Cognitive therapy for bulimia nervosa: an AB

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lar belief area that is examined in patients is metacognitive belief about the effects of bingeing and vomiting on self-control in line with metacog- nitive therapy of ...
Clinical Psychology and Psychotherapy Clin. Psychol. Psychother. 14, 402–411 (2007) Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/cpp.548

Practitioner Cognitive Therapy for Report Bulimia Nervosa: An A-B Replication Series Myra Cooper,1* Gillian Todd,2 Hannah Turner3 and Adrian Wells4 1

University of Oxford, Oxford University of Cambridge 3 University of Southampton 4 University of Manchester 2

Objective: To investigate whether a new treatment for bulimia nervosa (BN) works, and to examine its effects on key cognitions and behaviours hypothesized to be important in the underlying model. Method: An A-B single-case series with follow-up was conducted. Treatment was based on a specific model of BN. It consisted of individualized formulation, enhancing motivation for change, cognitive restructuring of specific cognitions, behavioural experiments and targeting particular underlying assumptions and negative self-beliefs. Relapse prevention was also addressed. Results: All treatment completers did extremely well and no longer met Diagnostic and Statistical Manual of Mental Disorders, 4th edition revised (DSM-IV) criteria for bulimia nervosa. Two were entirely symptom-free at the end of treatment and at follow-up. The third experienced only very occasional binge eating and vomiting. Individual scores on self-report symptom measures and on all measures of cognition indicated a return to normative levels. Discussion: Treatment focusing on specific cognitive change is a promising intervention for BN. Further work might usefully evaluate this treatment in a larger study. Copyright © 2007 John Wiley & Sons, Ltd.

A number of treatment approaches have been advocated for bulimia nervosa (BN), including a range of treatments based on cognitive– behavioural therapy (CBT) principles (e.g., Agras, Walsh, Fairburn, Wilson, & Kraemer, 2000). These therapies typically include a range of behavioural (e.g., exposure and response prevention, monitoring of food intake, meal planning and problem solving), as well as cognitive strategies such as cognitive restructuring. In all cases, the initial focus of treatment is on behavioural change, for example, eliminating dieting through adopting a regular

* Correspondence to: Myra Cooper, Isis Education Centre, University of Oxford, Warneford Hospital, Oxford, OX3 7JX. E-mail: [email protected]

Copyright © 2007 John Wiley & Sons, Ltd.

pattern of eating that includes planning three meals a day plus snacks. Focus on challenging negative automatic thoughts related to core psychopathology normally occurs only after the initial behavioural tasks are well established. Finally, a relapse prevention plan is typically developed. Treatment based on cognitive–behavioural principles has been shown to be effective (see for example, the review conducted by Hay & Bacaltchuk, 2004), and CBT is widely regarded as the treatment of choice for BN (NICE, 2004). Nevertheless, a significant number of people with BN who receive CBT do not make a good recovery, and it is acknowledged that existing treatments require further development. One important factor not targeted, and thought to be missing in treatment by several researchers and clinicians, is modifying key

CT for Bulimia Nervosa: An A-B Replication Series core or negative self-beliefs and dysfunctional assumptions that are thought to be important in the development of BN (see review by Cooper, 2005). Existing CBT interventions vary in the extent to which they are directly linked to any underlying theoretical mechanisms. The most widely applied approach (see for example, Wilson & Fairburn, 1998) is based on a model in which cognition, in the form of extreme weight and shape concerns, has a key role together with a range of behaviours, including dieting, binge eating and compensatory behaviours, such as purging, fasting or excessive exercise. While progress has been made in evaluating the status of the theoretical assumptions of the models, it has also been suggested that current models require further elaboration (e.g., Jansen, 2001). A cognitive model for BN has been described that includes a detailed vicious circle formulation of the factors that maintain binge eating, as well as dysfunctional assumptions and negative self-beliefs (Cooper, Todd, & Wells, 2000; Cooper, Wells, & Todd, 2004). It highlights the role of a range of cognitions specific to BN, such as positive and negative beliefs about eating, thoughts of no control and permissive thoughts, all of which serve to maintain binge eating. Empirical support has been found for its central predictions, for example, in a repeated-measures crossover study in women with BN, where it was found that manipulating positive beliefs about eating predicted eating behaviour (greater food consumption) while manipulating negative beliefs about eating predicted greater urge to restrict food consumption (Todd, 2006). In addition, it emphasizes the contribution of deeper-level cognitions, including underlying assumptions and negative self-beliefs, which are hypothesized to be particularly important in the development of the disorder. A particular belief area that is examined in patients is metacognitive belief about the effects of bingeing and vomiting on self-control in line with metacognitive therapy of psychological disorder (Wells, 2000; Cooper, Todd, & Wells, in press). Compared with existing models, the new model places greater emphasis on cognition and cognitive processes. It includes a more detailed analysis of the cognitions involved in maintaining the disorder, and unlike existing models, also identifies the cognitions that may play a causal role in the development of BN. Preliminary work supports the usefulness of the specific cognitions and beliefs identified (e.g., Cooper, Cohen-Tovee, Todd, Wells, & Tovee, 1997; Cooper, Todd, Woolrich, Somerville, & Wells, 2006). Copyright © 2007 John Wiley & Sons, Ltd.

