Stig Poulsen

A Randomized Controlled Trial of Psychoanalytic Psychotherapy or Cognitive-Behavioral Therapy for Bulimia Nervosa

OBJECTIVE The authors compared psychoanalytic psychotherapy and cognitive-behavioral therapy (CBT) in the treatment of bulimia nervosa. METHOD A randomized controlled trial was conducted in which 70 patients with bulimia nervosa received either 2 years of weekly psychoanalytic psychotherapy or 20 sessions of CBT over 5 months. The main outcome measure was the Eating Disorder Examination interview, which was administered blind to treatment condition at baseline, after 5 months, and after 2 years. The primary outcome analyses were conducted using logistic regression analysis. RESULTS Both treatments resulted in improvement, but a marked difference was observed between CBT and psychoanalytic psychotherapy. After 5 months, 42% of patients in CBT (N=36) and 6% of patients in psychoanalytic psychotherapy (N=34) had stopped binge eating and purging (odds ratio=13.40, 95% confidence interval [CI]=2.45-73.42; p<0.01). At 2 years, 44% in the CBT group and 15% in the psychoanalytic psychotherapy group had stopped binge eating and purging (odds ratio=4.34, 95% CI=1.33-14.21; p=0.02). By the end of both treatments, substantial improvements in eating disorder features and general psychopathology were observed, but in general these changes took place more rapidly in CBT. CONCLUSIONS Despite the marked disparity in the number of treatment sessions and the duration of treatment, CBT was more effective in relieving binging and purging than psychoanalytic psychotherapy and was generally faster in alleviating eating disorder features and general psychopathology. The findings indicate the need to develop and test a more structured and symptom-focused version of psychoanalytic psychotherapy for bulimia nervosa.

No-shows, drop-outs and completers in psychotherapeutic treatment: demographic and clinical predictors in a large sample of non-psychotic patients.

Background: A primary challenge in mental health services is a high rate of non-attendance (i.e. no-show and drop-out) for patients referred to treatment for psychiatric disorders. Aim: The aim of the present study was to assess the influence of demographic and clinical variables on mental health treatment attendance and to investigate differences in predictors for no-shows and drop-outs. Methods: A naturalistic study of 2473 non-psychotic consecutive patients offered psychotherapeutic treatment at a community mental health centre in Denmark. Fifteen demographic and clinical variables were recorded at assessment. Bivariate and multiple logistic regression analyses were conducted to investigate the associations between these variables and no-show and drop-out. Results: Of the 2473 participants, 668 (27.0%) did not show up for treatment, whereas 290 (11.7%) dropped out of treatment. Regression analysis showed that the significant predictors of treatment no-show were: age below 25, no more than the compulsory 9 years of school education, no sick leave, a diagnosis of personality disorder, a Global Assessment of Functioning score (GAF) below 40 or above 70, no previous psychiatric/psychological treatment, no use of antidepressants and substance abuse. The significant predictors of treatment drop-out were: age below 45, no more than the compulsory 9 years of school education or up to 11 years of school education, no vocational/university education, unemployment and substance abuse. Conclusion: No-show was predicted by both demographic and clinical factors, whereas drop-out was predicted by demographic factors and substance abuse as the only clinical factor. Results and strategies to reduce non-attendance are discussed.

Reflective Functioning in 70 Patients Suffering from Bulimia Nervosa

OBJECTIVE This study is the first to evaluate the reflective functioning abilities of patients suffering from bulimia nervosa (BN). METHOD Seventy patients fulfilling Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for BN were interviewed with the Adult Attachment Interview, which was subsequently coded for reflective functioning (RF). RESULTS On average, the sample of patients suffering from BN had close to normal mentalizing abilities. However, the distribution of RF scores was significantly different from the distribution of RF in a non-clinical control group, showing a more polarized pattern with more low and high RF scores. CONCLUSION The study indicates that the theory of mentalization may contribute to understanding BN. However, bulimic pathology may develop and be maintained despite good mentalizing abilities.

Psychoanalytic psychotherapy for bulimia nervosa: A manualized approach

A condensed version of a manual for two-year psychoanalytic psychotherapy for bulimia nervosa, developed for a clinical trial comparing psychoanalytic psychotherapy and cognitive behaviour therapy, is presented. The conceptualization of the psychopathology is outlined followed by a presentation of the specific principles of psychoanalytic psychotherapy for bulimia nervosa. The phases of the therapy and the adaptation of the therapy to different patterns of personality are described, and principles for training and supervision are outlined.

Subtypes in bulimia nervosa: the role of eating disorder symptomatology, negative affect, and interpersonal functioning

BACKGROUND The aim of the study was to investigate whether patients with bulimia nervosa (BN) could be subdivided into clinically meaningful groups reflecting the complex patterns of eating disorder symptoms and personality characteristics that face the clinician. METHODS Seventy patients diagnosed with BN using the Eating Disorder Examination were assessed with measures of negative affect, attachment patterns, and interpersonal problems. An exploratory hierarchical cluster analysis was performed. RESULTS The study found two main subtypes differing primarily in terms of symptom severity and level of negative affect, but these subtypes were further subdivided into four clinically relevant subtypes: A dietary restraint/negative affect/high symptomatic group, an emotionally overcontrolled group, a low dietary restraint/emotionally underregulated group, and a high functioning/securely attached group. CONCLUSIONS The study indicates that cluster-analytic studies, including a broad range of instruments measuring eating disorder symptoms as well as negative affect, relational patterns, and other personality characteristics, may contribute to an integration of previously suggested models of subtypes in BN.

Feedback in group psychotherapy for eating disorders: A randomized clinical trial.

