cognitive-behavioral group psychotherapy of bulimia nervosa: importance of logistical variables

Cognitive-Behavioral Group Psychotherapy of Bulimia Nervosa: Importance of Logistical

Variables

James E. Mitchell Richard L. Pyle Claire Pomeroy Mary Zollman Ross Crosby Harold Seim

Elke D. Eckert Robert Zimmerman

(Accepted 21 January 1993)

Although much of the psychotherapy for psychiatric disorders is conducted on a weekly basis, several researchers in the field of bulimia nervosa have utilized a more intensive approach as a means to strengthen treatment effects. A second issue concerns the amount of emphasis that should be placed on encouraging the interruption of bulimic symptoms early in treatment. In the current study we systematically studied these two issues. Subjects were randomly assigned to one of four forms of cognitive-behavioral group psychotherapy, the four cells differing on the variables of intensity and emphasis on abstinence. The results in- dicate that a high intensity approach, an early abstinence approach, or a combination of these two approaches are all significantly more effective in inducing remission in patients with bulimia nervosa compared with a weekly psychotherapy that uses the same manual- based cognitive-behavioral therapy approach. 0 1993 by john Wiley & Sons, lnc.

Bulimia nervosa, first delineated as a discrete diagnostic entity in 1979 by Russell, has been shown to be a prevalent problem among young women in Western industrial so- cieties (Pyle, 1985) and to have significant psychiatric and medical morbidity (Mitchell, Seim, Colon, & Pomeroy, 1987; Fairburn et al., 1985). During the last decade controlled psychotherapy treatment trials of this disorder have been published, often employing

James E. Mitchell, M.D., i s Professor, Richard 1. Pyle, M.D., is Associate Professor, Elke D. Eckert, M.D., i s Pro- fessor, Mary Zollman is Principal Dietitian, Ross Crosby, Ph.D., is Research Associate, and Robert Zimmerrnan, Ph.D., i s Research Associate in the Department of Psychiatry, University of Minnesota Medical School, Minneapo- lis. Claire Pomeroy, M.D., is Assistant Professor in the Infectious Disease Section, Department of Medicine, Uni- versity of Minnesota. Harold Seirn, M.D., is Assistant Professor, Department of Medicine, University of Minnesota. Address reprint requests to Dr. Mitchell, Department of Psychiatry, University of Minnesota Medical School, Box 393 Mayo, University Hospital, 420 Delaware Street, SE, Minneapolis, MN 55455.

lnternational Journal of Eating Disorders, Vol. 14, No. 3, 277-287 (1993) 0 1993 by John Wiley & Sons, Inc. CCC 0276-3478/93/030277-11

278 Mitchell et al.

behavioral and cognitive-behavioral techniques (Freeman & Munro, 1988; Lacey, 1983; Yates & Sambrailo, 1984; Connors, Johnson, & Stuckey, 1984; Fairburn, Kirk, O’Connor, & Cooper, 1986; Freeman, Sinclair, Turnbull, & Annandale, 1985; Kirkley, Schneider, Agras, & Bachman, 1985; Ordman & Kirschenbaum, 1985; Wilson, Rossiter, Kleifield, & Lindholm, 1986; Lee & Rush, 1986; Wolchik, Weiss, & Katzman, 1986; Leitenberg, Rosen, Gross, Nudelman, & Vara, 1988; Mitchell, Pyle, Eckert, Hatsukami, Pomeroy, & Zimmerman, 1990; Agras, Schneider, Arnow, Raeburn, & Teich, 1989; Fairburn, Jones, reveler, Carr, Solomon, OConnor, Burton, & Hope, 1991; Pyle, Mitchell, Eck- ert, Hatsukami, Pomeroy, & Zimmerman, 1990). The results of these studies are difficult to summarize given the differences in the studies that have been conducted. However, in general psychotherapy approaches using structured techniques have been shown to be superior to waiting lists or minimal intervention controls. Data as to whether or not cognitive-behavior techniques are superior to other forms of structured intervention remain controversial.

