The relative efficacy of fluoxetine and manual-based self-help in the treatment of outpatients with bulimia nervosa.

A randomized, placebo-controlled study was conducted examining the singular and combined effects of fluoxetine and a self-help manual on suppressing bulimic behaviors in women with bulimia nervosa. A total of 91 adult women with bulimia nervosa were randomly assigned to one of four conditions: placebo only, fluoxetine only, placebo and a self-help manual, or fluoxetine and a self-help manual. Subjects were treated for 16 weeks. Primary outcome measures included self-reports of bulimic behaviors. Fluoxetine and a self-help manual were found to be effective in reducing the frequency of vomiting episodes and in improving the response rates for vomiting and binge-eating episodes. Furthermore, both factors were shown to be acting additively on the primary and secondary efficacy measures in this study. Results are discussed in relation to previous research and the implications for treatment of bulimia nervosa.

Commitment to treatment goals in prediction of group cognitive-behavioral therapy treatment outcome for women with bulimia nervosa.

The purpose of this study was to investigate potential client variables that predict favorable response to group cognitive-behavioral therapy in a sample of women (N = 143) seeking treatment for bulimia nervosa. Similar to findings of previous studies, bulimic symptom remission at end of treatment was predicted by baseline degree of bulimic symptom severity but not by depressive symptomatology or perfectionism. After these variables were controlled for, both pretreatment ratings of desire to discontinue bulimic behaviors and expected success significantly added to prediction of treatment outcome. The primary variable found to predict longer term outcome was symptom remission at the end of treatment and at the 1-month follow-up.

Predictors of treatment outcome for binge eating disorder.

OBJECTIVE: The purpose of this study was to identify predictors of short-term treatment outcome for individuals with binge eating disorder (BED). METHOD: Fifty women who met DSM-IV criteria for BED were enrolled in a manual-based group cognitive-behavioral therapy that consisted of fourteen 1-hr sessions over an 8-week period. Baseline measures included the frequency of self-reported binge eating from the Eating Behaviors-IV (EB-IV), severity of binge eating and dietary restraint using the Binge Eating Scale (BES) and Three-Factor Eating Questionnaire (TFEQ), depressive symptoms as assessed by the Beck Depression Inventory (BDI) and the Hamilton Depression Rating Scale (HDRS), and self-esteem as measured by the Rosenberg Self-Esteem Questionnaire (RSEQ). RESULTS: Logistic regression analyses indicated that the baseline frequency of self-reported episodes of binge eating that were objectively large predicted the likelihood of such episodes at the end of treatment. No variables predicted the likelihood of binge eating episodes that were objectively and subjectively large at the conclusion of treatment. DISCUSSION: This study indicates that the frequency of binge eating episodes at baseline is predictive of outcome status at the end of treatment, suggesting that meaningful prognostic factors in BED are identifiable.

Utilization of empirically supported psychotherapy treatments for individuals with eating disorders: A survey of psychologists.

OBJECTIVE: The purpose of this study was to assess the primary methods used by psychotherapists in treating individuals with eating disorders and to determine the extent to which certain empirically supported psychotherapies (i.e., cognitive behavioral therapy [CBT] and interpersonal psychotherapy [IPT]) are used in clinical settings. METHOD: Surveys developed for this study were sent to 500 psychologists randomly selected from a list of all licensed doctoral-level psychologists in an upper midwestern state. RESULTS: Despite the findings that CBT techniques were reported to be frequently used, most respondents identified something other than CBT or IPT as their primary theoretical approach. In addition, the majority of respondents indicated not having received training in the use of manual-based, empirically supported treatment approaches for working with individuals with eating disorders, although most reported a desire to obtain such training. CONCLUSIONS: Although commonly referred to as the "treatments of choice" in research literature, manual-based, empirically supported approaches to working with individuals with eating disorders has not received adequate dissemination.

Hedonics of binge eating in women with bulimia nervosa and binge eating disorder.

