Identifying inconsistencies in exotic pet regulations that perpetuate trade in risky species.

Regulatory inconsistencies at different jurisdictional levels have contributed to the global expansion of the exotic pet trade, with resultant increases in the spread of invasive species and pathogens. Researchers have enumerated multiple limitations and environmental risks posed by international and national rules that govern the exotic pet trade, yet little attention has focused on the regulation of the exotic pet trade within national borders. We reviewed state-level regulations that apply to the trade of vertebrate animal taxa in the United States. Definitions and classifications for regulating different vertebrate taxa varied greatly across states, and the terms pet and companion animal were poorly defined and inconsistent across states. States implemented regulations that permit trade in exotic vertebrate pets that are banned from import into the United States owing to public health and conservation concerns. Once species have been imported into the United States, inconsistent internal regulations facilitate the movement of animals that pose substantial invasion and disease risks. Violations of state laws were typically listed as misdemeanors, and the median fine for violating state wildlife trade laws was $1000. Inconsistent and incomplete regulation of exotic vertebrate pets across state borders, in conjunction with limited penalties for violating regulations, has facilitated continued possession of exotic pets in states where these animals are banned. Based on our review of regulatory weaknesses, we conclude that a transition to a federally enforced list of vertebrate species that may be traded as pets is needed, with all other vertebrate species banned from the exotic pet trade unless their potential invasion and disease risks have been assessed and demonstrated to be low or nonexistent.

Identificación de las inconsistencias en las regulaciones de las mascotas exóticas que perpetúan el mercado de especies riesgosas Resumen Las inconsistencias regulatorias en diferentes niveles regulatorios han contribuido a la expansión mundial del mercado de mascotas exóticas, con un incremento resultante en la dispersión de especies invasoras y patógenos. Los investigadores han enumerado varias limitaciones y riesgos ambientales que representan las normas nacionales e internacionales que dictan el mercado de mascotas exóticas, pero se ha puesto poca atención en la regulación de este mercado dentro de las fronteras nacionales. Revisamos las regulaciones a nivel estatal que aplican al mercado de taxones de vertebrados en los Estados Unidos (EU). Entre los estados, las definiciones y clasificaciones para regular el mercado de los diferentes taxones de vertebrados variaron mucho y los términos mascota y animal de compañía contaban con definiciones deficientes e incoherentes. Los estados implementaron regulaciones que permiten el mercado de vertebrados como mascotas exóticas cuya importación está prohibida para los EU debido a cuestiones de salud pública y conservación. Una vez que las especies han sido importadas a los EU, las regulaciones internas incoherentes facilitan el traslado de animales que representan un riesgo importante de invasión y de enfermedad. Con frecuencia, las violaciones a las leyes estatales se denominaban delitos menores y la multa promedio por violar las leyes estatales de comercio de fauna era de $1,000. La regulación incompleta e incoherente del mercado de mascotas exóticas entre los límites estatales, en conjunto con las penalizaciones limitadas por violar las regulaciones, ha facilitado la posesión continua de mascotas exóticas en estados en donde estos animales están prohibidos. Con base en nuestra revisión de las debilidades regulatorias, concluimos que se necesita transitar a una lista con aplicación federal de especies de vertebrados que pueden ser comercializadas como mascotas, con todas las demás especies de vertebrados vetadas del mercado a menos de que se haya evaluado su riesgo potencial de invasión y de enfermedad y se haya demostrado que es bajo o inexistente.

Investigating How to Align Schools' Marketing Environments With Federal Standards for Competitive Foods.

BACKGROUND: Limiting food and beverage marketing to children is a promising approach to influence children's nutrition behavior. School-based marketing influences nutrition behavior and studies have consistently found marketing for nonnutritious foods and beverages in schools. No studies have examined the resources necessary to align school marketing environments with federal school nutrition standards. The purpose of this study was to determine how to improve school marketing environments so that they align with new federal competitive food nutrition standards. METHODS: We assessed food marketing environments in 3 Portland, Maine schools using the Food and Beverage Marketing Survey (FBMS) and provided technical assistance to bring their marketing environments into conformity with the federal competitive food regulations, tracking resources and strategies for marketing removal. RESULTS: Noncompliant marketing was significantly reduced pre- to postintervention. Intervention strategies were facilitated by the School Health Coordinator and school-based wellness teams. CONCLUSIONS: Low monetary resources were required to remove marketing not compliant with federal nutrition standards for foods sold in schools. Several key challenges remain to sustain efforts. This study provides timely information for policymakers to support crafting policies that address the realities of school nutrition environments and universal enforcement challenges.

Implicit Prosody and Cue-based Retrieval: L1 and L2 Agreement and Comprehension during Reading.