403 An earlier self-help guide based on this model has been developed with an individualized formulation incorporating cognitive therapy strategies, including an emphasis on enhancing motivation for change, strategies to challenge negative selfbeliefs and behavioural experiments (Cooper et al., 2000). It focuses primarily on cognitive rather than behavioural change as a first-line approach. Treatment begins with motivational strategies, including work on identifying problems and goals, the advantages and disadvantages of changing, and modifying fears about change. An individualized formulation is developed, including the full range of automatic thoughts and beliefs and their relationship to the associated behaviours, emotions and physiological features of BN. In our more recent developments of the treatment, we have boosted initial therapeutic work on automatic thoughts of metacognitions related to lack of control, where behavioural experiments have an important role, before using both verbal restructuring and further behavioural experiments to modify positive and other negative beliefs. Dysfunctional behaviour, which maintains dysfunctional cognitions, is tackled. This includes, for example, weight, shape and eating-related behaviours, calorie counting and dietary restrictions. Deeper-level cognitions, particularly negative selfbeliefs, are addressed using a range of generic techniques designed for modifying schema, including the use of cognitive continua, imagery modification and historical tests of beliefs. This approach contrasts with that of traditional CBT for BN, where the initial focus is on direct behaviour change, and reducing a range of dieting behaviours, including introducing previously avoided foods. While work on thought challenging occurs later on, in traditional CBT it is generally limited to ‘problematic thoughts’, and not extended to core beliefs. An open study of treatment based on the new model, and using the manual with guided self-help (Cooper et al., 2000), has produced promising results (Pritchard, Bergin, & Wade, 2004), providing preliminary support for the new treatment. Some relevant measures of the cognitions in this model now exist, including the Eating Disorder Belief Questionnaire (EDBQ; Cooper et al., 1997) and the Eating Disorder Thoughts Questionnaire (EDTQ; Cooper et al., 2006). These measures and their individual items may be administered to track cognitive change and to examine whether treatment changes the key cognitions hypothesized by the model to be responsible for the maintenance and development of the problem. Clin. Psychol. Psychother. 14, 402–411 (2007) DOI: 10.1002/cpp

404 It has been noted that in the development of new treatments, it is wise to conduct treatment development work, rather than consider a largescale randomized control study (RCT) (Agras & Berkovitz, 1980). Moreover, detailed assessment of behaviour and cognitions is not usually possible within a large-scale RCT. Thus, we conducted a series of single cases, which would allow us to explore the potential value of the new treatment, before proceeding to a large-scale costly and timeconsuming RCT, as well as allow us to collect detailed information that would enable us to discover if the treatment might be effective in changing key cognitions as well as key behaviours. In order to provide an ecologically valid and representative group of participants, they were selected from all available cases of those who had a primary diagnosis of BN in local tertiary services. Previous studies have generally either used unselected samples, with many participants coming straight from their family physician or General Practitioner (GP), or have imposed strict inclusion and exclusion criteria that may exclude more severe cases (Mitchell, Maki, Adson, Ruskin, & Crow, 1997). The current study had two questions: 1. Is treatment for BN that focuses on cognitive change associated with reduced key behavioural symptoms of the disorder? 2. Is treatment associated with change in relevant cognitions hypothesized to be important in the development and maintenance of the disorder? We also aimed to comment on the nature of our sample, and how outcome (tentatively) compares with that in previous studies where treatment has placed relatively greater emphasis on behavioural change.