OBJECTIVE: Potential differences in the hedonics of binge eating between female subjects with bulimia nervosa (BN) and female subjects with binge eating disorder (BED) were examined. METHOD: Women seeking treatment for BN (N = 29) and BED (N = 49) completed the Eating Hedonics Questionnaire. RESULTS: Subjects in both groups reported similar precipitants and levels of distress associated with binge eating. Of interest, BED subjects were more likely to report that they enjoyed the food, the taste of the food, the smell and the texture of the food while binge eating. In addition, the BED group reported more relaxation and less physical discomfort and anxiety as a consequence of binge eating compared to the BN group. DISCUSSION: There are interesting and potentially important differences between individuals with BN and BED in the cognitions and behaviors associated with binge eating.

Prior treatment received by patients with bulimia nervosa.

OBJECTIVE: This study examined the frequency with which subjects with bulimia nervosa (BN) presenting for treatment or follow-up studies had previously received either adequate pharmacologic treatment or cognitive-behavioral therapy (CBT). METHOD: Semistructured telephone screening of individuals who called in response to advertisements about research studies was used to establish diagnoses and to clarify prior pharmacologic and psychotherapeutic treatments for BN. RESULTS: Of 581 women responding, 353 (60.8%) had probable BN. Overall, 61.4% of these subjects had received psychotherapy (96.7%) but rarely CBT (6.9%). Over one half (63.7%) had received pharmacologic treatment, most commonly with fluoxetine (72.5%). Of those having received any medication treatment, 46.2% were judged to have received at least one adequate trial. Overall, 35.0% of those previously treated had received at least one prior course of adequate pharmacotherapy or CBT for BN. CONCLUSION: Although efficacious treatments for BN have been established, they have not been received by most individuals presenting for further treatment.

Binge eating disorder with and without a history of purging symptoms.

OBJECTIVE: The purpose of this study was to evaluate whether a history of purging behaviors in individuals with binge eating disorder (BED) is associated with increased comorbid psychopathology, dietary restraint, severity of eating pathology, and attitudinal disturbance in self-esteem and body image. METHOD: Sixty-three women meeting DSM-IV criteria for BED who were participating in a psychotherapy treatment study were subclassified according to whether they reported a history of purging behavior using self-induced vomiting or laxatives (HP; N = 24) or no such history (NHP; N = 39). The two groups were compared on the following variables: DSM-IV Axis I Lifetime diagnoses, Hamilton Depression Rating Scale, Body Shape Questionnaire, Three Factor Eating Questionnaire, Binge Eating Scale, and the Rosenberg Self-Esteem Scale. RESULTS: Data analyses revealed no significant differences between the two BED subgroups on any of the measures. DISCUSSION: These findings indicate that a history of purging behavior in BED is not associated with increased rates of comorbid psychopathology, severity of eating problems, dietary restraint, or attitudinal disturbance. Purging history does not appear to be a clinically meaningful variable with which to subclassify individuals with BED.

Group cognitive-behavioral treatment of binge eating disorder: a comparison of therapist-led versus self-help formats.

OBJECTIVE: The purpose of this study was to compare three group cognitive-behavioral therapy (CBT) treatment models and a waiting list control condition (WL). METHOD: Sixty-one women who met DSM-IV criteria for binge eating disorder (BED) received treatment with the same cognitive-behavioral treatment manual in 14 one-hour sessions over an 8-week period. All sessions consisted of psychoeducation for the first 30 min and group discussion for the second half hour. In the therapist-led condition (TL; n = 16), a doctoral therapist led both the psychoeducational component and group discussion. In the partial self-help condition (PSH; n = 19), participants viewed a 30-min psychoeducational videotape, followed by participation in a therapist-led discussion. In the structured self-help condition (SH; n = 15), subjects viewed the 30-min psychoeducational videotape and subsequently led their own 30-min discussion. Eleven subjects were assigned to a wait-list control condition (WL). The primary outcome variables were frequency and duration of self-reported binge eating episodes. RESULTS: A mixed effects linear modeling (random regression) analysis indicated that subjects in all three active treatment conditions showed a decrease in binge eating symptoms over time. No group differences in rates of change over time were observed, although analysis of covariance indicated that all three treatment conditions showed significantly greater improvement in binge eating compared to the WL condition. DISCUSSION: The findings from this preliminary study suggest that CBT for BED can be delivered effectively in a structured group self-help format.

