Elizabeth M. Pratt

Therapeutic Alliance and Treatment Adherence in Two Interventions for Bulimia Nervosa: A Study of Process and Outcome

The relationship between therapeutic alliance, therapist adherence to treatment protocol, and outcome was analyzed in a randomized trial of cognitive-behavioral therapy (CBT) and interpersonal psychotherapy for bulimia nervosa. Independent observers rated audiotapes of full-length therapy sessions. Purging frequency was the primary outcome variable. There were no significant therapist or Therapist x Treatment effects on outcome. Although results showed high levels of alliance and adherence across treatments, CBT was associated with greater adherence. Across treatments and time points, better adherence was associated with enhanced alliance. Treatment condition and baseline purging frequency, but not adherence, predicted outcome. Early alliance predicted posttreatment purging frequency. In temporal analyses, prior symptom change assessed early in treatment was significantly related to subsequent adherence at midtreatment.

Perfectionism in women with binge eating disorder.

OBJECTIVE This study examined self-oriented (SOP), socially prescribed (SPP), and other-oriented (OOP) perfectionism in 127 obese women with binge eating disorder (BED). METHOD Relationships between eating disorder and general psychopathology variables and SOP, SPP, and OOP were assessed. Levels of SOP, SPP, and OOP in the BED sample were compared with those of 32 normal weight women with bulimia nervosa (BN) and 60 obese non-eating-disordered individuals (NED). Structural equation modeling (SEM) was used to test models of the maintenance of BED. RESULTS Only SPP was significantly associated with eating disorder variables related to BED. All three groups demonstrated similar levels of SPP and OOP. BN and BED groups scored significantly higher than the NED group on SOP only. SEM resulted in two models with good fits. DISCUSSION Further research is needed on the roles of SPP and SOP in BED and on weight and shape overconcern in BED maintenance models.

Behavioral and cognitive impulsivity in obsessive–compulsive disorder and eating disorders

This study compared self-reported impulsivity and neurocognitively assessed response inhibition in obsessive-compulsive disorder (OCD), eating disorder (ED), and healthy control participants. Participants completed the Barratt Impulsiveness Scale (BIS-11), stop-signal reaction time task, and measures of OCD and ED symptomatology (Yale-Brown Obsessive-Compulsive Scale and Eating Disorders Examination-Questionnaire). Compared to controls, both clinical groups reported higher levels of impulsivity on the BIS-11 however; only the OCD demonstrated increased stop-signal reaction time. Heightened levels of self-reported impulsivity may reflect the experience of anxiety in both OCD and ED populations whereas a lack of inhibitory control may represent a specific behavioral deficit in OCD.

Predictors of Dropout from Psychosocial Treatment in Opioid-Dependent Outpatients

BACKGROUND AND OBJECTIVES Early dropout is common in substance abuse treatment settings and may lead to poorer outcomes relative to those completing a full course of treatment. Attempts to identify predictors of dropout have yielded mixed results, highlighting the need for additional research in this area to clarify risk and protective factors to guide intervention and retention efforts. This study evaluated predictors of dropout from psychosocial treatment among opioid-dependent patients on methadone maintenance therapy. METHODS Participants included 78 patients who had failed to respond to at least 4 months of methadone maintenance plus group counseling with clinic substance abuse counselors, and were enrolled in a study of randomized psychosocial treatment in addition to treatment-as-usual. Several factors that have been implicated in previous studies as well as two affective variables (distress intolerance and coping motives for drug use) were examined. RESULTS Results indicated that when controlling for various risk factors, age was the only significant predictor of dropout, with younger patients more likely to discontinue treatment early. CONCLUSIONS This study replicates previous findings in opioid-dependent samples that younger patients are at an increased risk of early treatment dropout. CONCLUSIONS AND SIGNIFICANCE Targeted intervention may be needed to retain young patients in drug abuse treatment.

