Download - 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 ap- proach 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 diffi- cult 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 sub- jects to one of four treatment cells: (1) drug therapy using the tricyclic antidepressant imipramine hydrochloride; (2) placebo therapy; (3) imipramine combined with inten- sive cognitive-behavioral group psychotherapy; and (4) placebo combined with inten- sive cognitive-behavioral group psychotherapy. All three active treatment cells were superior to placebo; however, on target eating variables such as frequency of binge eat- ing and vomiting the amount of improvement obtained with the intensive group psy- chotherapy component was superior to that obtained with antidepressant treatment alone. The addition of antidepressant treatment to group psychotherapy improved out- come on mood and anxiety variables, but was also associated with an increased drop- out 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 inten- sive technique involving a total of 45 hr of group time. The program also clustered vis- its 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 con- trol 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 em- phasis 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) mini- mum of 85% ideal body weight (Metropolitan Life Insurance Tables, 1959); (4) not cur- rently receiving pharmacotherapy or psychotherapy for bulimia nervosa or any other psychiatric condition; (5) DSM-111-R criteria for bulimia nervosa with the additional cri- terion 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 pro- tocol.
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 treat- ment 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 empha- sis 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 be- ginning 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 psycho- therapy 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
Logistical Variables 281
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 cov- ered during these sessions. Physicians were asked to discuss the current level of symp- toms 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 tech- niques 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 sub- jects 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 pe- riod 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 reduc- tions 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 signifi- cance. 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 re- ductions on both scales in each group. On the global severity and improvement mea- sures, 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 treat- ment 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 ap- pear 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
ell m
eans
and
res
ults
of t
he p
rim
ary
anal
ysis
of
cova
rian
ce fo
r se
lf-r
atin
gs of
eat
ing
beha
vior
s an
d ph
ysic
ians
rat
ings
5 2.
n
111 -
F Te
sts
-. Tr
eatm
ent M
ean t S
D"
(Abs
tinen
ce/In
tens
ity)
A-1
H
ighk
Iigh
(N =
33)
E
<
B
P 111
Abs
tinen
ce
Inte
nsity
In
tera
ctio
n A
-2
B-1
B-2
(dj =
1,1
38)
(dj =
1,1
38)
(df
= 1
,138
) s. Ly
rD
Hig
hLow
Lo
w/H
igh
Low
Low
(N
= 4
1)
(N =
35)
(N
= 3
4)
F P
F P
F
Eatin
g B
ehav
iors
-Illb
B
inge
epi
sode
s (p
er
wee
k)
Bas
elin
e La
st v
isit
Bas
elin
e La
st v
isit
wee
k)
Bas
elin
e La
st v
isit
Bas
elin
e La
st v
isit
wee
k)
Bas
elin
e La
st v
isit'
Glo
bal S
ever
ity
Bas
elin
e La
st v
isitd
Last
vis
it'
Bas
elin
e La
st v
isit
Bas
elin
e La
st v
isit
Bin
ge ti
me
(per
wee
k)
Vom
it ep
isod
es (p
er
Laxa
tive
use
(per
wee
k)
Abs
tinen
t da
ys (
per
Glo
bal I
mpr
ovem
ent'
Ham
ilton
Dep
ress
ion
Ham
ilton
Anx
iety
9.02
f 5
.43
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
.95
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
.53
10.6
f 8
.34
1.91
f 4
.38
1.54
f 6
.93
.ooo k
,00
0
1.63
f 1
.54
5.62
f 2
.15
4.41
f 0
.89
3.15
f 0
.89
2.45
t 0
.84
9.29
f 7
.03
4.70
t 5
.84
5.27
f 4
.49
2.07
f 2
.98
10.3
f 6
.97
1.29
5 4
.97
12.8
t 8
.01
1.86
2 5
.23
10.8
f 9
.19
2.44
f 8
.35
1.47
f 4
.96
.115
f .6
86
0.98
f 1
.28
5.86
f 2
.24
4.71
f 0
.58
3.19
f 0
.67
2.40
f 0
.56
11.6
f 7
.21
5.28
2 5
.98
5.60
2 4
.59
2.28
f 2
.90
8.66
f 4
.76
3.31
f 3
.70
15.3
2 1
2.0
3.51
f 4
.64
9.63
f 7
.15
4.22
f 4
.66
1.56
f 4
.46
,489
2 2
.12
1.25
t 1
.37
3.88
f 2
.32
4.65
2 0
.69
3.72
t 1
.04
2.94
f 1
.03
11.1
f 7
.28
4.63
f 5
.64
5.76
f 4
.42
2.06
f 2
.95
3.55
0.31
2.48
2.56
2.16
5.80
0.79
0.26
0.07
0.67
,005
.581
,118
.112
,144
.017
,375
,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
,460
.003
,512
.363
,361
,231
2.96
3.56
1.15
1.49
2.12
6.24
8.86
8.70
0.04
0.62
~
"Mea
ns fo
r las
t vis
it ar
e ad
just
ed f
or b
asel
ine
cova
riate
. Mea
ns w
ith d
iffer
ent s
uper
scrip
ts a
re s
igni
fican
tly d
iffer
ent
(p <
ve
sts
in it
alic
s rep
rese
nt a
ppro
xim
ate
F fo
r Pi
llais
mul
tivar
iate
tes
ts.