Onset of binge eating and dieting in overweight women: implications for etiology, associated features and treatment.

This study investigated differences between overweight binge eating women who reported the onset of binge eating prior to or following the onset of dieting (binged first [BF], or dieted first [DF]). Of overweight binge eating subjects enrolled in a treatment study, 38.7% indicated binge eating first, and 48.1% dieting first. The mean age of onset of binge eating differed significantly between the two groups (11.8 years vs. 25.7 years). More of the BF group (82.5%) satisfied proposed binge eating disorder (BED) criteria than did the DF group (52.0%), although short of significantly. The results suggest that: (a) the leading hypothesis concerning dieting as a cause of binge eating does not apply to a substantial number of individuals who binge eat; (b) there may be an early pattern and a late pattern in the development of binge eating among overweight individuals; and (c) the early or binge first pattern may be more likely to result in BED.

Agreement between survey and interview measures of weight control practices in adolescents.

OBJECTIVE: The present study examined agreement between survey and interview measures of weight control practices in a nonclinical sample of adolescents. METHOD: Surveys were administered in three school health classes. Clinical interviews were conducted in a student subsample (N = 43). RESULTS: Survey-based prevalences for eating behaviors in the past month were: trying to lose weight, 44%; binge eating, 41%; vomiting, 4.7%; laxative use, 0%; and fasting, 14%. Interview-based prevalences were 30%, 11.6%, 0%, 0% and 0%, respectively. Sensitivity was high for all behaviors assessed. However, positive predictive values were low. DISCUSSION: Surveys may be useful as preliminary screening tools for prevention programs, but may yield inflated estimates of unhealthy weight control practices in nonclinical adolescent populations. Research is needed to examine whether adolescents overreport weight control practices on surveys or whether they are less willing to disclose such practices in a private interview.

Differences in body image and depression among obese women with and without binge eating disorder.

Obese individuals with binge eating disorder (BED) differ from obese non-binge eating (NBE) individuals in a number of clinically relevant ways. This study examined attitudinal responses to various measures of body image in women seeking obesity treatment, by comparing NBE participants (n = 80) to those with BED (n = 48). It was hypothesized that women with BED would demonstrate greater attitudinal disturbance of body image compared to NBE individuals. It was further hypothesized that significant differences between groups would remain after statistically controlling for degree of depression. Consistent with the primary hypothesis, BED participants reported significantly increased attitudinal disturbance in body dissatisfaction and size perception compared to NBE participants. Although shared variance was observed between measures of depression and body image on some items, several aspects of increased body image disturbance remained after statistically controlling for depression. Treatment implications and recommendations for future research are discussed.

Clinical characteristics associated with binge eating in obese females: a descriptive study.

OBJECTIVE: To investigate differences in clinical characteristics of obese female participants based on presence and degree of binge eating behavior. DESIGN: Descriptive comparison of various clinical characteristics of obese women diagnosed with binge eating disorder (BED) assessed by semi-structured interview to those for similar weight participants reporting subthreshold BED and those who do not binge eat. SUBJECTS. 185 healthy women seeking obesity treatment (age: 20-55 y, BMI: 28.4-51.5 kg/m2). MEASUREMENTS: Baseline self-report questionnaires included the Weight and Eating Patterns (QEWP), Eating Disorders Questionnaire (EDQ), Beck Depression Inventory (BDI); clinical interviews included the Hamilton Depression Rating Scale (HDRS) and Structured Clinical Interview for DSM-III-R-Patient Version (SCID-P). RESULTS: In comparison to other obese women, obese participants meeting full BED criteria report an earlier onset of binge eating, increased food cravings, increased diet pill use, decreased fasting, greater fear of gaining weight, increased body perception disturbance, and increased depressive symptomatology and general psychopathology. CONCLUSIONS: Obese women with BED report greater eating-related and general psychopathology than non-binge eating disordered women of comparable weight. Although endorsement of food cravings unrelated to hunger was associated with binge eating diagnosis, the role of dietary restriction among this population remains unclear and requires further investigation. Theoretical and clinical implications that binge eating episodes for individuals with BED may be related to negative affect states and increased dietary disinhibition are discussed.