Multiple measures of rapid response as predictors of remission in cognitive behavior therapy for bulimia nervosa

Bulimia nervosa (BN) treatment studies consistently observe that substantial reductions in purging frequency after four weeks of treatment predict outcome. Although baseline levels of other variables have been compared to change in purging, measures of early change in other domains have not been examined. This study aimed to compare percentage change in purging, depression, and cognitive eating disorder (ED) symptoms for associations with BN remission post-treatment and at six months follow-up. Data from N = 43 patients with BN in a clinical trial comparing the broad and focused versions of enhanced cognitive behavior therapy (CBT-E; Fairburn, 2008) were utilized. Measures included self-reported purging frequency, Beck Depression Inventory (BDI) score, and a mean of items from the Eating Disorder Inventory Body Dissatisfaction and Drive for Thinness subscales. Results indicated that both percentage change in purging frequency and percentage change in BDI score at week four/session eight were significantly associated with remission at termination. The optimal cutoffs for purging change and BDI score change were 65% decrease and 25% decrease respectively. Only change in BDI score at week four significantly predicted remission at six-month follow-up. These data suggest that change in depressive symptoms may be as important as ED symptom change to predict outcome in some groups.

An fMRI investigation of the fronto-striatal learning system in women who exhibit eating disorder behaviors

In the present study, we sought to examine whether the fronto-striatal learning system, which has been implicated in bulimia nervosa, would demonstrate altered BOLD activity during probabilistic category learning in women who met subthreshold criteria for bulimia nervosa (Sub-BN). Sub-BN, which falls within the clinical category of Eating Disorder Not Otherwise Specified (EDNOS), is comprised of individuals who demonstrate recurrent binge eating, efforts to minimize their caloric intake and caloric retention, and elevated levels of concern about shape, weight, and/or eating, but just fail to meet the diagnostic threshold for bulimia nervosa (BN). fMRI data were collected from eighteen women with subthreshold-BN (Sub-BN) and nineteen healthy control women group-matched for age, education and body mass index (MC) during the weather prediction task. Sub-BN participants demonstrated increased caudate nucleus and dorsolateral prefrontal cortex (DLPFC) activation during the learning of probabilistic categories. Though the two subject groups did not differ in behavioral performance, over the course of learning, Sub-BN participants showed a dynamic pattern of brain activity differences when compared to matched control participants. Regions implicated in episodic memory, including the medial temporal lobe (MTL), retrosplenial cortex, middle frontal gyrus, and anterior and posterior cingulate cortex showed decreased activity in the Sub-BN participants compared to MCs during early learning which was followed by increased involvement of the DLPFC during later learning. These findings demonstrate that women with Sub-BN demonstrate differences in fronto-striatal learning system activity, as well as a distinct functional pattern between fronto-striatal and MTL learning systems during the course of implicit probabilistic category learning.

Gender differences in clinical trials of binge eating disorder: An analysis of aggregated data.

OBJECTIVE The aim of the study was to examine gender differences in baseline and outcome variables in clinical trials for binge eating disorder (BED). METHOD Data from 11 randomized controlled psychosocial treatment studies were aggregated (N = 1,325: 208 male, 1,117 female). Baseline and outcome symptoms were assessed via the interview and questionnaire versions of the Eating Disorder Examination (EDE). Multilevel analyses were conducted investigating gender differences at baseline and posttreatment, defined as EDE scores, objective binge episode (OBE) reduction, and OBE remission at termination. RESULTS Few males from low socioeconomic status or minority groups participated in the outcome studies. Males reported significantly lower EDE global, shape, weight, and eating concerns at baseline. No main effects of gender were found in treatment outcome scores when controlling for baseline differences; however, baseline EDE global score (which showed gender differences at baseline) and OBEs directly predicted outcome for both males and females. A significant interaction between gender, treatment length, and shape/weight concerns indicated that males with lower shape/weight concerns achieved OBE remission in shorter treatments, whereas men with high shape/weight concerns and women with either high or low shape/weight concerns were more likely to achieve OBE remission in treatments of longer duration. CONCLUSIONS These results suggest BED treatment studies must improve their recruitment of men and appeal to men with lower shape/weight concerns. Additionally, longer term treatments, although more efficacious for women and men with more severe shape/weight concerns, may not be necessary for men with low shape/weight concerns. (PsycINFO Database Record

The relationship between decision-making and perfectionism in obsessive-compulsive disorder and eating disorders.

