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BackgroundThis secondary data analysis seeks to replicate and extend findings that early response to treatment in adolescent bulimia nervosa (BN) predicts outcome, resulting in earlier identification of patients who might need a different treatment approach.MethodsParticipants were 71 adolescents (M ± SD: 15.69 ± 1.55 years; 93% female; 75% non-Hispanic) with a Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) diagnosis of BN or partial BN enrolled in a two-site treatment study. Participants were randomized to cognitive behavioral therapy for adolescents (CBT-A), family-based treatment for BN (FBT-BN), or supportive psychotherapy (SPT). The Eating Disorder Examination was administered at baseline, end-of-treatment (EOT), 6-month, and 12-month follow-up. Binge eating and purge symptoms were self-reported at each session. Outcome was defined as abstinence of binge eating and compensatory behaviors (self-induced vomiting, laxative use, diet pills, diuretics, compensatory exercise, fasting) in the 28 days prior to assessment. Receiver operating characteristic (ROC) analyses were utilized to assess the viability of predicting treatment outcomes based on reduction of symptoms within the first 10 sessions of treatment.ResultsROC analyses suggest that reduction in purging at session 2 (AUC =.799, p < .001) and binge eating at session 4 (AUC =.750, p < .01) were independently related to abstinence of symptoms at EOT, regardless of treatment type. Symptom reduction later in treatment predicted outcome at follow-up, as change in binge eating at session 8 and purging at session 9 were the strongest predictors of abstinence at 6-month follow-up (AUCs =.726-.763, ps < .01). Change in binge eating, but not purging behaviors, was significantly related to abstinence at 12-month follow-up (AUC =.766, p < .01). Only slight differences emerged based on treatment group, such that reductions in symptoms most predictive of abstinence at EOT occurred one session sooner in FBT-BN than SPT.ConclusionReductions in binge eating and purge symptoms early in adolescent BN treatment suggest better outcome, regardless of treatment modality. Additional research with larger samples is needed to better understand which treatments, if any, contribute to earlier change in BN symptoms and/or likelihood of improved patient response.

ObjectiveFamily-based treatment (FBT) for adolescent anorexia nervosa (AN) promotes faster weight restoration when compared to other treatments. However, the mechanisms through which this occurs are not clarified. This study explored the trajectories of parental self-efficacy and perceived family flexibility during FBT and systemic family therapy (SyFT). We also explored whether parental self-efficacy mediates the effects of treatment on weight gain early in treatment.Method158 adolescents (12-18 years old; 89% girls) and their parents were randomized to FBT or SyFT. Parental self-efficacy as well as adolescents' and parental perceptions of the family's flexibility were collected at baseline and at sessions 2, 4, 6, and 8.ResultsOver time, only parents in FBT reported significantly greater self-efficacy. The change in maternal self-efficacy over the first 8 weeks of treatment was a significant mediator of session 10 weight gain. There were no significant group differences in perceived flexibility by session 8.DiscussionBoth parents in FBT and mothers in SyFT understand early the need to change their family's rules and roles. However, the specific strategies of FBT appear to mediate early weight gain in AN.

ObjectiveThere is a paucity of randomized clinical trials (RCTs) for adolescents with bulimia nervosa (BN). Prior studies suggest cognitive-behavioral therapy adapted for adolescents (CBT-A) and family-based treatment for adolescent bulimia nervosa (FBT-BN) could be effective for this patient population. The objective of this study was to compare the relative efficacy of these 2 specific therapies, FBT-BN and CBT-A. In addition, a smaller participant group was randomized to a nonspecific treatment (supportive psychotherapy [SPT]), whose data were to be used if there were no differences between FBT-BN and CBT-A at end of treatment.MethodThis 2-site (Chicago and Stanford) randomized controlled trial included 130 participants (aged 12-18 years) meeting DSM-IV criteria for BN or partial BN (binge eating and purging once or more per week for 6 months). Outcomes were assessed at baseline, end of treatment, and 6 and 12 months posttreatment. Treatments involved 18 outpatient sessions over 6 months. The primary outcome was defined as abstinence from binge eating and purging for 4 weeks before assessment, using the Eating Disorder Examination.ResultsParticipants in FBT-BN achieved higher abstinence rates than in CBT-A at end of treatment (39% versus 20%; p = .040, number needed to treat [NNT] = 5) and at 6-month follow-up (44% versus 25%; p = .030, NNT = 5). Abstinence rates between these 2 groups did not differ statistically at 12-month follow-up (49% versus 32%; p = .130, NNT = 6).ConclusionIn this study, FBT-BN was more effective in promoting abstinence from binge eating and purging than CBT-A in adolescent BN at end of treatment and 6-month follow-up. By 12-month follow-up, there were no statistically significant differences between the 2 treatments.Clinical trial registration informationStudy of Treatment for Adolescents With Bulimia Nervosa; http://clinicaltrials.gov/; NCT00879151.