Deg
rees
of
Free
dom
var
y w
ith t
he a
naly
sis.
dA-l
, B-2
2>A
-2, B
-1 in
impr
ovem
ent
'Bas
elin
e cl
inic
al G
loba
l Sev
erity
ratin
gs s
erve
d as
cov
aria
te fo
r ana
lysi
s of
impr
ovem
ent
ratin
gs.
'A-1
, A
-2,
B-l>
B-2
'A-1
, B
-2>A
-2, 8
1
.05)
.
,014
.061
.286
,224
.148
,014
,003
.004
,851
.433
N
co
W
N
cc e
Tabl
e 3.
C
ell m
ean
s an
d re
sult
s of
the
pri
mar
y an
alys
is o
f co
vari
ance
for
sub
ject
rat
ings
-I
F T
ests
Abs
tinen
ce
A-1
A
-2
B-1
B-2
(df
= 1
,138
) H
igh/
Hig
h H
ighL
ow
Low
/Hig
h LO
WLO
W
(N =
41)
(N
= 3
5)
(N =
34)
F
-
(N =
33)
Glo
bal I
mpr
ovem
ent
Sym
ptom
Che
ck L
ist-9
0 G
loba
l Sev
erity
Inde
x
Las
t vis
it
Bas
elin
e L
ast v
isit"
Bas
elin
e L
ast v
isit
Bas
elin
e L
ast v
isit
Bas
elin
e L
ast v
isitb
W
eiss
man
Soc
ial
Adj
ustm
ent
Wor
k B
asel
ine
Las
t vis
it
Bas
elin
e L
ast v
isit'
Bas
elin
e L
ast v
isit
Posi
tive
sym
ptom
s to
tal
Posi
tive
sym
ptom
dis
tres
s
Bec
k D
epre
ssio
n
Soci
al
Ext
ende
d fa
mily
1.85
f 1
.47
1.12
f 5
88
.597
f .5
25
48.4
? 1
6.8
28.6
f 1
9.8
1.98
4 ,
520
1.63
f .5
20
17.6
f 7
.59
9.11
? 9
.73
1.99
2 .
589
1.75
? ,
645
2.57
f .6
60
2.22
2 ,
801
1.83
? .6
19
1.79
,6
19
1.69
f 0
.88
,985
f ,6
04
,450
? ,
432
44.6
f 1
8.1
24.5
f 1
8.6
1.82
? .
561
1.42
? ,
367
14.4
f 7
.98
6.48
4 5
.812
1.97
2 ,
688
1.56
f ,6
23
2.41
f ,5
00
1.97
f ,50
9
1.61
f ,4
13
1.64
2 ,
413
1.43
? 0
.99
1.25
f .6
52
,466
f 4
45
52.5
? 1
8.2
24.7
f 1
8.9
2.04
2 ,
588
1.53
f ,5
01
17.6
f 9
.04
5.77
t 7
.32
2.02
f ,5
99
1.63
f .4
46
2.55
* ,6
78
2.24
f .6
64
1.65
? ,
465
1.64
f .4
65
2.00
f 1
.22
1.17
4 ,6
14
,661
? ,
725
47.3
5 1
6.7
31.5
f 2
4.7
2.12
2 .