METHOD Participants Four female patients with a DSM-IV diagnosis (American Psychiatric Association, 2000) of BN were referred from tertiary eating disorder services. An A-B design with follow up (Barlow & Hersen, 1984) was used to evaluate the effects of treatment. The baseline phase ranged from 5 to 7 weeks. One patient dropped out very early in treatment. Brief background details on the three patients who completed treatment, and all planned follow-ups, are provided below. Copyright © 2007 John Wiley & Sons, Ltd.

M. Cooper et al. Patient 1 was aged 19 years. She had a body mass index (BMI = kg/m2) of 24.2 at assessment. She met DSM-IV criteria for major depression, and had a history of anorexia nervosa. She had previously received psychiatric outpatient treatment in a specialist child and family service for her eating disorder. At the start of treatment, she was on sick leave from her full-time job. Her eating disorder had begun at age 15 years. Patient 2 was aged 17 years. She had a body mass index (BMI = kg/m2) of 25.5 at assessment. She did not meet DSM-IV criteria for major depression, but had previously received psychiatric treatment for both depression and BN in an adolescent mental health service as an outpatient. She had received drug treatment (fluoxetine) on at least two occasions and CBT, with a focus on the behavioural elements. During treatment she continued to take 20 mg fluoxetine daily. She was a full-time student throughout treatment and follow-up. The onset of her eating disorder was at age 15 years. Patient 3 was aged 17 years. She had a body mass index (BMI = kg/m2) of 20.7 at assessment. She did not meet DSM-IV criteria for major depression, and had no previous psychiatric treatment. She had been referred to and taken on by a tertiary service because of the apparent severity of her problem. Her eating disorder had begun at age 14 years. She was in full-time education throughout treatment and follow-up.

Measures Self-report questionnaires were completed at assessment, beginning of treatment, end of treatment, and at 3 and 6 months follow-up. Ninemonths follow-up data were also available for patient 1. Measures of eating disorder and general psychopathology were administered. To assess eating disorder psychopathology, the Eating Attitudes Test (EAT; Garner & Garfinkel, 1979), a widely used measure of the symptoms associated with eating disorders, and the EDBQ) Cooper et al., 1997), a measure of negative self-beliefs and underlying assumptions related to eating disorders. were administered. To asses general psychopathology, the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), a widely used measure of depressive symptoms; Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer, 1988), a measure of anxiety symptoms; and the Rosenberg Self-Esteem Scale (RSE; Rosenberg, 1965), a measure of self-esteem, were administered. All the self-report measures used have good psyClin. Psychol. Psychother. 14, 402–411 (2007) DOI: 10.1002/cpp

CT for Bulimia Nervosa: An A-B Replication Series chometric properties, and have been widely used in the assessment of eating disorder patients. Weekly ratings were made on key behaviours (bingeing, compensatory behaviours) and key cognitions (items from the EDBQ sub-scales, and from an early version of the Thoughts Questionnaire [Cooper et al., 2006] covering all three sub-scales).

Procedure Patients were recruited consecutively from suitable patients currently on three tertiary service waiting lists. All met DSM-IV criteria for BN. To be included, patients had to be aged over 17 years and regard BN as their primary problem. They also had to have a current body mass index (BMI = kg/m2) of 18 or over but below 27. They had to be available for the duration of treatment and for a 6-month follow-up.

Outline of Treatment Each participant was seen by a clinician experienced in treating eating disorder clients with cognitive therapy. A detailed treatment manual was written specifically for the study, based on the treatment outlined in Cooper et al. (2000). Two therapists conducted the treatments (GT and HT). GT has a post-graduate certificate qualification in cognitive therapy. HT received cognitive therapy training as part of post-graduate clinical psychology training. Supervision, including monitoring of treatment fidelity and use of the model, during the course of the study was provided by MC, an experienced supervisor and trainer for a post-graduate cognitive therapy diploma course, who also has a post-graduate certificate in cognitive therapy. Treatment began with strategies to enhance motivation and was followed by goal setting, formulation, identification and challenging of specific automatic thoughts, and then worked on underlying assumptions, core beliefs and relapse prevention. Problem behaviours hypothesized to be maintaining the patient’s symptoms were also addressed. This was achieved by identifying and challenging the relevant maintaining cognitions using behavioural experiments, and not through behavioural change per se. Individual sessions reviewed progress, worked on specific problems using cognitive strategies and set homework. As recommended in cognitive therapy (e.g., Beck, 1995), a collaborative partnership was developed, and the principles of CT treatment followed, Copyright © 2007 John Wiley & Sons, Ltd.