Comorbidity and binge eating disorder.

Research in obesity has generally not demonstrated an association with increased rates of psychopathology compared to normal-weight comparison groups. However, studies of obese individuals from clinical samples with recurrent binge eating or binge eating disorder (BED) have generally revealed increased rates of psychiatric comorbidity compared to non-binge eating obese individuals. Also, several studies have reported finding an association between BED and elevated rates of psychological distress, social problems, and impaired self-esteem. This report provides an overview of research findings regarding psychiatric comorbidity among individuals with BED, and it presents suggestion for future research.

An age-matched comparison of subjects with binge eating disorder and bulimia nervosa.

The purpose of this study was to compare data from a group of obese subjects with binge eating disorder (BED) with data from a group of normal weight bulimia nervosa (BN) subjects. Subjects were compared using the Eating Disorder Questionnaire (EDQ), the Eating Disorder Inventory (EDI), the Personality Disorders Questionnaire for DSM-III-R (PDQ-R), the Hamilton Anxiety and Depression Rating Scales, and the Beck Depression Inventory. A group of 35 age-matched subjects were selected retrospectively from treatment study subjects. The EDQ findings indicated that members of the BN group desired a lower body mass index, were more afraid of becoming fat, and more uncomfortable with their binge eating behavior than the BED group members. The BED subjects had a younger age of onset of binge eating behavior (14.3) than the BN subjects (19.8), even though both groups started dieting at a similar age (BED = 15.0, BN = 16.2). The EDI results showed BN subjects had more eating and weight-related pathology, with significantly higher scores on five of the eight subscales. On the PDQ-R more BN subjects endorsed Axis II impairment (BN = 69%, BED = 40%). While demonstrating greater eating pathology in the BN group, this study also found significant pathology and distress in BED subjects.

Onset of binge eating, dieting, obesity, and mood disorders among subjects seeking treatment for binge eating disorder.

Binge eating disorder (BED) identified in adulthood is often clinically associated with obesity and a lifetime history of affective disorders. Several authors have suggested that dieting may predispose individuals to binge eating which then may lead to obesity. However, few BED studies have examined the chronology of the onset of binge eating, dieting, obesity, and mood disorders. This study evaluated retrospective reports from 30 women participating in a BED treatment study. Although the majority of subjects in this adult sample were obese, initiation of binge eating behavior usually occurred during adolescence at a time when most subjects reported being of normal weight. Obesity developed several years after the age of onset of meeting BED criteria. Onset of binge eating usually predated that of dieting or major depressive disorder in the majority of subjects. The results support the importance of early intervention for binge eating.

Diagnosing binge eating disorder: level of agreement between self-report and expert-rating.

We assessed the correlation between a self-report questionnaire and an expert-rating including an initial interview and a longitudinal evaluation on the diagnosis of binge eating disorder (BED) in a sample of 100 obese women participating in a treatment program for weight reduction. The level of diagnostic agreement between patient-rating and expert-rating with regard to the presence or absence of BED was modest, with a kappa value of .57. According to Shrout, Spitzer, and Fleiss (Archives of General Psychiatry, 44, 172-177, 1987) this represents fair to good agreement beyond chance. The self-report instrument did not produce higher estimates of the frequency of BED in this selected sample of treatment seekers than the expert-rating, as observed in studies on the epidemiology of bulimia nervosa in community samples. The questionnaire identified 40 cases of BED, the expert-rating 43 cases. The results indicate that the disagreement between self-report and interview was mainly due to discordances in three of the diagnostic criteria of BED--namely loss of control, marked distress regarding binge eating, and the frequency requirement of two binge eating episodes per week for a 6-month period. Inconsistencies between subjects and clinicians with regard to the definition of an overeating episode and with regard to the behavioral indicators of loss of control did not lead to differences between self-report and observer-rating in the final diagnosis of BED.