Our group has been interested in developing and testing a cognitive-behavioral group approach for bulimia nervosa. In a previous study (Mitchell et al., 1990) we compared pharmacotherapy and our group psychotherapy by randomizing outpatient bulimic subjects to one of four treatment cells: (1) drug therapy using the tricyclic antidepressant imipramine hydrochloride; (2) placebo therapy; (3) imipramine combined with intensive cognitive-behavioral group psychotherapy; and (4) placebo combined with intensive cognitive-behavioral group psychotherapy. All three active treatment cells were superior to placebo; however, on target eating variables such as frequency of binge eating and vomiting the amount of improvement obtained with the intensive group psychotherapy component was superior to that obtained with antidepressant treatment alone. The addition of antidepressant treatment to group psychotherapy improved outcome on mood and anxiety variables, but was also associated with an increased dropout rate, and did not result in additional improvement on eating variables. A similar study by Agras, Rossiter, Arnow, Schneider, Telch, Raeburn, Bruce, Perl, & Koran, (1992) using desipramine and cognitive-behavior therapy, also found superiority for the psychotherapy approach.

The psychotherapy approach used in our previous protocol utilized a highly intensive technique involving a total of 45 hr of group time. The program also clustered visits early in treatment to provide subjects with the support and encouragement thought necessary to gain control of their behavior, and asked subjects to attempt to gain control of their eating behaviors beginning their third week of treatment (emphasis on early interruption) during which they were seen for a total of 15 hr.

Thus, in this previous study, and in the subsequent 6-month follow-up (Mitchell et al., 1990; Pyle et al., 1990) the efficacy of the psychotherapy program we utilized has been established. However, logistically it is a difficult program to administer. It would be impractical in many mental health care delivery systems because it is conducted in the evening and requires a great deal of therapist time. Therefore, we were interested in determining if this psychotherapy program could be made less intensive, that is, with fewer visits per week. We were also interested in evaluating the importance of the emphasis on early interruption of eating symptoms, because this is an important variable both clinically and theoretically.

In the current article we report the short-term outcome of a randomized trial of group psychotherapy involving four treatment cells: (1) a high intensity, high emphasis on early interruption model; (2) a high intensity, no emphasis on early interruption model; (3) a low intensity, high emphasis on interruption model; and (4) a low intensity, no emphasis on early interruption model.

Logistical Variables 279

METHOD

Potential subjects were recruited from the Eating Disorders Clinic at the University of Minnesota and from newspaper advertisements requesting symptomatic volunteers with bulimia nervosa. Subjects were initially screened by telephone. They were then mailed packets of information that contained details about the evaluation process and instructions to begin self-monitoring their eating behavior (Eating Behaviors 111) (Mitch- ell, Hatsukami, Eckert, & Pyle, 1985).

Criteria for inclusion included the following: (1) minimum age 18; (2) female; (3) minimum of 85% ideal body weight (Metropolitan Life Insurance Tables, 1959); (4) not currently receiving pharmacotherapy or psychotherapy for bulimia nervosa or any other psychiatric condition; (5) DSM-111-R criteria for bulimia nervosa with the additional criterion of binge eating coupled with self-induced vomiting and/or laxative abuse at a minimum frequency of three times a week for the 6 months prior to evaluation; (6) no concurrent medical or psychiatric condition that would preclude safe outpatient therapy; (7) not diagnosed as having bipolar affective disorder or schizophrenia; (8) not actively abusing drugs or alcohol. Individuals with a history of drug or alcohol abuse could par- ticipate if they have been in control of such problems for at least 6 months.

Subjects were evaluated (visit 0) by one of the study psychiatrists. This evaluation included a psychiatric interview and the completion of a structured check-off sheet for DSM-111-R criteria for various forms of psychopathology.

Subjects who met inclusion criteria and who had given written informed consent un- derwent a screening physical examination. Laboratory work and an electrocardiogram were performed. Subjects were asked to return 1 week later for randomization to type of group. Subjects were not aware which group model they would be attending until the first night of group participation.

The short-term treatment phase lasted for a period of 12 weeks, from visit 1 to visit 12. Each subject self-monitored eating behavior on a daily basis (EB 111), subjects were seen by a physician biweekly for the completion of ratings, completed self-rating forms periodically, and had their serum electrolytes checked three times during the protocol.

