G. Terence Wilson

Understanding and preventing relapse.

This chapter examines relapse by integrating knowledge from the disorders of alcoholism, smoking, and obesity in an attempt to emphasize in a prototypical manner the overlap in etiological mechanisms and treatment rationales for disorders with powerful, underlying biological self-regulation components. Commonalities across these areas suggest at least three basic stages of behavior change: motivation and commitment, initial change, and maintenance. A distinction is made between the terms lapse and relapse, with lapse referring to the process (slips or mistakes) that may or may not lead to an outcome (relapse). The natural history of relapse is discussed, as are the consequences of relapse for patients and the professionals who treat them. Information on determinants and predictors of relapse is evaluated, with the emphasis on the interaction of individual, environmental, and physiological factors. Methods of preventing relapse are proposed and are targeted to the three stages of change. Specific research needs in these areas are discussed.

Enhancing motivation for change in treatment-resistant eating disorders.

Denial and resistance to change are prominent features in most patients with anorexia nervosa. The egosyntonic quality of symptoms can contribute to inaccuracy in self-report, avoidance of treatment, difficulties in establishing a therapeutic relationship, and high rates of attrition and relapse. Individuals with bulimia nervosa are typically more motivated to recover, but often ambivalent about forfeiting the ideal of slenderness and the protective functions of binge-purge behavior. Few attempts have been made to assess denial and resistance in the eating disorders, or to examine alternative strategies for enhancing motivation to change. Review of the clinical literature indicates a striking convergence of recommendations across conceptually distinct treatment approaches. Clinicians are encouraged to acquire a frame of reference that can help them understand the private experience of individuals with eating disorders, empathize with their distress at the prospect of weight gain, and acknowledge the difficulty of change. The Socratic method seems particularly well-suited to work with this population because of its emphasis on collaboration, openness, curiosity, patience, focused and systematic inquiry, and individual discovery. Four themes are crucial in engaging reluctant eating-disordered clients in therapy: the provision of psychoeducational material, an examination of the advantages and disadvantages of symptoms, the explicit use of experimental strategies, and an exploration of personal values.

Psychological treatment of eating disorders.

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

A comparison of different methods for assessing the features of eating disorders in patients with binge eating disorder.

The authors compared 3 methods for assessing the features of eating disorders in patients with binge eating disorder (BED). Participants were administered the Eating Disorder Examination (EDE) interview and completed the EDE Questionnaire (EDE-Q) at baseline. Participants prospectively self-monitored their eating behaviors daily for 4 weeks and then completed another EDE-Q. The EDE and the EDE-Q were significantly correlated on frequencies of objective bulimic episodes (binge eating) and on the Dietary Restraint, Eating Concern, Weight Concern, and Shape Concern subscales. Mean differences in the EDE and EDE-Q frequencies of objective bulimic episodes were not significant, but scores on the 4 subscales differed significantly, with the EDE-Q yielding higher scores. At 4 weeks, the EDE-Q retrospective 28-day assessment was significantly correlated with the prospective daily self-monitoring records for frequency of objective bulimic episodes, and the mean difference between methods was not significant. The EDE-Q and self-monitoring findings for subjective bulimic episodes and objective overeating differed significantly. Thus, in patients with BED, the 3 assessment methods showed some acceptable convergence, most notably for objective bulimic episodes.

Psychological Treatments of Binge Eating Disorder

CONTEXT Interpersonal psychotherapy (IPT) is an effective specialty treatment for binge eating disorder (BED). Behavioral weight loss treatment (BWL) and guided self-help based on cognitive behavior therapy (CBTgsh) have both resulted in short-term reductions in binge eating in obese patients with BED. OBJECTIVE To test whether patients with BED require specialty therapy beyond BWL and whether IPT is more effective than either BWL or CBTgsh in patients with a high negative affect during a 2-year follow-up. DESIGN Randomized, active control efficacy trial. SETTING University outpatient clinics. PARTICIPANTS Two hundred five women and men with a body mass index between 27 and 45 who met DSM-IV criteria for BED. Intervention Twenty sessions of IPT or BWL or 10 sessions of CBTgsh during 6 months. MAIN OUTCOME MEASURES Binge eating assessed by the Eating Disorder Examination. RESULTS At 2-year follow-up, both IPT and CBTgsh resulted in greater remission from binge eating than BWL (P < .05; odds ratios: BWL vs CBTgsh, 2.3; BWL vs IPT, 2.6; and CBTgsh vs IPT, 1.2). Self-esteem (P < .05) and global Eating Disorder Examination (P < .05) scores were moderators of treatment outcome. The odds ratios for low and high global Eating Disorder Examination scores were 2.8 for BWL, 2.9 for CBTgsh, and 0.73 for IPT; for self-esteem, they were 2.4 for BWL, 1.9 for CBTgsh, and 0.9 for IPT. CONCLUSIONS Interpersonal psychotherapy and CBTgsh are significantly more effective than BWL in eliminating binge eating after 2 years. Guided self-help based on cognitive behavior therapy is a first-line treatment option for most patients with BED, with IPT (or full cognitive behavior therapy) used for patients with low self-esteem and high eating disorder psychopathology. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00060762.

