Examination Questionnaire, the Depression, Anxiety, and Stress Scale, and the Pediatric Quality of Life questionnaire. Adolescents who earned elevated scores on both the Weight Concern and Shape Concern subscales of the Eating Disorder Examination Questionnaire were considered at high risk for the development of eating disorders (56.8%).

RESULTS

Comparisons of high- and normal-risk groups revealed that high-risk adolescents reported higher levels of depression [F(3,76) = 5.75, p = 0.019], anxiety [F(3,76) = 5.67, p = 0.020], and stress [F(3,75) = 8.50, p = 0.005], and greater impairments in physical health [F(3,77) = 10.7, p = 0.002], emotional functioning [F(3,77) = 5.3, p = 0.024], and social functioning [F(3,77) = 10.0, p = 0.002]. There were no differences in school functioning [F(3,77) = 1.5, p = 0.219]. Among the high-risk adolescents, over half (52.2%) reported binge eating at least once in the past month.

DISCUSSION

Results suggest that overweight adolescents at high risk for the development of eating disorders also experience elevated levels of negative affect, impairment in health-related quality of life, and eating disturbances, although prospective data are needed to determine the directionality between eating disorder pathology and general psychopathology. Further research is warranted to evaluate whether behavioral weight loss interventions should be enhanced for this high-risk subset.

Is family therapy useful for treating children with anorexia nervosa? Results of a case series

OBJECTIVE

Research suggests that family-based treatment (FBT) is an effective treatment for adolescents with anorexia nervosa (AN). This retrospective case series was designed to examine its usefulness with younger children.

METHOD

Data were abstracted from medical records of 32 children with a mean age of 11.9 years (range 9.0-12.9) meeting diagnostic criteria for AN (n=29) and eating disorder not otherwise specified-restricting type (n=3) who were treated at two sites with FBT. Baseline characteristics, before and after weights, and Eating Disorder Examination (EDE) scores were compared with an adolescent cohort (N=78) with a mean age of 15.5 years (range 13.1-18.4) who were treated with FBT.

RESULTS

Children with AN share most disordered eating behaviors with their adolescent counterparts; however, their EDE scores are significantly lower than adolescents at both pre- and posttreatment assessments. Over the course of treatment with FBT, children showed statistically and clinically significant weight gain and improvements in eating disordered thinking as measured by the EDE.

CONCLUSION

FBT appears to be an acceptable and effective treatment for AN in children.

Recruitment for an adolescent bulimia nervosa treatment study

OBJECTIVE

This objective of this study was to investigate the recruitment rate for a clinical treatment trial for adolescents with bulimia nervosa.

METHOD

Recruitment rates for a 5-year randomized controlled trial for adolescent bulimia nervosa were analyzed.

RESULTS

Although the rate of randomization fluctuated over the course of the study, the overall rate of participants recruited was fairly consistent. The number of participants who were assessed for the study but who did not qualify, and the number of participants who qualified for the study but who chose not to join, were also consistent.

CONCLUSION

These findings suggest that it is feasible to recruit adolescents for a bulimia nervosa treatment trial. A better understanding of the reasons behind a participant's decision to stay in a treatment study versus discontinue a treatment study, as well as differences between adult and adolescent patients, could aid in the design of future treatment studies.

Eating attitudes and behaviours in South african adolescents and young adults

We examined the presence and severity of disordered eating attitudes and behaviours in a group of 895 South Africans. The Eating Attitude Test-26 (EAT-26), the Bulimic Investigatory Test, Edinburgh (BITE) and the Rosenberg Self-esteem Scale (RSE), were administered to high-school and college students (515 White, 126 Black, and 254 'Coloured'). There were few differences between these three groups on measures of eating disorder pathology and self-esteem. A small number of participants (3.5%) were identified as at 'high risk' for an eating disorder as shown by scores in the clinical range for both the EAT-26 and BITE. Weight, self-esteem and age were predictors for this subgroup. This study suggests that ethnicity per se may not 'protect' against the development of disordered eating attitudes and behaviours in nonwestern black populations. These findings remain tentative until future survey studies employ interviews to confirm eating disorder diagnosis.

DSM-IV threshold versus subthreshold bulimia nervosa

OBJECTIVE

The purpose of the present work is to determine whether bulimia nervosa (BN) and eating disorder not otherwise specified, BN type (EDNOS-BN) were qualitatively distinct in terms of eating and general psychopathology.

METHOD

This study presents a comparison of 138 women with BN and 57 with EDNOS-BN from a multisite study on eating-related and general psychopathology measures.

RESULTS

Although women with BN reported higher lifetime history rates of anorexia nervosa, greater binge eating and vomiting frequency, and more eating concerns, no significant differences were observed between groups on measures of perfectionism, impulsivity, obsessive-compulsiveness, anxiety, depressive symptomatology, or alcohol/substance problems. Based on the partial eta2 values, the distinction between BN and EDNOS-BN accounted for <5% of the criterion variance in general psychopathology measures. Post hoc analyses comparing EDNOS-BN with objective bulimic episodes (OBEs; n=34) versus no OBEs (n=23) found greater EDEQ-4 Restraint subscale scores for EDNOS-BN without OBEs. However, there was no significant difference on the EDEQ-4 Eating Concern subscale between the two EDNOS-BN subgroups.