ObjectiveAdolescents with Anorexia Nervosa (AN), treated with family-based treatment (FBT) who fail to gain 2.3 kg by the fourth week of treatment have a 40-50% lower chance of recovery than those who do. Because of the high risk of developing enduring AN, improving outcomes in this group of poor responders is essential. This study examines the feasibility and effects of a novel adaptive treatment (i.e., Intensive Parental Coaching-IPC) aimed at enhancing parental self-efficacy related to re-feeding skills in poor early responders to FBT.Method45 adolescents (12-18 years of age) meeting DSM TR IV criteria for AN were randomized in an unbalanced design (10 to standard FBT; 35 to the adaptive arm). Attrition, suitability, expectancy rates, weight change, and psychopathology were compared between groups.OutcomesThere were no differences in rates of attrition, suitability, expectancy ratings, or most clinical outcomes between randomized groups. However, the group of poor early responders that received IPC achieved full weight restoration (>95% of expected mean BMI) by EOT at similar rates as those who had responded early.ConclusionsThe results of this study suggest that it is feasible to use an adaptive design to study the treatment effect of IPC for those who do not gain adequate weight by session 4 of FBT. The results also suggest that using IPC for poor early responders significantly improves weight recovery rates to levels comparable to those who respond early. A sufficiently powered study is needed to confirm these promising findings.

ImportanceAnorexia nervosa (AN) is a serious disorder with high rates of morbidity and mortality. Family-based treatment (FBT) is an evidence-based therapy for adolescent AN, but less than half of those who receive this approach recover. Hence, it is important to identify other approaches to prevent the development of the chronic form of AN for which there is no known evidence-based treatment.ObjectiveTo compare FBT with systemic family therapy (SyFT) for the treatment of adolescent-onset AN.Design, setting, and participantsResearch in Anorexia Nervosa (RIAN) is a 2-group (FBT and SyFT) randomized trial conducted between September 2005 and April 2012. Interviewers were blinded to the treatment condition. A total of 564 adolescents receiving care at 6 outpatient clinics experienced in the treatment of AN were screened. Of these, 262 adolescents did not meet the inclusion criteria and 138 declined to participate; hence, 164 adolescents (aged 12-18 years) of both sexes meeting the criteria for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, AN (except for amenorrhea) were enrolled. Three participants were withdrawn from FBT and 7 were withdrawn from SyFT after serious adverse events occurred.InterventionsTwo manualized family therapies with 16 one-hour sessions during 9 months. Family-based therapy focuses on the facilitation of weight gain, whereas SyFT addresses general family processes.Main outcomes and measuresThe primary outcomes were percentage of ideal body weight (IBW) and remission (≥95% of IBW). The a priori hypothesis was that FBT would result in faster weight gain early in treatment and at the end of treatment (EOT).ResultsThere were no statistically significant differences between treatment groups for the primary outcome, for eating disorder symptoms or comorbid psychiatric disorders at the EOT or follow-up. Remission rates included FBT, 33.1% at the EOT and 40.7% at follow-up and SyFT, 25.3% and 39.0%, respectively. Family-based therapy led to significantly faster weight gain early in treatment, significantly fewer days in the hospital, and lower treatment costs per patient in remission at the EOT (FBT, $8963; SyFT, $18 005). An exploratory moderator analysis found that SyFT led to greater weight gain than did FBT for participants with more severe obsessive-compulsive symptoms.Conclusions and relevanceThe findings of this study suggest that FBT is the preferred treatment for adolescent AN because it is not significantly different from SyFT and leads to similar outcomes at a lower cost than SyFT. Adolescents with more severe obsessive-compulsive symptoms may receive more benefits with SyFT.Trial registrationclinicaltrials.gov Identifier NCT00610753.