All the therapy groups were highly structured, and used the same two basic manu- als: The Healthy Eating Meal Planning System (based on a diabetic exchange diet) that pro- vides patients with information about nutrition and weight regulation as well as meal planning skills, and the Bulimia Nervosa Group Treatment Manual (which uses behavioral and cognitive-behavioral techniques). The time course of treatment for the four treatment cells is outlined in Table 1. As can be seen, two of the therapies were of higher intensity (A1 and B1) and two of lower intensity (A2 and B2). Two used a high emphasis on early interruption model (A1 and A2) and two did not (B1 and B2). The early interruption models also employed a clustering of visits early in treatment, at the time when subjects were asked to attempt to gain control of their eating behavior as a group. Therefore, in two of the models (A1 and A2) the visits were clustered toward the beginning of therapy whereas in the other two models (B1 and B2) they were distributed evenly over the course of 10 weeks. In groups B1 and B2 subjects were not asked to gain control of their eating at the same time, but were encouraged to improve at the rate they found appropriate. All groups were conducted in the evening between 5:OO and 8:OO p.m. Each evening generally consisted of two or three components: (1) pre- sentation or lecture focused on the management of eating problems, (2) group psychotherapy that again was focused on material covered in the manual, and (3) at times, group dining experiences. If subjects went to dinner, they went between the lecture

N

W 0

Tab

le 1.

D

escr

iptio

n on

four

gro

up tr

eatm

ent m

odel

s

Em

phas

is

on

Tota

l T

reat

men

t G

roup

G

roup

A

bstin

ence

In

tens

ity

Hou

rs

Dur

atio

n D

inne

rs

Sess

ions

for

Each

Wee

k in

Tre

atm

ent

12

3 4

5 6

7 8

9 10

11

12

A1

Hig

h H

igh

45.0

12

12

2

25

43

21

11

11

1 A

2 H

igh

Low

22

.5

12

6 1

13

31

11

11

11

1 B1

Lo

w

Hig

h 45

.0

12

12

22

22

22

22

2 2

2

2 82

Lo

w

Low

22

.5

12

6 1

11

11

11

11

11

1


and the group psychotherapy. Subjects were not allowed to go to the bathroom alone following eating.

The general approach in all the models was to begin with an emphasis on self- monitoring and meal planning, then to move to an understanding of behavioral and cognitive-behavioral techniques. Lastly, groups focused on relapse prevention and the reintroduction of feared foods, as well as exposure to high risk situations, during the last month of treatment.

In an attempt to standardize the interaction between the physicians responsible for the ratings and the subjects, guidelines were established as to what material could be covered during these sessions. Physicians were asked to discuss the current level of symptoms with each subject, were encouraged to verbally reinforce subjects for improvement and to ask the questions necessary to complete the Hamilton Anxiety and Hamilton De- pression Scales. Specific directions concerning eating behavior or other therapeutic techniques were to be avoided. It is of note that the physicians were not necessarily blind to group assignment. We assumed it would be impossible to maintain such a blind because subjects often made reference to what was happening in the groups.

Three therapists conducted the group meeting, one therapist per group meeting. Each therapist rotated among the four group models so as not to bias the results by therapist differences. The first author also met one evening with each group in order to be famil- iar with each subject.

RESULTS

Measures of efficacy included in this report are the self-reports of the frequencies of target eating behaviors such as binge eating, vomiting, and time spent binge eating each week, clinician rated Hamilton Depression (Hamilton, 1960) and Hamilton Anxiety Rat- ing Scales (Hamilton, 1959), and global ratings of severity and improvement as well as the self-rated Eating Disorders Inventory (EDI; Gardner, Olmstead, & Polivy, 1983), Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbangh, 1961), Hopkins Symptom Checklist (Derogacis, Lipman, & Covi, 1973), and Weissman Social Adjustment Scale (Weissman & Bothwell, 1976). For the ED1 the eight subscales are presented.

The primary data analysis was an end-point analysis using the last rating available when the subject completed the study, was terminated prematurely, or dropped out. A two-way analysis of covariance was used with presence or absence of high intensity and the presence or absence of emphasis on early interruption as the two factors. The visit one pretreatment rating was used as the covariate. All subjects who completed visit two were included in the analysis. Only the end point analysis will be reported because this is the most conservative.

The characteristics of the subjects in the four groups were as follows: (1) A-1, mean age = 25.8 2 6.8, main duration of illness 8.8 ? 5.7 years; (2) A-2, mean age = 25.6 ? 6.0, mean duration of illness 7.8 2 5.0 years; (3) B-1, mean age = 26.4 5 5.7, mean duration of illness 8.6 2 6.1 years; (4) B-2, mean age = 25.7 2 6.8, mean duration of illness 9.1 ? 7.6 years.