CONCLUSION

The findings highlight the clinical significance of BN partial syndrome and prompt reevaluation of existing BN diagnostic boundaries. Post hoc analyses also underscore the need for greater differentiation within EDNOS.

Impulsivity and compulsivity in bulimia nervosa

OBJECTIVE

A primary objective of the current article is to investigate the relationship between impulsivity and compulsivity in patients with bulimia nervosa (BN). A second goal is to explore the relationship between impulsivity and compulsivity and related psychiatric problems.

METHOD

Two-hundred four females with BN completed several measures of impulsivity and compulsivity as well as measures of personality, substance use, eating pathology, and depression.

RESULTS

Participants reported considerable variability on measures of impulsivity and compulsivity and these scores were positively correlated with each other. Impulsive-compulsive groups differed in personality, substance use, eating, and depression.

CONCLUSION

These findings suggest that impulsivity and compulsivity can coexist in BN patients and that both traits may provide useful information about comorbid problems in women with BN.

Adolescents with bulimia nervosa and eating disorder not otherwise specified-purging only

OBJECTIVE

The purpose of the study was to better understand the phenomenology of bulimic symptomatology in an adolescent clinic sample.

METHOD

Adolescents with bulimia nervosa (BN; n = 36) and eating disorders not otherwise specified-purging but no objective bulimic episodes (EDNOS-P; n = 20) were compared on the Eating Disorder Examination (EDE), the Beck Depression Inventory (BDI), the Rosenberg Self-Esteem Scale (RSES), and the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS).

RESULTS

Subjects with EDNOS-P and BN were equivalent in terms of age and weight, but were less likely to have intact families. Nearly one half of EDNOS-P subjects purged exclusively outside of eating episodes in which they experienced a sense of loss of control. Although still at clinically significant levels, EDNOS-P subjects reported less concerns regarding weight, shape, and eating relative to BN. Groups were not significantly different on psychiatric comorbidity, but differed on self-esteem.

DISCUSSION

Results prompt reappraisal of current criteria of BN to encompass those who purge without binge eating.

Family-based treatment of eating disorders

The current article provides a brief description of the theory and empirical support for family treatment of eating disorders. The main literature related to family treatment for anorexia nervosa (AN) and bulimia nervosa (BN) is reviewed and the findings highlighted. Family treatment, particularly as devised by researchers at the Maudsley Hospital, appears to be an effective treatment for adolescents with short-term AN. It also may be an appropriate treatment for BN in the same age group, although evidence for this is in much shorter supply. Data support the use of family treatments for adolescents with eating disorders. Controlled trials and other systematic research are needed to determine whether family treatment is the best approach.

The dearth of psychological treatment studies for anorexia nervosa

OBJECTIVE

Anorexia nervosa (AN) was first described more than 130 years ago, yet few psychological treatments have been formally studied. Our objective was to review the available studies to understand whether these may highlight directions for future investigation.

METHOD

Medline and PsycINFO were consulted to identify relevant treatment studies. Twenty psychotherapy treatment studies were identified for review. These were divided in terms of patient age (adolescent vs. adult) and type of study (uncontrolled vs. controlled).

RESULTS

Without exception, adolescent studies (uncontrolled or controlled) involved the parents or family in the treatment. The adult studies were much more varied in terms of treatments that were compared. Most studies were statistically underpowered and only one utilized manualized treatments. More recent investigations have attempted to remedy these methodologic shortcomings.

DISCUSSION

The review highlights the effectiveness of one particular treatment modality for adolescents, but emphasizes the compelling need for further and larger systematic investigation into treatments for both adolescent and adult AN.

Bulimia nervosa in adolescents: a disorder in evolution?

BACKGROUND

There are few reports that describe the manifestation of bulimia nervosa (BN) among adolescents. Moreover, none make reference to the comparative clinical manifestation of adolescent BN and adolescent anorexia nervosa. Nor are any reports available of how distinct partial-syndrome BN cases are from those that meet full diagnostic criteria for BN.

OBJECTIVES

To describe 3 groups of adolescents, those with a full-syndrome eating disorder (BN and anorexia nervosa) or partial-syndrome BN, and to compare these groups along demographic, general psychopathology, and eating disorder variables.

DESIGN

The study population included 120 adolescents with eating disorders who were initially seen at The University of Chicago Eating Disorders Program, Chicago, Ill, for treatment. All participants completed an assessment prior to treatment.

MEASURES

Weight and height were obtained from all participants. Participants also completed a baseline demographic questionnaire (eg, menstrual status, ethnicity, family status), Beck Depression Inventory, Rosenberg Self-Esteem Scale, and the Eating Disorder Examination.