ObjectiveLong-term follow-up studies documenting maintenance of treatment effects are few in adolescent anorexia nervosa (AN). This exploratory study reports relapse from full remission and attainment of remission during a 4-year open follow-up period using a convenience sample of a subgroup of 65% (n = 79) from an original cohort of 121 participants who completed a randomized clinical trial comparing family-based therapy (FBT) and adolescent-focused individual therapy (AFT).MethodFollow-up assessments were completed up to 4 years posttreatment (average, 3.26 years). Available participants completed the Eating Disorder Examination as well as self-report measures of self-esteem and depression at 2 to 4 years posttreatment.ResultsTwo participants (6.1%) relapsed (FBT: n = 1, 4.5%; AFT: n = 1, 9.1%), on average 1.98 years (SD = 0.14 years) after remission was achieved at 1-year follow-up. Ten new participants (22.7%) achieved remission (FBT: n = 1, 5.9%; AFT: n = 9, 33.3%). Mean time to remission for this group was 2.01 years (SD = 0.82 years) from 1-year follow-up. There were no differences based on treatment group assignment in either relapse from full remission or new remission during long-term follow-up. Other psychopathology was stable over time.ConclusionThere were few changes in the clinical presentation of participants who were assessed at long-term follow-up. These data suggest that outcomes are generally stable posttreatment regardless of treatment type once remission is achieved. Clinical trial registration information-Effectiveness of Family-Based Versus Individual Psychotherapy in Treating Adolescents With Anorexia Nervosa; http://www.clinicaltrials.gov/; NCT00149786.

ObjectiveTo examine the predictive value of end of treatment (EOT) outcomes for longer term recovery status.MethodWe used signal detection analysis to identify the best predictors of recovery based on outcome at EOT using five different eating disorder samples from randomized clinical treatment trials. We utilized a transdiagnostic definition of recovery that included normalization of weight and eating related psychopathology.ResultsAchieving a body weight of 95.2% of expected body weight by EOT is the best predictor of recovery for adolescents with anorexia nervosa (AN). For adults with AN, the most efficient predictor of weight recovery (BMI > 19) was weight gain to greater than 85.8% of ideal body weight. In addition, for adults with AN, the most efficient predictor of psychological recovery was achievement of an eating disorder examination (EDE) weight concerns score below 1.8. The best predictor of recovery for adults with Bulimia Nervosa (BN) was a frequency of compensatory behaviors less than two times a month. For adolescents with BN, abstinence from purging and reduction in the EDE restraint score of more than 3.4 from baseline to EOT were good predictors of recovery. For adults with binge eating disorder, reduction of the Global EDE score to within the normal range (

The aim of the study is to explore whether identified parental and patient behaviors observed in the first few sessions of family-based treatment (FBT) predict early response (weight gain of 1.8 kg by session four) to treatment. Therapy film recordings from 21 adolescent participants recruited into the FBT arm of a multi-site randomized clinical trial were coded for the presence of behaviors (length of observed behavior divided by length of session recording) in the first, second and fourth sessions. Behaviors that differed between early responders and non-early responders on univariate analysis were entered into discriminant class analyses. Participants with fewer negative verbal behaviors in the first session and were away from table during the meal session less had the greatest rates of early response. Parents who made fewer critical statements and who did not repeatedly present food during the meal session had children who had the greatest rates of early response. In-vivo behaviors in early sessions of FBT may predict early response to FBT. Adaptations to address participant resistance and to decrease the numbers of critical comments made by parents while encouraging their children to eat might improve early response to FBT.

The 4 years that Michel Hersen spent at the University of Mississippi Medical Center (1970-1974) are described in this article from the viewpoint of his place in the history of the development of behavior analysis and therapy. The Department of Psychiatry at the University of Mississippi Medical Center became a leader in enhancing the role of psychologists as clinician researchers within psychiatry and applying basic findings from psychology to the bedside. A vigorous research program involving psychology residents and postdoctoral students, and psychology and psychiatry faculty emerged from this integration of science and practice. Many of the faculty members, including Michel Hersen, became leaders in the field of behavior therapy. Much of what was groundbreaking at the time is now commonplace within many medical schools. (Contains 1 figure.)

