Tricia Cook Myers

A randomized trial comparing the efficacy of cognitive–behavioral therapy for bulimia nervosa delivered via telemedicine versus face-to-face

OBJECTIVE A major problem in the delivery of mental health services is the lack of availability of empirically supported treatment, particularly in rural areas. To date no studies have evaluated the administration of an empirically supported manual-based psychotherapy for a psychiatric condition via telemedicine. The aim of this study was to compare the relative efficacy and acceptability of a manual-based cognitive-behavioral therapy (CBT) for bulimia nervosa (BN) delivered in person to a comparable therapy delivered via telemedicine. METHOD One hundred twenty-eight adults meeting DSM-IV criteria for BN or eating disorder-not otherwise specified with binge eating or purging at least once per week were recruited through referrals from clinicians and media advertisements in the targeted geographical areas. Participants were randomly assigned to receive 20 sessions of manual-based, CBT for BN over 16 weeks delivered either face-to-face (FTF-CBT) or via telemedicine (TV-CBT) by trained therapists. The primary outcome measures were binge eating and purging frequency as assessed by interview at the end of treatment, and again at 3- and 12-month follow-ups. Secondary outcome measures included other bulimic symptoms and changes in mood. RESULTS Retention in treatment was comparable for TV-CBT and FTF-CBT. Abstinence rates at end-of-treatment were generally slightly higher for FTF-CBT compared with TV-CBT, but differences were not statistically significant. FTF-CBT patients also experienced significantly greater reductions in eating disordered cognitions and interview-assessed depression. However, the differences overall were few in number and of marginal clinical significance. CONCLUSIONS CBT for BN delivered via telemedicine was both acceptable to participants and roughly equivalent in outcome to therapy delivered in person.

Migraine and stress : A daily examination of temporal relationships in women migraineurs

This study examined daily temporal relationships between stress, cognitive appraisal, coping, and migraine in a group of young women migraineurs sampled from a general population. Participants (N=20) meeting International Headache Society 1 criteria for migraine with or migraine without aura provided headache activity, perceived stress, cognitive appraisal, and coping strategy data across 2 months of data collection. A time‐series analytic approach was used to cross‐correlate daily stress, appraisal, and coping data with daily headache data controlling for factors that can inflate correlations in data collected across time. Analyses revealed that between 50% and 70% of subjects showed significant, substantial, and meaningful temporal correlations between their daily stress and their daily migraine activity. Furthermore, these data support the hypothesis that stress and migraine are reciprocally related (ie, cyclically influencing each other across time). In addition, despite some measurement concerns, our data suggest that cognitive appraisal and coping are also related to migraine activity in a reciprocal fashion.

Health care utilization in patients with eating disorders.

OBJECTIVE To examine health care costs among patients with eating disorders (EDs) using the Blue Cross Blue Shield of North Dakota claims database system. METHOD Four groups of individuals enrolled between 1999 and 2005 were identified: (1) a group diagnosed with EDs at the beginning of the study period, in 2000 or 2001; (2) a group diagnosed with EDs later in the study period, in 2004 or 2005; (3) a comparison group with depression; and (4) a non-eating disordered comparison group. RESULTS Health care costs were high for patients diagnosed with an ED during the period when the diagnosis was made but remained elevated in the years following. Such costs were consistently higher than those for the non-eating disordered comparison group, but similar to the depression comparison group. DISCUSSION Health care costs remained elevated after a diagnosis of an ED for an extended period of time.

'Excessive exercise' and eating-disordered behaviour in young adult women: further evidence from a primary care sample.

OBJECTIVE AND METHODS In order to replicate findings from previous community-based research, conducted in Australia, in a different sample, we examined relationships between exercise behaviour, eating-disordered behaviour and quality of life among young adult women attending one of two primary care facilities in the upper Midwest region of the United States. RESULTS A high level of guilt when exercise is missed was associated with markedly elevated levels of eating disorder psychopathology and significantly reduced quality of life. The combination of exercising solely for weight and shape and intense guilt after missing exercise was associated with very high levels of eating disorder psychopathology, comparable to those of individuals seeking specialist treatment. CONCLUSIONS The findings provide further evidence that where young adult women experience intense guilt when exercise is missed, high levels of eating disorder psychopathology and poor quality of life can be expected, particularly when exercising solely for weight or shape reasons is also reported. Information to this effect should be included in both eating disorder and obesity prevention programmes.