We were also interested in studying the course of dropouts during the study. We were concerned that in the period of clustered visits early in treatment in the A1 and A2 models, when there was a clear expectation of improvement in eating behavior, the

282 Mitchell et al.

dropout rate might increase. The dropout rates were modest, with 4 of 33 (12%) of subjects dropping out of the A1 group, 5 of 41 (12%) in the A2 group, 5 of 35 (14%) of the B1 group, and 6 of 34 (18%) of the B2 group. Most of the dropouts occurred during the first 6 weeks of treatment in all cells, without a clustering of dropouts during the period of frequent visits.

The results of the analysis of covariance for self-ratings of eating behavior and physician’s ratings are presented in Table 2. As can be seen there were dramatic reductions in target eating behaviors across all four groups. There is a nonsignificant trend suggesting a greater reduction in binge eating frequency in the Al , A2, and B1 groups compared to the 82 group. Although the reductions on the other variables in the first three groups are numerically superior to the B2 group, none reach statistical significance. However, the improvement in abstinent days per week is significantly different, with the interaction term suggesting superiority on this variable for the first three groups. The Hamilton Depression and Anxiety Scale score improvements also did not differ significantly among the four groups, although there appears to be significant reductions on both scales in each group. On the global severity and improvement measures, physicians rated subjects as more severely ill at the end of treatment in the A1 and B2 groups compared to the A2 and B1 groups, and they also rated the degree of improvement greater in groups A2 and B1 compared to A1 and B2 groups.

Data on the subject rated instruments are presented in Tables 3 and 4. There was not a significant difference in subject rated global improvement across the four groups. On the SCL-90, the Global Severity Index was not significantly different among the four groups, although there was a trend. The differences on the Positive Symptoms Total and Positive Symptoms Distress subscales were not different. Subjects in the A1 and B2 groups reported less improvement in depression on the Beck at the end of treatment than those in the A2 and B1 groups. Only three subscales on the Weissman So- cial Adjustment were examined because of the small sample sizes available for the other subscales. There was a significant effect for intensity on the social subscale, with less decrease in the higher intensity cells.

There were a number of significant differences on the ED1 (Table 4), but there did not appear to be any specific pattern to these differences. On the drive for thinness subscale, subjects in the B1 group seems to have the best outcome, whereas those in the B2 group appeared to have the worst. On the bulimia subscale and the interocep- tive awareness subscale, subjects in the first three groups had a superior outcome to those in the B2 group. On the ineffectiveness subscale, groups A1 and B2 had the worst outcomes although an examination of the raw data suggests that the differences may not be clinically important. On the body dissatisfaction subscale, groups 81 and B2 appear to have the best outcome.

In Table 5, the percent of subjects free of symptoms at the last visit are presented. As can be seen approximately two thirds of the patients who started treatment in the Al, A2, or B1 groups were free of symptoms during this last rating period, whereas only approximately 1 in 5 of the patients in the B2 group was asymptomatic.

DISCUSSION

Before discussing some of the specific results it is important to mention some of the limitations of the design, and in particular the problems in generalizing the results to other clinical settings. First, although our previous research would suggest that the ef-

Tab

le 2

. C

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eans

and

res

ults

of t

he p

rim

ary

anal

ysis

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cova

rian

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r se

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nsity

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tera

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(dj =

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38)

(df

= 1

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) s. Ly

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Hig

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Lo

w/H

igh

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Low

(N

= 4

1)

(N =

35)

(N

= 3

4)