This project focuses on structural and prosodic effects during reading, examining their influence on agreement processing and comprehension in native English (L1) and Spanish-English bilingual (L2) speakers. We consolidate research from several distinct areas of inquiry-cognitive processing, reading fluency, and L1/L2 processing-in order to support the integration of prosody with a cue-based retrieval mechanism for subject-verb agreement. To explore this proposal, the experimental design manipulated text presentation to influence implicit prosody, using sentences designed to induce subject-verb agreement attraction errors. Materials included simple and complex relative clauses with head nouns and verbs that were either matched or mismatched for number. Participants read items in one of three presentation formats (whole sentence, word-by-word, or phrase-by-phrase), rated each item for grammaticality, and responded to a comprehension probe. Results indicated that while overall, message comprehension was prioritized over subject-verb agreement computation, presentation format differentially affected both measures in the L1 and L2 groups. For the L1 participants, facilitating the projection of phrasal prosody onto text (phrase-by-phrase presentation) enhanced performance in agreement processing, while disrupting prosodic projection via word-by-word presentation decreased comprehension accuracy. For the L2 participants, however, phrase-by-phrase presentation was not significantly beneficial for agreement processing, and additionally resulted in lower comprehension accuracy. These differences point to a significant role of prosodic phrasing during agreement processing in both L1 and L2 speakers, additionally suggesting that it may contribute to a cue-based retrieval agreement model, either acting as a cue directly, or otherwise scaffolding the retrieval process. The discussion and results presented provide support both for a cue-based retrieval mechanism in agreement, and the function of prosody within such a mechanism, adding further insight into the interaction of retrieval processes, cognitive task load, and the role of implicit prosody.

Motivational Text Message Intervention for Eating Disorders: A Single-Case Alternating Treatment Design Using Ecological Momentary Assessment.

OBJECTIVE: This study tested a motivational text message treatment adjunct for individuals with eating disorders (EDs) who exhibited high dietary restraint/restriction. METHOD: A replicated single-case alternating treatment design was used to examine (a) the feasibility of combining a brief motivational interview with subsequent text messages and (b) the influence of the text messages on eating behaviors and motivation to change in individuals with EDs (N=12). The protocol was 8weeks and the text messages were adjunctive to cognitive-behavioral therapy. RESULTS: The intervention was well accepted (mean rating=7/10) and feasible within the context of monetary compensation (mean daily monitoring compliance =91%). Text messages did not impact behavioral outcomes: dietary restraint and kilocalorie intake. They had mixed effects on motivation to change dietary restraint, measured by the Readiness and Motivation Questionnaire (RMQ). When receiving text messages, RMQ precontemplation scores (desire to restrict) significantly increased, indicating decreased motivation; however, action scores (effort toward reducing dietary restraint) significantly increased, indicating increased motivation. These effects were moderated by weight status. Underweight individuals (n=4; body mass index [BMI]<19.0) reported increased ambivalence-that is, an increased desire to restrict and increased action toward reducing restriction-in response to the text messages. Normal weight participants (n=8; BMI>19.0) reported only increased action toward reducing restriction in response to the text messages. DISCUSSION: These data demonstrate text messages are a potentially feasible and acceptable treatment adjunct and may be effective at increasing motivation to change for normal weight individuals, while their influence on underweight patients is more complex. These findings provide a foundation for future research in technology-based motivational interventions for EDs and offer preliminary evidence for using these methods among normal weight individuals.

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.

Multifaceted approach to reducing occurrence of severe hypoglycemia in a large healthcare system.

PURPOSE: Substantial reductions in inpatient episodes of severe hypoglycemia achieved by a large healthcare system through enhanced use of technology and sustained quality-improvement initiatives are described. SUMMARY: After internal data collection and analysis revealed that severe hypoglycemia accounted for 75% of all systematically monitored adverse drug events in its hospital network, St. Louis-based BJC HealthCare designed and executed a multifaceted approach to reducing hypoglycemia events. Initiated by a pharmacist-led task force, the project entailed (1) automated event detection and creation of dashboards for comparing hypoglycemia rates among at-risk patients at 11 BJC facilities, (2) implementation of evidence-based and internal best practices in use at BJC's top-performing hospitals, (3) development of an online "Hypoglycemic Event Analysis Tool" (HEAT) to support event investigation and collection of data on causative factors, and (4) the assembly of targeted interventions at a "Hypoglycemia Facility Strategy Tracking" (H-FaST) intranet site. As a result of the launch of the HEAT and H-FaST tools and associated provider education activities, the systemwide rate of hypoglycemia events in the specified at-risk patient population declined from 6.45 per 1000 patient-days during a preimplementation baseline period (July-December 2009) to 1.32 per 1000 patient-days during a designated postimplementation period (January-June 2014), an 80% overall reduction in hypoglycemia (p < 0.01); reductions in severe hypoglycemia events ranging from 70% to 100% were observed at all 11 hospitals. CONCLUSION: A multifaceted, evidence-based, data-driven approach enabled a large healthcare system to markedly reduce the frequency of severe hypoglycemia events.

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

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.

A randomized, controlled trial of the efficacy of an interoceptive exposure-based CBT for treatment-refractory outpatients with opioid dependence.