405 including agenda setting, reviewing progress, setting of homework, etc. In sessions, the therapist worked actively to help the patient identify and challenge thoughts—through verbal restructuring and, as suggested above, by planning and conducting behavioural experiments. Patients were also encouraged to read relevant chapters from the self-help book (Cooper et al., 2000), and to undertake the exercises suggested in the book—both in session and at home—to supplement the individual therapy each received in the clinic (i.e., treatment was not merely guided self-help but involved in session individually tailored psychotherapy). All patients participated in a 5- to 7-week notreatment baseline phase. The EAT, BDI, BAI and RSE were completed at the start and at the end of the baseline phase, immediately prior to the start of treatment. Patients were seen initially for up to 14 sessions. Additional sessions were subsequently negotiated individually if both the therapist and the patient agreed this might be useful. Patient 1 had six additional sessions. Patients 3 and 4 had the planned number of sessions. Patients were followed up at 3 and 6 months after their final treatment session (and also at 9 months in the case of patient 1), and the self-report measures were re-administered on each occasion.

Data Collection Patients completed weekly ratings (see below) at the start and end of baseline, weekly during the treatment phase and also at each follow-up appointment.

Results Baselines Baselines for bingeing and vomiting were either stable, fluctuating with no strong trend towards an increase or a decrease, or increasing slightly. Baselines for the Thoughts Questionnaire were stable, as were those for individual EDBQ items, with the exception of patient 1, where it is possible that there was a trend for these scores to decrease during this phase.

Self-Report Questionnaire Measures Data for each patient on the EAT, BDI, BAI, RSE and the four sub-scales of the EDBQ at the beginning of the baseline can be seen in Table 1. Data for each patient on the EAT, BDI, BAI, RSE and the four sub-scales of the EDBQ at the start of Clin. Psychol. Psychother. 14, 402–411 (2007) DOI: 10.1002/cpp

406

M. Cooper et al. Table 1.

Descriptive data for all patients at each assessment point

Data at first assessment or start of baseline

Pt 1 Pt 2 Pt 3

EAT

BDI

BAI

RSE

EDBQ1

EDBQ2

EDBQ3

EDBQ4

44 82 64

38 9 16

21 10 12

18 26 19

65 20 71

80 65.5 45.5

73.3 73.3 81.7

81 84 66

Data at the start of treatment

Pt 1 Pt 2 Pt 3

EAT

BDI

BAI

RSE

EDBQ1

EDBQ2

EDBQ3

EDBQ4

43 83 62

34 8 13

21 17 11

18 25 19

70 36.1 71

81.6 68.2 45.5

96.6 86.6 81.7

84 52 66

Data at the end of treatment

Pt 1 Pt 2 Pt 3

EAT

BDI

BAI

RSE

EDBQ1

EDBQ2

EDBQ3

EDBQ4

14 11 9

10 2 1

10 4 4

29 32 23

13 11 10

13.6 29 4.5

31.6 46.6 30

14 10 8

Data at 3 months follow-up

Pt 1 Pt 2 Pt 3

EAT

BDI

BAI

RSE

EDBQ1

EDBQ2

EDBQ3

EDBQ4

17 9 4

19 2 3

21 2 1

21 31 29

35 18 8

30.9 20 0

50 30 26.6

22 14 8

Data at 6 months follow-up

Pt 1 Pt 2 Pt 3

EAT

BDI

BAI

RSE

EDBQ1

EDBQ2

EDBQ3

EDBQ4

12 2 2

19 1 2

14 0 3

22 33 29

54 4 9

14.5 9 0.9

33.6 10.8 20

30 2 2

EDBQ2

EDBQ3

EDBQ4

Data at 9 months follow-up

Pt 1

EAT

BDI

BAI

RSE

EDBQ1

9

15

9

28

13

11

20

10

EAT = Eating Attitudes Test. BDI = Beck Depression Inventory. BAI = Beck Anxiety Inventory. RSE = Rosenberg Self-Esteem Scale. EDBQ = Eating Disorder Belief Questionnaire— 1 = negative self-beliefs, 2 = weight and shape as means to acceptance by others, 3 = weight and shape as means to self-acceptance, 4 = control overeating. Pt = patient.

