Susanne Lunn

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.

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.

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

Psychosocial aspects of human immunodeficiency virus (HIV) infection in a pre-HAART sample.

The psychosocial consequences of HLV-infection were studied using a semi-structured interview and the psychiatric questionnaire SCL-90-R, in 3 matched groups of homosexual men: 20 patients with Aids, 20 asymptomatic HIV-infected and 20 non-infected controls. The data was collected before the HAART (Highly Active Anti-retroviral Therapy) era. The results showed that the infected subjects more often concealed their homosexuality, engaged in more risky sexual behavior and were less inclined to regard AIDS as a serious problem. The infected subjects also revealed more psychopathology on 5 of the 9 indexes on the SCL-90. Across all 3 groups, contact ability was correlated to being open about homosexuality and to psychological well-being. These results indicate that HIV has considerable impact on psychological well-being among the infected and point to the need for health-care workers to be especially attentive to those HIV-infected who have difficulty in talking to others about their situation.

Individual psychotherapeutic treatment of Anorexia Nervosa

Lunn S. Individual psychotherapeutic treatment of Anorexia Nervosa. Acta Psychiatr Scand Suppl. 361, Vol. 82. 1990: 23–28.

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.

Eating Disorders and Mentalization: High Reflective Functioning in Patients with Bulimia Nervosa.

The theory of mentalization has recently been applied in the area of eating disorders (Skårderud 2012). This article reports a qualitative study based on interviews with five women suffering from bulimia nervosa. All five scored high on the Reflective Functioning Scale, indicating a highly developed ability to mentalize. The present qualitative study, which focuses on the women’s capacity to relate to and regulate affects, supports the finding that they are relatively skilled at reflecting on their own and others’ thoughts and emotions. However, this highly developed capacity for mentalization is apparently not helping them regulate their emotions. This suggests that the capacity to mentalize may not be as closely related to the capacity to regulate affects as Fonagy et al. (2002) have proposed. Indeed, the concept of mentalization may be overinclusive and in need of stricter definition. Thus, it might be envisaged that while the ability to mentalize is closely related to the ability to put feelings into words (the opposite of alexithymia), an ability to mentalize may not necessarily entail a capacity to regulate affects. Finally, the study illustrates that far from all eating-disordered patients have problems mentalizing.

Mentalizing in the presence of another: Measuring reflective functioning and attachment in the therapy process

Abstract Objective: In this paper, we test the reliability and validity of two novel ways of assessing mentalizing in the therapy context: the Reflective Functioning scale (RF) applied to code psychotherapy transcripts (In-session RF), and the Exploring scale of the Patient Attachment Coding System (PACS), which measures in-session autonomy and is linked with secure attachment in psychotherapy. Method: Before treatment, 160 patients in different types of psychotherapy and from three different countries were administered the Adult Attachment Interview (AAI), which was rated with the RF scale. One early psychotherapy session for each patient was independently rated with the In-session RF scale and with the PACS Exploring scale. Results: Both scales were found to be reliable and to have concurrent validity with the RF scale rated on the AAI, with the PACS Exploring scale found to be a better predictor of RF on the AAI. Conclusions: These results suggest that the PACS Exploring scale might be a practical method for assessing RF in psychotherapy research and a way for researchers and clinicians to track patients’ RF on an ongoing basis. These results also provide information regarding the ways in which differences in RF manifest during psychotherapy sessions. Clinical or methodological significance of this article Researchers and clinicians can assess patients’ mentalizing based on any single psychotherapy transcript, in many therapeutic modalities The Exploring scale of the Patient Attachment Coding System can yield a reliable measure of reflective functioning based on any single psychotherapy transcript, in many therapeutic modalities Client differences in mentalizing manifest in part independently of the therapist’s contributions