Many patients diagnosed with opioid dependence do not adequately respond to pharmacologic, psychosocial, or combination treatment, highlighting the importance of novel treatment strategies for this population. The current study examined the efficacy of a novel behavioral treatment focusing on internal cues for drug use (Cognitive Behavioral Therapy for Interoceptive Cues; CBT-IC) relative to an active comparison condition, Individual Drug Counseling (IDC), when added to methadone maintenance treatment (MMT) among those who had not responded to MMT. Participants (N=78) were randomly assigned to receive 15 sessions of CBT-IC or IDC as an adjunct to ongoing MMT and counseling. Oral toxicology screens were the primary outcome. Results indicated no treatment differences between CBT-IC and IDC and a small, significant reduction of self-reported drug use, but no change on toxicology screens. Tests of potential moderators, including sex, anxiety sensitivity, and coping motives for drug use, did not yield significant interactions. Among opioid-dependent outpatients who have not responded to MMT and counseling, the addition of IDC or CBT-IC did not result in additive outcome benefits. These results highlight the need for more potent treatment strategies for opioid dependence, particularly among those who do not fully respond to frontline treatment.

Prevention of inpatient hypoglycemia with a real-time informatics alert.

BACKGROUND: Severe hypoglycemia (SH), defined as a blood glucose (BG) <40 mg/dL, is associated with an increased risk of adverse clinical outcomes in inpatients. OBJECTIVE: To determine whether a predictive informatics hypoglycemia risk-alert supported by trained nurse responders would reduce the incidence of SH in our hospital. DESIGN: A 5-month prospective cohort intervention study. SETTING: Acute care medical floors in a tertiary care academic hospital in St. Louis, Missouri. PATIENTS: From 655 inpatients on designated medical floors with a BG of <90 mg/dL, 390 were identified as high risk for hypoglycemia by the alert system. MEASUREMENTS: The primary outcome was the incidence of SH occurring in high-risk intervention versus high-risk control patients. Secondary outcomes included: number of episodes of SH in all study patients, incidence of BG < 60 mg/dL and severe hyperglycemia with a BG >299 mg/dL, length of stay, transfer to a higher level of care, the frequency that high-risk patient's orders were changed in response to the alert-intervention process, and mortality. RESULTS: The alert process, when augmented by nurse-physician collaboration, resulted in a significant decrease by 68% in the rate of SH in alerted high-risk patients versus nonalerted high-risk patients (3.1% vs 9.7%, P = 0.012). Rates of hyperglycemia were similar on intervention and control floors at 28% each. There was no difference in mortality, length of stay, or patients requiring transfer to a higher level of care. CONCLUSION: A real-time predictive informatics-generated alert, when supported by trained nurse responders, significantly reduced inpatient SH.

Readability and comprehension of self-report binge eating measures.

UNLABELLED: The validity of self-report binge eating instruments among individuals with limited literacy is uncertain. This study aims to evaluate reading grade level and multiple domains of comprehension of 13 commonly used self-report assessments of binge eating for use in low-literacy populations. We evaluated self-report binge eating measures with respect to reading grade levels, measure length, formatting and linguistic problems. RESULTS: All measures were written at a reading grade level higher than is recommended for patient materials (above the 5th to 6th grade level), and contained several challenging elements related to comprehension. Correlational analyses suggested that readability and comprehension elements were distinct contributors to measure difficulty. Individuals with binge eating who have low levels of educational attainment or limited literacy are often underrepresented in measure validation studies. Validity of measures and accurate assessment of symptoms depend on an individual's ability to read and comprehend instructions and items, and these may be compromised in populations with lower levels of literacy.

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.

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.

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.

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.

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.

Bed enclosures: suitable safety net?

Healthcare personnel with the authority to set patient safety initiatives should consider this technology as a strategy to enhance clinical outcomes.

Evidence Equals Excellence: The application of an evidence-based practice model in an academic medical center.

An evidence-based practice (EBP) program that is designed to develop mentors in both clinical and academic settings has the potential for transforming a health care organization. This article describes an innovative program, Evidence Equals Excellence, which consists of two components: a clinical practice component for health care clinicians and an academic program for baccalaureate and graduate nursing students. The development of EBP mentors creates a core group of clinicians who can assist fellow staff members apply evidence at the bedside. An academic program prepares new graduates to partner easily with clinical mentors to support and initiate successful practice changes.

Personality factors associated with methadone maintenance dose.

OBJECTIVES: Methadone is the most frequently prescribed medication for the treatment of opioid dependence in the U.S., and questions relating to appropriate dosing of methadone remain an important issue. Given accumulating evidence suggesting an elevated prevalence of personality pathology in opioid dependent populations, as well as evidence of an association between Cluster B characteristics and substance use severity, we hypothesized that patients with such pathology would have elevated methadone dose prescriptions. METHODS: Participants were 54 opioid dependent individuals recruited from a methadone maintenance clinic. RESULTS: RESULTS indicated that participants with symptoms consistent with Cluster B pathology had a significantly higher mean prescribed methadone dose relative to participants without Cluster B pathology. CONCLUSION: The presence of personality traits appears to influence methadone maintenance. Implications of this finding are discussed.

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.