treatment can also be seen in Table 1. With the exception of patient 2, who experienced an increase in her symptoms on several measures between assessment and start of treatment, there was little difference between scores on these measures at baseline assessment and start of treatment. All patients experienced large decreases in EAT scores during treatment—and all continued to improve their scores during follow-up, when scores for all three could be considered well within a normal range. The same pattern was observed for self-esteem measured using the RSE. There was a marked increase in self-esteem and a continued Copyright © 2007 John Wiley & Sons, Ltd.

increase over follow-up for all three patients. Depression and anxiety (BDI and BAI scores) also fell in all three patients. Scores of patients 2 and 3 scores continued to fall during follow-up. Patient 1 experienced some increase in both these scores during follow-up, particularly for depression, which was above normal at 6 months follow-up, although considerably lower than it had been at the start of treatment. However, by 9 months follow-up, her scores had fallen again with the BAI score now in the normal range and the BDI now only slightly above normal. EDBQ sub-scale scores are discussed in the section on cognitive change below. Clin. Psychol. Psychother. 14, 402–411 (2007) DOI: 10.1002/cpp

CT for Bulimia Nervosa: An A-B Replication Series

Behavioural Change This was judged using self-reported frequency of bingeing, dieting and compensatory behaviours on the weekly ratings sheet (also completed for the previous week at follow-up). There was little difference between patient scores at assessment and

407 at start of treatment on these measures. Change in frequency of bingeing and bingeing over the course of the study for each patient can be seen in Figures 1–3. The frequency of bingeing and vomiting dropped to low levels compared with the fre-

rating per week

10 9 8 7 6 5 4 3 2 1 0

bingeing vomiting Eating beliefs EDBQ items

1 2 3 4 5

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

treatment (weeks)

baseline (weeks)

3 6 9

follow-up (months)

rating per week

Figure 1. Patient 1—frequency of bingeing and vomiting, and belief changes over treatment. EDBQ = individual eating disorder belief items 8 7 6 5 4 3 2 1 0

bingeing vomiting Eating beliefs EDBQ items

1 2 3 4 5

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

baseline (weeks)

treatment (weeks)

3 6 follow-up (months)

rating per week

Figure 2. Patient 2—frequency of bingeing and vomiting, and belief changes over treatment. EDBQ = individual eating disorder belief items 10 9 8 7 6 5 4 3 2 1 0

bingeing vomiting Eating beliefs EDBQ items

1 2 3 4 5 6 7

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

baseline (weeks)

treatment (weeks)

3 6

follow-up (months)

Figure 3. Patient 3—frequency of bingeing and vomiting, and belief changes over treatment. EDBQ = individual eating disorder belief items

Copyright © 2007 John Wiley & Sons, Ltd.

Clin. Psychol. Psychother. 14, 402–411 (2007) DOI: 10.1002/cpp

408 quency at the start of treatment. Patient 4 scored 0 on both measures by the end of treatment (from 5 on both); patient 2 dropped to 1 on both measures (from ratings of 5). Patient 1 dropped to 1 on bingeing and 2 on vomiting. At 3 and 6 months follow-up, these gains were maintained for patient 4, and increased for patient 2, so that by 6 months both rated bingeing and vomiting frequency as 0, i.e., frequency of ‘not at all’ over the preceding week. Patient 1 showed an increase in bingeing and vomiting at 3 months follow-up, but by 6 months she had returned (almost) to her end-oftreatment low levels for both. At 9 months, she had further improved—her score on bingeing was 1 and 0 on vomiting. Other compensatory behaviour, where present, also decreased in frequency. Dieting frequency fell for all three patients. Exercise frequency fell in the two patients who reported using this for weight control.