F P

F P

F

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g B

ehav

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epi

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elin

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st v

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(per

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(per

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per

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Ham

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Ham

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9.02

f 5

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2.10

f 4

.40

11.6

f 6

.95

1.51

f 2

.99

9.41

f 7

.06

2.13

t 4

.33

1.20

f 2

.65

.113

f 3

84

1.34

f 1

.55

5.83

f 2

.14

4.39

2 0

.70

3.49

2 1

.03

2.73

f 0

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11.1

t 7

.84

5.69

f 5

.93

5.61

t 4

.53

3.14

t 4

.21

8.24

f 5

.84

1.82

f 3

.58

10.8

f 7

.87

1.71

t 3

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10.6

f 8

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1.91

f 4

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1.54

f 6

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0

1.63

f 1

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5.62

f 2

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4.41

f 0

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3.15

f 0

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2.45

t 0

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9.29

f 7

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4.70

t 5

.84

5.27

f 4

.49

2.07

f 2

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10.3

f 6

.97

1.29

5 4

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12.8

t 8

.01

1.86

2 5

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10.8

f 9

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2.44

f 8

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1.47

f 4

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.115

f .6

86

0.98

f 1

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5.86

f 2

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4.71

f 0

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3.19

f 0

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2.40

f 0

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11.6

f 7

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5.28

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5.60

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2.28

f 2

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8.66

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3.31

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15.3

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9.63

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4.22

f 4

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1.56

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2 2

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3.88

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4.65

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t 1

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f 7

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4.63

f 5

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5.76

f 4

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2.06

f 2

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3.55

0.31

2.48

2.56

2.16

5.80

0.79

0.26

0.07

0.67

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.581

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.112

,144

.017

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,609

,785

,414

3.62

1.98

1.88

0.91

0.55

9.41

0.43

0.83

0.84

1.45

.004

,161

.172

,342

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.003

,512

.363

,361

,231

2.96

3.56

1.15

1.49

2.12

6.24

8.86

8.70

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(N =

41)

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nsity

(d

f =

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ract

ion

(df

= 1

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2.

47

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0.17

1.77

0.33

2.

03

1.03

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06

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3.71

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1.63

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3.44

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,204

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Table 5. condition: Percent symptom free at last visit

Eating disorder symptoms by treatment

Treatment Condition (Abstinence/Intensity)

A1 A-2 8-1 B-2 High/High Highnow Low/High Low/Low (N = 33) (N = 41) (N = 35) (N = 34) X2 p

Binging 69.7% 73.2% 70.6% 32.4% 16.7 .OOO Vomiting 72.7% 70.7% 76.5% 29.4% 21.4 .OOO Laxative 93.9% 100% 97.1% 91.2% 3.99 ,261 Any 63.6% 68.3% 67.6% 20.6% 22.4 .OOO

fects of this group are maintained, we do not yet have longitudinal follow-up data on the current sample and therefore cannot comment on long-term outcome. Also the group techniques used are highly structured and were delivered by therapists who have worked with this system for a minimum of 5 years, all of whom have extensive back- ground in both cognitive-behavioral techniques and nutritional counseling and all of whom work almost exclusively with eating disorder patients. Therefore, it is unclear whether or not the results could be replicated in another setting where therapists may be less experienced with these patients and/or with this approach. Third, what was la- beled cognitive-behavioral techniques vary considerably from center to center, and the results of this study should not be considered generalizable to those obtained in other centers using similar terminology to characterize their programs. A fourth major limitation to this study is the fact that the key variables studied, the target eating behaviors, are monitored using patient self-report. This reliance on self-report remains a major limitation to research in this area, because we know that patients with this disorder at times are untruthful about their behavior. Unfortunately, there is no validated method of knowing for sure what a subject's status is relative to eating behavior. Last, physicians monitoring subjects in this study were not blind as to group assignment; however, they had very limited contact with the participants and did not have a particular bias toward any single group model, because all were considered active treatment.

The results of this study suggest that the manual-based highly structured group psychotherapy program used in our clinic is most effective when it is administered in an intensive fashion such as twice a week, when it is administered using an early interruption approach with clustered visits early in treatment, or when both intensity and early interruption are used. A particularly important finding of this study is that when these same cognitive-behavioral therapy techniques are applied in a once a week group, a format that is commonly employed in the group psychotherapy of bulimia nervosa, the results are less powerful, with the majority of subjects still actively bulimic at the end of treatment albeit much improved in their eating behavior.

The most important question raised by this research that currently is unanswerable, is, does abstinence at the end of treatment predict a good outcome at long-term follow- up? An unpublished follow-up study done by our group does suggest that abstinence at the end of treatment is associated with a superior long-term outcome. Data from researchers at the University of Toronto (Maddocks, Kaplan, Woodside, Langdon, & Pi- ran, (1992) suggest the same conclusion. Further follow-up of the subjects included in the current experiment may help to clarify the importance of achieving abstinence in treatment.

Supported in part by grant MH43296 from the National Institute of Mental Health.

Logistical Variables

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