BACKGROUND AND OBJECTIVES Obsessive-compulsive disorder (OCD) and eating disorders (EDs) show phenotypic similarities and have been independently associated with deficits in decision-making and maladaptive perfectionism. However, research directly comparing the two disorders is sparse and the significance of observed similarities remains in question. Therefore, the present study compared decision-making in OCD and EDs in relationship to perfectionistic personality traits. METHODS Sixty-one women were enrolled in the study comprising 3 mutually exclusive groups: 19 with OCD, 17 with EDs, and 21 healthy controls. Decision-making performance on the Iowa Gambling Task under two conditions, ambiguity and risk, was examined in relationship to perfectionistic traits. RESULTS Behavioral results indicated that EDs participants, relative to both OCD and control participants, were impaired in decision-making under conditions of risk. Heightened perfectionism was associated with less risky decision-making in OCD, but more risky decision-making in EDs. LIMITATIONS Sample size was small and all participants were women, which may limit generalizability. CONCLUSION Results support decision-making deficits in EDs, which may be related to a dysfunctional determination of risk versus reward. This study is the first to suggest that the relationship between perfectionism and risk taking may manifest differently in these phenotypically similar disorders.

Focused vs. Broad enhanced cognitive behavioral therapy for bulimia nervosa with comorbid borderline personality: A randomized controlled trial.

OBJECTIVE A subset of individuals with bulimia nervosa (BN) have borderline personality disorder (BPD) symptoms, including chronic negative affect and interpersonal problems. These symptoms predict poor BN treatment outcome in some studies. The broad version of Enhanced Cognitive Behavior Therapy (CBT-E) was developed to address co-occurring problems that interfere with treatment response. The current study investigated the relative effects, predictors, and moderators of CBT-E for BN with BPD and co-occurring mood/anxiety disorders. METHOD Fifty patients with BN and threshold or sub-threshold BPD and current or recent Axis I mood or anxiety disorders were randomly assigned to receive focused CBT-E (CBT-Ef) or broad CBT-E (CBT-Eb) specifically including an interpersonal module and additional attention to mood intolerance. RESULTS Forty-two percent of the sample reported remission from binge eating and purging at termination. Significant changes across symptom domains were observed at termination and at 6-month follow-up. Though CBT-Ef predicted good outcomes in multivariate models, the severity of affective/interpersonal problems moderated treatment effects: participants with higher severity showed better ED outcomes in CBT-Eb, whereas those with lower severity showed better outcomes in CBT-Ef. Severity of affective/interpersonal BPD symptoms at baseline predicted negative outcomes overall. Follow-up BPD affective/interpersonal problems were predicted by baseline affective/interpersonal problems and by termination EDE score. DISCUSSION This study supports the utility of CBT-E for patients with BN and complex comorbidity. CBT-Ef appears to be more efficacious for patients with relatively less severe BPD symptoms, whereas CBT-Eb appears to be more efficacious for patients with more severe BPD symptoms.

Alliance-focused therapy for anorexia nervosa: integrative relational and behavioral change treatments in a single-case experimental design.

Evidence supporting outpatient treatments for anorexia nervosa (AN) is severely lacking, due to low retention and poor outcome. One explanation for drop-out is weak treatment alliances. A single-case experimental analysis accompanied by in-depth qualitative description is presented for Ms. O, who received a novel treatment for AN called Alliance Focused Treatment (AFT) that attends to ruptures in the alliance, interpersonal difficulties and emotional avoidance. At intake Ms. O met diagnostic criteria for AN, Major Depressive Disorder, and Social Phobia. She was characterized as having symptoms of Obsessive Compulsive, Avoidant, and Depressive personality disorders. Treatment began with a Baseline followed by the experimental (AFT) and comparison treatments (Behavioral Change Treatment [BCT]) using a replicated experimental single-case phase change design. Graphs of slopes of kilocalorie and alliance change facilitated observation of treatment effects. Ms. O participated in 16 sessions of AFT and 8 sessions of BCT with specific benefits. Ratings of the treatment alliance were consistently high and she evidenced significant changes in weight, quality of life, and personality pathology. Associations between rupture/repair episodes and kilocalorie increases were observed. The utility of the treatment relationship in facilitating emotional expression was evident. At posttreatment, Ms. O endorsed cognitive AN symptoms, although these were not explicitly treated. This study provides preliminary support for the feasibility and effect of AFT and BCT, and highlights the importance of the alliance in treating adults with AN. Further research on emotion regulation in AN and its effect on the treatment relationship are needed.