Cognitive Change Two patients’ scores on the EDBQ sub-scales fell markedly during treatment, and gains continued to be made over follow-up. The third also experienced marked change with treatment and made further gains during follow-up, except in negative self-belief ratings, which rose slightly during follow-up, although not reaching pre-treatment levels. The pattern of change in scores at the different assessment points for all four sub-scales can be seen in Table 1. Weekly ratings allowed change in individual cognitive items to be assessed. Positive beliefs, thoughts of no control, negative beliefs and permissive thoughts were measured using individual items from an early version of the Thoughts Questionnaire. The pattern of change in scores on these items (average of all four items) during the course of the study for each patient can be seen in Figures 1–3. In all three patients scores fell markedly with treatment, and gains were either maintained or continued to be made during follow-up. The individual thoughts assessed were as follows: positive beliefs—‘eating will take away/distract me from the bad feelings’; control thoughts—‘I can’t control my eating’; negative beliefs—‘I’ll get fat’; permissive thoughts—‘Now I’ve started eating I might as well carry on’. Individual EDBQ items (one from each of its four sub-scales) were also assessed weekly during treatment. The pattern of change in scores on these items (average of all four items) can be seen in Figures 1–3. As for the Thoughts Questionnaire items, scores of all three patients fell noticeably Copyright © 2007 John Wiley & Sons, Ltd.

M. Cooper et al. with treatment, and gains were generally either maintained or continued to be made during follow-up. The individual thoughts assessed were as follows: negative self-beliefs—‘I’m no good’; weight and shape as a means to acceptance by others—‘If I gain weight it means I am a bad person’; weight and shape as a means to selfacceptance—‘If my stomach is flat I’ll be more desirable’; control over eating—‘If I eat three meals a day like other people I’ll gain weight’.

Comparison with Results from Other Studies Differences in assessment measures, and relative lack of cognitive measures in previous studies, make comparison of pre- and post-treatment scores with those obtained in other studies difficult. However, this was attempted where possible. Studies used for comparison purposes included the following: Cooper and Steere (1995), Agras et al. (2000), Fairburn, Cooper, and Cooper (1986), Wilson, Rossiter, Kleinfield, and Lindholm (1986), Agras, Schneider, Arnow, Raeburn, and Telch (1989), Wilson, Eldredge, Smith, and Niles (1991), Fairburn, Jones, Peveler, Hope, and O’Connor (1993) and Garner, Rockert, Davis, Garner, Olmsted, and Eagle (1993). The participants in the current study were, on the whole, rather younger (and thus with a rather shorter history), but generally similar in BMI scores to the comparison studies. However, at pretreatment, the current sample scored rather more highly on eating disorder symptoms as measured by the EAT, lower on self-esteem as measured by the RSE, and higher on depressive symptoms as measured by the BDI. In addition, they were much more likely to have a psychiatric history and to have received previous psychiatric treatment. Two participants also continued to take psychotropic medication throughout the duration of the study, whereas this appears to have been an exclusion criterion in the majority of the comparison studies. Unlike many participants in the comparison studies, none of our patients were recruited from primary care or via advertisement (the latter sources potentially indicative of less severe problems). Overall then, although rather younger, our participants would appear to be a relatively severe group. At the end of treatment, participant scores on the EAT, RSE and BDI were generally well below the post-treatment means of participants in the comparison studies. Scores on cognitive measures could not be directly compared. Nevertheless, inspection of the post-treatment EDE scores in the Clin. Psychol. Psychother. 14, 402–411 (2007) DOI: 10.1002/cpp

CT for Bulimia Nervosa: An A-B Replication Series comparison studies indicated that they generally remained more than 1 standard deviation (SD) above the mean scores of a non-eating disordered group (M.J. Cooper, unpublished data). The EDBQ scores of the current sample, however, were all reduced to within 1 SD of non-eating disordered group means (Cooper et al., 1997). No comparable data were available for the individual Thoughts Questionnaire items. Overall then, the current participants experienced considerable change in both behavioural and cognitive symptoms of BN.