Objective: Thin body preoccupation and social pressure to be thin (TBPSP) in adolescence are risk factors for the development of full and partial bulimia nervosa and binge eating disorder. This study examined precursors of these potent risk factors. Method: A prospective study followed 134 children from birth to 11.0 years and their parents. Recruitment began in January 1990 and ended in March 1991. The study was completed in December 2002. Results: Two moderators identified different groups at risk for the development of TBPSP. A father with high body dissatisfaction characterized the largest group in which TBPSP was elevated for girls who were concerned about and attempted to modify their weight and for children with fathers who had a high drive for thinness. A child at risk for overweight characterized the second smaller group. Parental behaviors such as overcontrol of their child's eating, together with later pressure from parents and peers to be thin, were related to higher levels of TBPSP. Conclusions: Different pathways lead to the development of eating disorder psychopathology. These results suggest that prevention programs for eating disorders should begin in early childhood, possibly involving parental education and behavior change, and that different prevention programs may be required for different pathways. (Contains 1 table and 2 figures.)

Objective: To describe the relative effectiveness of a short versus long course of family-based therapy (FBT) for adolescent anorexia nervosa at long-term follow-up. Method: This study used clinical and structured interviews to assess psychological and psychosocial outcomes of adolescents (ages 12-18 years at baseline) who were previously treated in a randomized clinical trial using family therapy between 1999 and 2002. Results: Eighty-three percent (71/86) of subjects participated in follow-up assessments of current psychological and psychosocial functioning. In addition, 49% (35) were interviewed using the Eating Disorder Examination. Mean length of follow-up was 3.96 years (range 2.3-6.0 years). There were no statistically significant differences between the two groups on any measure at long-term follow-up. As a whole, the group was doing well with 89% above 90% ideal body weight, 74% with Eating Disorder Examination scores within the normal range, and 91% of postmenarcheal females not on birth control had menstrual return. Conclusions: A short course of family therapy is as effective as a longer course at follow-up. (Contains 5 tables.)

Objective: Research suggests that family treatment for adolescents with anorexia nervosa may be effective. This study was designed to determine the optimal length of such family therapy. Method: Eighty-six adolescents (12-18 years of age) diagnosed with anorexia nervosa were allocated at random to either a short-term (10 sessions over 6 months) or long-term treatment (20 sessions over 12 months) and evaluated at the end of 1 year using the Eating Disorder Examination (EDE) between 1999 and 2002. Results: Although adequately powered to detect differences between treatment groups, an intent-to-treat analysis found no significant differences between the short-term and long-term treatment groups. Although a nonsignificant finding does not prove the null hypothesis, in no instance does the confidence interval on the effect size on the difference between the groups approach a moderate .5 level. However, post hoc analyses suggest that subjects with severe eating-related obsessive-compulsive features or who come from nonintact families respond better to long-term treatment. Conclusions: A short-term course of family therapy appears to be as effective as a long-term course for adolescents with short-duration anorexia nervosa. However, there is a suggestion that those with more severe eating-related obsessive-compulsive thinking and nonintact families benefit from longer treatment. J. Am. Acad. Child Adolesc. Psychiatry, 2005;44(7):632-639. Key Words: anorexia nervosa, family therapy.

Cognitive-behavioral therapy (CBT) for bulimia nervosa (BN) has received considerable empirical support for its efficacy. However, few investigators have examined the mechanisms proposed to account for the reduction of BN symptoms during CBT. The current study examined the associations between therapist interventions, client mechanisms, and symptoms during treatment in a sample of 56 clients undergoing CBT for BN. Results suggested that behavioral interventions were most associated with symptom change during treatment whereas relational interventions were most associated with change in client mechanisms such as client engagement. Additionally, some changes in BN symptoms were mediated by changes in proposed client mechanisms whereas others were directly associated with therapist interventions. Implications of these findings for CBT theory of BN treatment and CBT treatment process research methodology are discussed.

Considers three types of organizational changes that may facilitate the development of behavioral medicine teaching, practice, and research over the next decade: (1) role of Department of Behavioral Medicine within the medical school; (2) support for development of research collaborations across centers; (3) changes in role and organization of scientific societies that support behavioral medicine. (Author/NB)

Summarizes data pertaining to separate and combined effects of cognitive-behavioral and psychopharmacologic treatments for obesity and bulimia nervosa. Anorexiant medication appears to enhance restraint and facilitates weight loss with behavioral interventions in the treatment of obesity, but relapse occurs once medication is withdrawn. Antidepressants appear to enhance restraint whereas cognitive-behavioral treatment decreases restraint in the treatment of bulimia. (Author/PVV)