595
1.53
? ,
670
16.6
2 9
.16
9.82
2 9
.55
2.16
? 1
.30
1.63
5 ,6
34
2.44
2 ,6
39
2.07
5 ,6
11
1.75
2 .
635
1.78
5 ,
635
.08
1.45
0.
22
0.24
0.01
0.01
,4
24
0.09
.44
.01
P ,779
.1
55
.638
.623
,988
,997
,7
33
t764
,510
.916
Inte
nsity
(d
f =
1,1
38)
Inte
ract
ion
(df
= 1
,138
)
F -
1.14
2.
47
0.08
0.17
1.77
0.33
2.
03
1.03
5.59
.01
P -
.288
,0
06
,776
,676
,186
,570
.1
13
.312
.019
.910
F P
3.71
1.
07
4.24
3.08
1.63
7.30
1.
33
1.05
.16
3.44
,056
,3
86
,041
.082
,204
,008
,2
66
,308
,693
,066
"A-2
, B-l
> A
-1, 8
-2 in
impr
ovem
ent
bA-2
, B-1
> A
-1, 8
-2 in
im
prov
emen
t 'A
-2,
8-2
> A
-1, 8-
1 in
impr
ovem
ent
5 R
'p 2 %
T
-
Logistical Variables 285
In Y In
t-" CL,
h 0 9
$ 3
8 c!
? 3
? m z
286 Mitchell et al.
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 limi- tation to this study is the fact that the key variables studied, the target eating behav- iors, 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, physi- cians monitoring subjects in this study were not blind as to group assignment; how- ever, 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 psy- chotherapy 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 inter- ruption 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 re- searchers 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
REFERENCES
287
Agras, W. S., Rossiter, E. M., Arnow, B., Schneider, J., Telch, C. F., Raebum, S. D., Bruce, B., Perl, M., & Koran, L. M. (1992). Pharmacological and cognitive-behavioral treatment for bulimia nervosa: A controlled comparison. American Journal of Psychiatry, 149, 82-87.
Agras, W. S., Schneider, 1. A., Arnow, B., Raeburn, S. D., & Teich, C. F. (1989). Cognitive behavioral and response-prevention treatments for bulimia nervosa. Journal of Consulting Clinical Psychology, 57, 215-221.
Beck, A. T., Ward, C. M., Mendelson, M., Mock, J. E., & Erbangh, J. K. (1961). An inventory for measuring depression. Archives of Geneneral Psychiatry, 4, 561 -571.
Bulimic Nervosa Group Training Manual, University of Minnesota Eating Disorders Program, 3rd Edition, 1991.
Connors, M. E., Johnson, C. L., & Stuckey, M. K. (1984). Treatment of bulimia with brief psychoeducational group therapy. American Journal of Psychiatry, 141, 1512-1516.
Derogats, L. R., Lipman, 8. S., & Covi, L. (1973). SCL 9 0 An outpatient psychiatric rating scale: Preliminary report. Psychopharmacology Bulletin, 9, 13-28.
Fairburn, C. G., Cooper, P. J., Kirk, J., OConnor, M. E., (1985). The significance of the neurotic symptoms of bulimia nervosa. Journal of Psychiatry Research, 29, 135-140.
Fairburn, C. G., Jones, R., reveler, R. C., Can, S. J., Solomon, R. A., OConnor, M. E., Burton, J., & Hope, R. A. (1991). Three psychological treatments for bulimia nervosa. Archives of General Psychiatry, 48,463-469.
Fairburn, C. G., Kirk, J., OConnor, M., & Cooper, P. J. (1986). A comparison of two psychological treat- ments for bulimia nervosa. Behavior, Research and Therapy, 24, 629-643.
Freeman, C., Sinclair, F., Turnbull, J., & Annandale, A. (1985). Psychotherapy for bulimia: A controlled study. Journal of Psychiatry Research, 19, 473-478.