COMBINING PHARMACOTHERAPY AND PSYCHOTHERAPY IN THE TREATMENT OF PATIENTS WITH EATING DISORDERS

The available treatment literature supports a role for medication management in the treatment of both AN and BN. The data on BN are clearer and suggest that antidepressant therapy--fluoxetine being the drug most widely studied--is superior to treatment with placebo but less effective than CBT alone, with one such study suggesting that the combination may provide optimal treatment. Specific recommendations as to when to add or not add antidepressants to CBT have been made, although the rules suggested here have yet to be empirically tested. Although the data on AN are much more limited, information available suggests a lack of efficacy for SSRIs in patients with AN at low weight and considerable use for SSRIs when used in combination with psychotherapy for patients with AN following weight recovery. Where do we go from here? Several pressing issues require careful study. First, in the case of patients with AN, can other agents, in particular the new atypical antipsychotics, be useful in treating patients when they are at low weight? In terms of relapse prevention, can the available findings indicating a role for antidepressants in relapse prevention be replicated, and, if so, can predictor variables that are associated with antidepressant response be identified? In the case of BN, clinicians need to know more about the best possible way to sequence interventions. It has been proposed to add medication to CBT early in treatment if the response to CBT alone is thought to be inadequate. However, other models should be considered, such as stepped-care models in which self-help manuals are used in conjunction with medications. The advantage of these interventions is they could be made more widely available than CBT, which requires a specialists care. Also, several other new agents, such as sibutramine, which is a drug with serotonin and norepinephrine reuptake inhibition effects, should be tested empirically in subjects with BN, given their pharmacologic profiles.

Pharmacotherapy and medical complications of eating disorders in children and adolescents.

In this article, the authors cover two areas of interest regarding eating disorders in childhood and adolescence: (1) the detection of eating disorders in medical practice and their medical complications and (2) the psychopharmacologic treatment of patients with eating disorders.

Self-Harm and Bulimia Nervosa: A Complex Connection

There is some evidence to suggest that eating disordered individuals are unusually likely to engage in self-harm behavior. However, the nature of the relationship among self-harm, bulimia nervosa, and related constructs such as borderline personality disorder and multi- impulsive bulimia nervosa remains unclear. This article briefly addresses the nature of this relationship and discusses two possible mechanisms for self-harm behavior in bulimia nervosa. Additionally, a protocol for managing such behavior in the treatment of eating disordered individuals is presented.

Stress, headache, and physiological disregulation : A time-series analysis of stress in the laboratory

This study examined the stress‐headache relationship from a disregulation framework by monitoring both physiological responses (eg, pulse, blood volume, skin resistance, and EMG) and self‐reported responses to a stressful event in tension and migraine headache sufferers, as well as in headache‐free controls. Responses were analyzed via time‐series analyses to determine whether self‐reports of stress were correlated with physiological measures of stress. It was hypothesized that tension and migraine headache sufferers would show fewer significant correlations than control participants between their self‐reports of stress and physiological activity. Data analyses supported this hypothesis for tension headache sufferers, but generally not for migraine headache sufferers. The most compelling support for the hypothesis in tension headache sufferers came from the cross‐correlations between self‐reported stress and pulse rate.

Evidence-based mental health interventions for traumatized youth: a statewide dissemination project.

Psychological trauma in childhood has been shown to increase a variety of psychological disturbances and psychiatric disorders. Although evidence-based treatments for children who have been traumatized exist, they are infrequently used by clinicians treating children. The present paper describes the creation of the Treatment Collaborative for Traumatized Youth (TCTY) which is a statewide partnership in North Dakota designed to disseminate efficacious treatments for traumatized children and monitor outcomes across a broad, rural, geographic expanse. The paper reviews the dissemination strategy developed by the TCTY, reports outcomes regarding both clinicians and child participants, and highlights problems identified in the project and solutions that were generated.

The Menstrual Cycle and Migraine: A Time-Series Analysis of 20 Women Migraineurs

This study examined the prevalence of menstrually related headache and the relationship between the menstrual cycle and stress in a group of young women migraineurs sampled from a general population. Participants (N=20) meeting International Headache Society1 criteria for migraine with or migraine without aura and not meeting criteria for menstrual migraine, provided daily headache activity, perceived stress, cognitive appraisal, and coping strategy data during two menstrual cycles. Multiple regression was used to analyze these data following a time‐series approach in which the phases of the menstrual cycle were used as predictors of variation in each participant’s headache, stress, appraisal, and coping data. Analyses revealed that fewer participants than expected showed significant relationships between their menstrual cycle and their headache activity (20%). However, for these women the amount of variation explained by the menstrual cycle was substantial. We suggest that, though some women’s migraines vary with their menstrual cycle, the number of women substantially affected may be much smaller than has been estimated in the literature. Relationships between the menstrual cycle and the stress process were also found; however, inconsistencies between this and a previous study in our laboratory 2 suggest that the nature of this relationship may vary across women migraineurs.