DISCUSSION All three patients who completed treatment appeared to do well. By 6 months follow-up, two patients were entirely symptom-free, i.e., abstinent from the key behavioural symptoms of BN— i.e., binge-eating and vomiting. The third patient (patient 1) also appeared to do relatively well, and although she experienced an increase in her symptoms at 6 months, by 9 months she was also entirely free of vomiting and had only very occasional episodes of binge eating. None of the patients met DSM-IV criteria for a diagnosis of either eating disorder or major depression at their final follow-up. Scores on self-report measures indicated improvement in self-esteem and in symptoms of anxiety and depression. In all but one case (patient 1 on the BDI at 9 months follow-up), scores were within a normal, non-clinical range. There were also changes in scores on the measures of cognition, both on deeper-level core or negative self-beliefs and assumptions and negative automatic thoughts. For all three patients who completed treatment, EDBQ sub-scale scores fell into a normal, non-eating disordered range. Belief in individual cognitive items on the weekly rating sheet also decreased (although conclusions here for patient 1 on EDBQ items need to be cautious given that baseline measures appeared to be decreasing slightly). Overall, the findings suggest that treatment focused on cognitive change as a first step, and as described here, was associated with significant improvements. The findings also indicate that it may not be necessary as a first step within a cognitive approach to modify behaviour. A good outcome might be achieved by identifying and modifying a range of specific cognitions, without an initial focus on direct behavioural change. If such a finding was substantiated, then CBT does not necessarily have to proceed in the format and sequence currently advocated. This might improve Copyright © 2007 John Wiley & Sons, Ltd.

409 the acceptability and compliance with treatment for some patients. In terms of specific strategies used, the new treatment diverges from traditional CBT in using a rather broader, as well as different, range of strategies. Unlike the new treatment, CBT, as traditionally delivered, uses a number of behavioural modification strategies, including self-monitoring of behaviour, goal setting, exposure and response prevention, scheduling of alternative activities and graded exposure. These techniques are not part of the new treatment. CBT as traditionally delivered also generally confines itself to challenging of problematic thoughts using verbal challenging via ‘evidence for and against’, and to challenging of attitudes regarding weight and shape using ‘advantages and disadvantages’ analysis. The new treatment provides a range of other strategies, all of which are designed to target cognitions, particularly metacognitions concerning control and use of eating and purging to regulate feelings and selfconcept (e.g., Wells, 2000; Cooper et al., in press). In the new treatment, there is extensive use of behavioural experiments and a broad range of verbal and behaviourally based strategies designed to target metacognitions and deeper-level beliefs about the self. It was noteworthy that all the participants in the current study were tertiary referrals; thus, as a group, it is possible that they had features previously associated with failure to engage, poor outcome, and/or dropping out from treatment. The occurrence of such features in tier 3 patients has been documented in a large sample (Peake, Limbert, & Whitehead, 2005). Such patients might be expected to do less well in cognitive therapy than those recruited from primary care or by advertisement. Although rather younger than patients in comparison samples, we are not aware of any research that suggests that such patients are significantly easier to treat. Although the comparisons are necessarily limited by our small number of patients, given the stringency of selection criteria in many RCTs of CBT for BN (e.g., exclusion of patients on medication), it is possible that our patients may have been more typical of patients seen by practising clinicians in routine, albeit tertiary, care than those seen in many RCTs. Despite this, in the current study, improvements comparable to those in previous studies where selection criteria may have favoured less severely ill, and potentially less typical, patients were obtained. Where comparisons could be attempted, the pretreatment scores of the current sample on selfClin. Psychol. Psychother. 14, 402–411 (2007) DOI: 10.1002/cpp

410 report measures, i.e., on the EAT, BDI and RSE were high compared with those of patients in previous studies. This also suggested that they were a relatively severe group. Despite this, change across treatment was obtained for these patients. Of particular note was the finding that scores on measures of cognition fell into a normal non-eating disordered range at the end of treatment and at follow-up. The results suggest that treatment focusing specifically on the cognitions thought to maintain eating disorder is acceptable to patients. However, the sample size in this study is small and one patient appeared not to respond as much as the other two. The design does not allow us to examine the contribution of non-specific treatment effects to outcome. Given that the treatment was administered and also supervised by those responsible for developing it, it is important that the findings receive independent replication. Nevertheless, despite the limitations, the current results are encouraging and indicate that further evaluations of the new treatment might be worthwhile.

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