Freeman, C. P. L., & Munro, J. K. M. (1988). Drug and group treatments for bulimiahulimia nervosa. Journal of Psychosomatic Research, 32, 647-660.
Gardner, G. M., Olmstead, M. P., & Polivy, J. (1983). Development and validation of multidimensional eat- ing disorder inventory for anorexia nervosa and bulimia. International Journal of Eating Disorders, 2, 15-33.
Hamilton, M. (1959). The assessment of anxiety by rating. British Journal ofMedical Psychology, 32, 50-55. Hamilton, M. (1960). A rating Scale for depression. Journal of Neurology, Neurosurgery and Psychiatry, 23, 56-62. Healthy Eating Manual, University of Minnesota Eating Disorders Program, 3rd Edition, 1992. Kirkley, 8. G., Schneider, J. A., Agras, W. S., & Bachman, J. A. (1985). Comparison of two group treatments
for bulimia. Journal of Consulting Clinical Psychology, 53, 43-48. Lacey, J. H. (1983). Bulimia nervosa, binge eating, and psychogenic vomiting: A controlled treatment study
and long-term outcome. British Medical Journal of Clinical Research, 286, 1609- 1613. Lee, N. F., & Rush, A. J. (1986). Cognitive-behavioral group therapy for bulimia. International Journal of Eating
Disorders, 5, 559-615. Leitenberg, H., Rosen, J. , Gross, J., Nudelman, S., & Vara, L. S. (1988). Exposure plus response-prevention
treatment of bulimia nervosa. Journal of Consulting Clinical Psychology, 56, 535-541. Maddocks, S., Kaplan, A. S., Woodside, D. B., Langdon, L., & Piran, N. (1992). Two year follow-up of bu-
limia nervosa: The importance of abstinence as the criterion of outcome. lnternational Journal of Eating Dis- orders, 12, 133-141.
Metropolitan Life Insurance Company. (1959). New height standards for men and women. Stat Bull Metrop lnsur Co., 40, 1-4.
Mitchell, 1. E., Hatsukami, D., Eckert, E., & Pyle, R. (1985). Eating Disorders Questionnaire. Psychopharma- cology Bulletin, 21, 1025-1043.
Mitchell, J. E., Pyle, R. L., Eckert, E. D., Hatsukami, D., Pomeroy, C., & Zimmerman, R. (1990). A compari- son studv of antidepressants and structured intensive group psychotherapy in the treatment of bulimia - - _ . _ . nervosa.'Archives of 'General Psychiatry, 47, 149- 157.
Mitchell, J. E., Seim, H. C., Colon, E., & Pomeroy, C. (1987). Medical complications and medical manage- ment of bulimia. Annals of Internal Medicine, 207, 71-77.
Ordman, A. M., & Kirschenbaum, D. S. (1985). Cognitive-behavioral therapy for bulimia: An initial outcome stddy. Journal of Consulting Clinical Psychology, 53, 305-313.
Pyle, R. L. (1985). The epidemiology of eating disorders. Pediatrician, 12, 102-109. Pyle, R. L., Mitchell, J. E., Eckert, E. D., Hatsukami, D., Pomeroy, C., & Zimmerman, R. (1990). Mainte-
nance treatment and 6-month outcome for bulimic patients who respond to initial treatment. American Journal of Psychiatry, 147, 871-875.
Russell, G. (1979). Bulimia nervosa: An ominous variant of anorexia nervosa. Psychological Medicine, 9, 429-448.
Weissman, M., & Bothwell, 5. (1976). Assessment of social adjustment by patient self-report. Archives of Gen- . - era/ Psychiatry, 3, 1111-1115:
nervosa: A controlled evaluation. Behavior and Theraw Research, 24, 277-288. Wilson, G. T., Rossiter, E., Kleifield, E. I., & Lindholm, L. (1986). Cognitive-behavioral treatment of bulimia
Wolchik, S . A., Weiss, L., & Katzman, M. A. (1986). An empirically validated short-term psychoeducational
Yates, A. J., Sambrailo, F. (1984). Bulimia nervosa: A descriptive and therapeutic study. Behavior and Research group treatment program for bulimia. International Journal of Eating Disorders, 5, 21-34.
Therapy, 22, 503-517.