RESULTS

Partial-syndrome BN cases are clinically quite similar to their full-syndrome counterparts. Only objective binge eating episodes and purge frequency distinguished BN and partial-syndrome BN cases. Anorexia nervosa cases, on the other hand, were quite distinct from BN and partial-syndrome BN cases on almost all variables.

CONCLUSION

Early recognition and swift treatment of eating disorders in adolescents, regardless of whether a diagnostic threshold is met, are imperative because they will lead to early intervention thereby potentially improving eating disorder recovery rates.

Report of the National Institutes of Health workshop on overcoming barriers to treatment research in anorexia nervosa

OBJECTIVE

Anorexia nervosa (AN) is associated with serious medical morbidity and has the highest mortality rate of all psychiatric disorders. The National Institutes of Health (NIH) Workshop on Overcoming Barriers to Treatment Research in Anorexia Nervosa convened on September 26-27, 2002 to address the dearth of treatment research in this area. The goals of this workshop were to discuss the stages of illness and illness severity, pharmacologic interventions, psychological interventions, and methodologic considerations.

METHOD

The program consisted of a series of brief presentations by moderators, each followed by a discussion of the topic by workshop participants, facilitated by the session chair.

RESULTS

This report summarizes the major discussions of these sessions and concludes with a set of recommendations related to the development of treatment research in AN based on these findings.

DISCUSSION

It is crucial that treatment research in this area be prioritized.

Binge eating and eating-related cognitions and behavior in ethnically diverse obese women

OBJECTIVE

To examine binge eating and eating-related cognitions and behavior in a sample of ethnically diverse women who are severely obese and seeking bariatric surgery.

RESEARCH METHODS AND PROCEDURES

Female bariatric surgery candidates (62 African Americans, 18 Latinas, 130 whites) completed questionnaires on binge eating and eating-related cognitions and behavior and completed a structured clinical interview to confirm binge-eating disorder diagnosis.

RESULTS

Ethnic minorities and whites did not differ in rates of binge-eating disorder (26.3%), binges per week (M = 0.95), or dietary restraint. Ethnic minorities reported less disinhibition, and there was a trend to report less hunger awareness than whites. After controlling for BMI and education, ethnicity accounted for significant variance in disinhibition (4%; p < 0.01). Ethnic minorities were younger, became overweight at a later age, and were overweight for fewer years than whites.

DISCUSSION

Results suggest that ethnicity exerts an important influence on disinhibition and that ethnic differences are not caused by BMI or education. Findings point to the need to continue to investigate the role of ethnicity, binge eating, and disinhibition in severely obese women, so that culturally appropriate services can be provided.

Characteristics of binge eating among women in the community seeking treatment for binge eating or weight loss

This study examined characteristics of binge eating among overweight women in the community seeking treatment for binge eating or weight loss. Five hundred and ninety-two women completed a telephone interview in which binge eating was thoroughly assessed. A large percentage of the sample (84.4%) reported features of binge eating consistent with the Diagnostic and Statistical Manual of Mental Disorders (4th ed., DSM-IV) definition of a binge. A significantly higher rate of DSM-IV BED (33.6%) was found compared to previous studies. Eleven percent of the sample denied bingeing/purging (nonbinge eating disorder, NBED) and 55.4% of the sample reported other eating problems such as bingeing or purging. Women with binge eating disorder (BED) had a higher BMI, became overweight earlier, and reported more unhealthy weight control methods than NBED women. BED women also reported more current and past depression and suicidal ideation than NBED women. BED reported more maternal overweight than NBED, but BED and NBED participants did not differ in paternal overweight or parental eating disorders. Future studies should investigate the relationship between binge eating and suicidal ideation to better understand whether depression precedes or follows binge eating.

Anorexia nervosa with comorbid psychosis and borderline mental retardation: a case report

Anorexia nervosa (AN) is often associated with comorbid depression or anxiety, but rarely with mental retardation or psychosis.

METHODS

The present report describes the case of a 22 year-old woman who met diagnostic criteria for anorexia nervosa, borderline mental retardation, and schizoaffective disorder.

RESULTS AND DISCUSSION

The case highlights the difficulties in differential diagnosis with these seemingly incompatible disorders. It also provides some insights into the unclear relationship between anorexia nervosa and these comorbid conditions.

Family Therapy Outcome in Adolescent Anorexia Nervosa

Anorexia nervosa is a serious psychosomatic illness which often follows a prolonged course. Recent long-term follow-up studies have indicated high mortality rates. It is therefore necessary to search for effective methods of treatment which could improve the outcome in anorexia nervosa. One controlled trial which evaluated the efficacy of different forms of psychological treatments has shown that family therapy is the superior treatment for patients with an early onset and short duration of illness. In this article I review the development of family therapy for anorexia nervosa with specific emphasis on the controlled family treatment studies at the Maudsley Hospital in London. The efficacy of outpatient family therapy for weight restitution in malnourished anorexia nervosa patients, and some effective ingredients of this treatment approach, are discussed.