Objective: To investigate the effect of client feedback in group psychotherapy on attendance and treatment outcome for patients with eating disorders. Method: We conducted a randomized clinical trial with central randomization stratified for diagnosis and treatment type according to a computer-generated allocation sequence concealed to the investigators. One-hundred and 59 adult participants, diagnosed with bulimia nervosa, binge eating disorder, or eating disorder not otherwise specified according to DSM–IV, were included. Eighty participants were allocated to the experimental group, and 79 participants to the control group. Both groups received 20–25 weekly group psychotherapy sessions. In the experimental group, participants gave and received feedback about therapy progress and alliance, measured before and after each session using the Outcome Rating Scale and the Group Session Rating Scale. The primary outcome was rate of attendance to treatment sessions; the secondary outcome was severity of eating disorder symptoms measured with the Eating Disorder Examination interview. Exploratory outcomes were psychological distress measured with the Symptom Checklist-90-R and the Outcome Rating Scale, social functioning measured with the Sheehan Disability Scale, and episodes of self-harm and suicide measured with a modified version of the Self-Harm Inventory. Results: Feedback compared with control did not affect the rate of attendance (0.59 vs. 0.58; p = .96), the severity of symptoms (2.03 vs. 2.02; p = .46), or any of the exploratory outcomes (p values from 0.06 to 0.67). Conclusions: Feedback neither increased attendance nor improved outcomes for outpatients in group psychotherapy for eating disorders. The results are discussed from different perspectives.

Client attachment in a randomized clinical trial of psychoanalytic and cognitive-behavioral psychotherapy for bulimia nervosa: Outcome moderation and change.

In the context of a randomized clinical trial of psychoanalytic psychotherapy (PPT) versus cognitive behavior therapy (CBT) for bulimia nervosa (BN), this study performed secondary analyses of (a) the relation between attachment and pretreatment symptom levels, (b) whether client pretreatment attachment moderated treatment outcome, (c) whether change in client attachment was associated with symptomatic change, and (d) whether client attachment changed differently in the 2 treatments. Sixty-nine women and 1 man of a mean age of 25.8 years diagnosed with BN were randomly assigned to either 2 years of weekly PPT or 5 months of CBT. Assessments at intake, after 5 months, and after 2 years included the Eating Disorder Examination to assess eating disorder symptoms, the Adult Attachment Interview to assess client attachment, and the Symptom Checklist 90-R to assess general psychiatric distress. Repeated measures were analyzed using multilevel analysis. Higher scores on attachment insecurity and attachment preoccupation were associated with more frequent binging pretreatment. Pretreatment attachment did not predict treatment outcome. In PPT, but not in CBT, reduction of binging was associated with an increase in attachment security. The 2 treatment types were not associated with significantly different patterns of attachment-related change. Degree and type of attachment insecurity is related to the frequency of binging in BN. Increase in attachment security may be a treatment-specific mechanism of change in PPT for BN. (PsycINFO Database Record

Group-Analytic Training Groups for Psychology Students: A Qualitative Study

This article presents results from a interview study of psychology students’ experiences from group-analytic groups conducted at the University of Copenhagen. The primary foci are the significance of the differences in participants’ personal aims for participation in the group, the impact of the composition of participants on the group process, and the professional learning through the group experience. In general the interviews show a marked satisfaction with the group participation. In particular, learning about group boundaries and about being in the dual position of both helper and client is seen as important. However, the fact that all group members are fellow students is challenging to the participants.

Helpful aspects of metacognitive therapy and cognitive behaviour therapy for depression: a qualitative study

Six clients in cognitive behaviour therapy (CBT) or metacognitive therapy (MCT) were interviewed about their experiences of therapy with a focus on helpful elements. Clients in both CBT and MCT mentioned the positive and informal relationship with the therapist as helpful. However, while clients in both therapies emphasized insight into the causes of depression and modification of negative maintenance patterns as helpful, the understanding of depression and the remedies for the condition differed. Clients in CBT focused on previous negative experiences as the cause of present maintenance patterns and mentioned changing negative thought patterns as helpful. Clients in MCT stated that the realization that rumination was their key problem and that they could choose not to engage in negative thinking had been crucial. Furthermore, clients in CBT tended to describe increased personal strength and self-confidence as the main gain from therapy, whereas MCT clients mentioned improved ways of coping with thoughts or problems. The importance attributed by the clients to technical factors differs from previous qualitative studies conducted across various therapeutic approaches, which have typically concluded that common therapeutic factors are more important than specific factors. It does, however, correspond with conclusions from other qualitative studies focusing explicitly on CBT.

Client attachment and therapist feelings in the treatment of bulimia nervosa.

The relationship between client attachment and therapist postsession feelings was investigated in a randomized clinical trial of psychoanalytic psychotherapy (PPT) and cognitive behavior therapy (CBT) for bulimia nervosa. Therapists completed feeling word checklists after each session, and client attachment was assessed with the Adult Attachment Interview. A factor analysis identified 3 feeling factors, Happy/Enthusiastic, Overwhelmed/Moved, and Indifferent/Bored. Positive feelings were predominant, but PPT therapists reported more negative and fewer positive feelings than CBT therapists did. Client improvement in terms of frequency of bulimic episodes and general psychiatric distress was related to an increase in Happy/Enthusiastic feelings. Multilevel analyses indicated significant interactions between therapy type and client dismissing versus preoccupied attachment in predicting therapist negative emotional reactions. PPT therapist felt more Indifferent/Bored the more dismissing clients were, whereas CBT therapists felt more Overwhelmed/Moved the more preoccupied clients were.