Assessment of eating disorders : Interview versus questionnaire

OBJECTIVE This study assessed the validity of the Eating Disorder Examination--Questionnaire (EDE-Q) in identifying eating disorder symptoms in female substance abusers. METHOD Subjects were assessed for the presence of eating disorder behaviors and attitudes using the Eating Disorder Examination (EDE), a semistructured interview, and the EDE-Q. The results of the two measures were then compared. RESULTS Results showed that the EDE-Q does identify eating disorders in this population. It is more accurate in assessing purging than the more complex features of binge eating and dietary restraint. DISCUSSION Eating disorders and substance abuse co-occur at a higher rate than expected by chance, and recent findings indicate that eating disorders often go undetected among patients with substance abuse. The EDE-Q appears to be an effective screening instrument for detecting the presence of eating disorder symptoms in this population.

Binge Eating Among Gastric Bypass Patients at Long-term Follow-up

Background: A better understanding of the relationship of eating behavior and attitudes to weight loss following gastric bypass (GBP) will enable the development of interventions to improve outcome. Thus, the present study sought to characterize the postoperative weight, eating behavior, and attitudes toward body shape and weight in a cross-section of GBP patients. A second objective was to examine the relationship of postoperative binge eating to surgery outcome. Methods: 99 patients who underwent GBP >2 and <7 years before the study start date completed the Eating Disorder Examination-Questionnaire (EDE-Q) and the Three-Factor Eating Questionnaire (TFEQ). Subjects self-reported their current body weight, weight change over the past 3 months, and lowest weight since surgery. Results: BMI remained significantly below the preoperative level, but significant weight regain was reported at long-term follow-up. 46% of participants reported recurrent loss of control over eating (objective or subjective bulimic episodes) on the EDE-Q. These patients constituted a distinctive subgroup with a less favorable outcome, including greater weight regain. Conclusion: Self-reported loss of control over eating was related to weight regain after GBP and may be an important target for clinical intervention. The relationship of binge eating and related psychopathology to outcome following GBP warrants further investigation.

Assessment of bulimia nervosa: An evaluation of the eating disorders examination

The Eating Disorders Examination (EDE) is a semistructured interview designed to assess the specific psychopathology of patients with eating disorders. It is claimed that the EDE is more sensitive than standardized self-report questionnaire measures of the central features of bulimia, such as the Eating Disorder Inventory (EDI). This study examined the relative merits of the EDE, EDI, and Restraint Scale (RS) in discriminating between 15 female patients with bulimia nervosa and 15 highly restrained, nonbulimic controls. The groups differed significantly only on the total score and the Bulimia subscale of the EDI. Significant group differences were found on four of the five subscales of the EDE, the exception being the Restraint subscale. The EDE is recommended for future studies of treatment outcome as a superior measure of the core pathology of bulimia nervosa than standardized questionnaires.

Efficacy of cognitive behavioral therapy and fluoxetine for the treatment of binge eating disorder: a randomized double-blind placebo-controlled comparison.

BACKGROUND Cognitive behavioral therapy (CBT) and certain medications have been shown to be effective for binge eating disorder (BED), but no controlled studies have compared psychological and pharmacological therapies. We conducted a randomized, placebo-controlled study to test the efficacy of CBT and fluoxetine alone and in combination for BED. METHODS 108 patients were randomized to one of four 16-week individual treatments: fluoxetine (60 mg/day), placebo, CBT plus fluoxetine (60 mg/day) or CBT plus placebo. Medications were provided in double-blind fashion. RESULTS Of the 108 patients, 86 (80%) completed treatments. Remission rates (zero binges for 28 days) for completers were: 29% (fluoxetine), 30% (placebo), 55% (CBT+fluoxetine), and 73% (CBT+placebo). Intent-to-treat (ITT) remission rates were: 22% (fluoxetine), 26% (placebo), 50% (CBT+fluoxetine), and 61% (CBT+placebo). Completer and ITT analyses on remission and dimensional measures of binge eating, cognitive features, and psychological distress produced consistent findings. Fluoxetine was not superior to placebo, CBT+fluoxetine and CBT+placebo did not differ, and both CBT conditions were superior to fluoxetine and to placebo. Weight loss was modest, did not differ across treatments, but was associated with binge eating remission. CONCLUSIONS CBT, but not fluoxetine, demonstrated efficacy for the behavioral and psychological features of BED, but not obesity.

Binge eating in bariatric surgery patients

OBJECTIVE Eating behavior, attitudes toward eating and body weight and shape, and depression were assessed in a sample of 64 morbidly obese gastric bypass surgery candidates. METHOD The Beck Depression Inventory (BDI), the Three-Factor Eating Questionnaire (TFEQ), and the Eating Disorder Examination (EDE) were administered at the first preoperative visit. RESULTS Twenty-five subjects (39%) reported at least one binge episode per week on average over the 3 months prior to seeking treatment. Binge eaters had significantly higher TFEQ Disinhibition and Hunger scores than nonbinge eaters. Binge eaters also differed from nonbinge eaters in terms of attitudes toward eating, shape, and weight. DISCUSSION A significant number of gastric bypass surgery candidates report binge eating. The findings are consistent with other studies showing binge eaters to be a distinctive subgroup of the obese.