Brit.J.

Psychiat. (1979), 134,55—59

Behaviour Therapy in Anorexia Nervosa * By ELKE

D. ECKERT,

SOLOMON

REGINA

C. GOLDBERG,

C. CASPER

and JOHN

KATHERINE

A. HALMI,

M. DAVIS

SUMMARY In three collaborating hospitals, 81 anorexia nervosa patients were randomly assigned to behaviour modification or its absence and followed over 35 days. There was no overall significant difference in weight gain in the two groups except in a subset of patients: those with no prior out-patient treatments. Anorexia variety

nervosa

is an illness

of controversial

for which

treatments

have

a

used. Behaviour modification treatment. It seems well suited

is one such for this disorder,

especially

when

in

the

acute

phase

Thompson, 1974; Leitcnberg Garfinkel et al, 1973).

been

abnormal

systematic

de

sensitization to reduce the anxiety and allow normal eating habits to emerge,

thus and

operant

are

suggested:

conditioning

by using

powerful

al,

1968;

Bachrach, Erwin and Mohr (1965) reported an anorectic patient who learned to vomit and stopped gaining weight when food intake was reinforced, but stopped vomiting and gained weight when reinforcement was made con tingent on weight gain. Most later reports indicate use of reinforcements contingent on weight gain rather than on eating behaviour. The latter approach makes sense, not only because it avoids teaching the patient to vomit,

eating behaviour and low weight are strikingly evident. Brady and Rieger (1972) have described anorectics as behaving as though they suffer from an eating or weight phobia—eating or weight gain generates anxiety and failure to eat, or weight loss, represents avoidance of the anxiety. From this analysis two behavioural

procedures

et

but

because

it

reduces

eating by decreasing It is also easier to accurately than to intake, and there is

re

the

anxiety

around

the emphasis on eating. monitor daily weights monitor 24-hour food less chance for power

inforcers contingent on eating or weight gain, thus allowing the anxiety to take care of itself.

struggles

There are very few reports on the use of syste

by using

matic desensitization for the treatment ofanorec tics (Hallsten, 1965; Lang, 1965; Schnurcr et al, 1976) and only one case report where de sensitization is used alone (Schnurer et al, 1976). Operant conditioning procedures have been

the strong effect of regular feedback of weight and caloric intake information on weight gain. Evaluation of behaviour therapy in anorexia nervosa is complicated by several factors. There

extremely

therapeutic effectiveness. Often, medications are used concurrently with behaviour therapy so that it is impossible to see which treatment is the effective one. Diagnostic criteria are often not carefully specified, resulting in the inclusion of patients suffering primarily from phobias, hysteria, or schizophrenia in the treatment studies. Most studies have small numbers of patients. Halmi's report of eight cases success

utilized

recently,

with

powerful

negative

re

such as bed rest, isolation, and tube

feeding, and positive reinforcement such as increased social and physical activities, con tingent on food intake or weight gain (Brady

and Rieger, et al, 1970; * This

study

1972; Halmi Bachrach was

Grants MH26218,

et al, 1975; Blinder

et al, 1965;

supported

MH26310,

by

Public

Bhanji Health

the technique

is virtually

effective and have been increasingly

inforcement

and arguments.

Agras et al (1974) were able to demonstrate,

and Service

fully

and MH26409. 55

treated

of systematic

no controlled

with

a

study

systematic

analysis,

evaluating

behaviour

its

56

BEHAVIOUR

THERAPY

modification programme, using no medication and meeting strict diagnostic criteria remains the largest and purest patient sample described in the literature (Halmi et al, 1975). Recent controversies (Feinstein, 1974; Agras

et al, 1974) over the efficacy and safety of using behavioural contingencies in treating anorexia nervosa certainly

have by provided

their no

lack of objectivity insight but rather

distorted impressions of effective treatment programmes for anorexia nervosa. Thus in order to test the effect of behaviour modification on weight gain, we thought it worthwhile to design and conduct a controlled treatment study comparing an operant conditioning paradigm

with a ward milieu therapy programme containing virtually no behavioural contin gencies related to weight gain. Behaviour modificationprogramme Forty patients were treated with the same operant conditioning programme with negative reinforcement of isolation and positive re inforcement of increased social and physical activities contingent on weight gain. After the 7-day observation period they were isolated and

restricted to their rooms except for the time when they ate meals in the unit dining rooms. While in isolation they were allowed occu pational therapy projects, radio and reading, but no television. Only hospital staff were allowed in the room. Privileges for weight were earned or with drawn at the end of 5-day periods. During the first five days, the patients were required only to maintain their weight to obtain increased privileges. For the next two periods, they were required to gain at least 0.5 kg per five days. Thereafter, they were required to gain 1 .0 kg per 5-day period. If they did not meet the required weight contingency at the end of any 5-day period, they lost some of their privileges. For the first 5-day period, the patients

received no visitors, phone calls, or mail. If the patients obtained the appropriate weight, on the sixth

day

(or the beginning

of the next

5-day

period) they were allowed to make one phone call, receive their mail, have one visitor for one hour, and be out of the room for one hour each day for the next five days. By the end of the

IN ANOREXIA

next

and

NERVOSA

each

succeeding

5-day

period,

if the

weight contingency was met, they could have an additional hour of visiting privileges, receive their mail, make an additional phone call, and be out of their room each day for an additional hour. Phone calls, visitors, and mail were receivedonly on the day privileges were earned.

The patients chose which hours they spent out of their rooms. Each patient received two hours a week of individual re-educative psychotherapy with emphasis on her interaction with others. staff, relatives, and visitors were instructed

The not

to discuss food and weight with the patients. Family counselling was given if appropriate. Programmefor patients without behaviour modification

The 41 patients who were not treated with behaviour modification were treated in the milieu particular to each collaborating hospital. Each patient received the same personal therapy programme as given to patients in the behaviour therapy groups. No privileges were contingent on weight, and each patient could receive visitors twice a week for two hours. Mail and phone calls were not restricted. The staff,

relatives, and visitors were instructed not to discuss food and weight with the patients. Note that by the design of the whole experiment (see paper 1 of this series) half the patients in each programme also received cyproheptadinc. Results

We addressed ourselves to two different questions in this research. The obvious first question was whether patients with behaviour modification

gained

more

weight

over

day treatment period than patients behaviour modification. The second

the 35-

without question

was whether or not there were specificsub

groups

of patients

in which

behaviour

modi

ficationwas more effectivethan no behaviour modification. The effects of the two programmes, behaviour

modification

and no behaviour

modification

on

weight was analyzed by a fixed effects analysis of covarianceusing the post-treatmentweight as a

dependent variable and the pretreatment weight as a covariate. The adjusted post-treatment weight

could

be interpreted

as a measure

of

ELKE D. ECKERT et at

57

TABLE I

Possible predictors of weight gain Means and standard deviations

N =81 VariableMeanStandard deviationPretreatment kg5.23Normal weight35.96 weight for age and height51 kg4.84Normal minus pretreatment weight15.80 kg5.67Percent admission319Hyperactivity below normal weight on (1 = absent, 4 = severe)1 .400.81Deliver@ in childhood complications(score range 6-12, lower score = more complications)11 .680.59Number 15Number of prior hospitalizations0.931 treatments0.530.65Prior of prior out-patient weeks)0.350.66Prior hospitalizations of adequate duration (4 weeks)0.290.51Prior outpatient treatments of adequate duration (12 gain)0.410.67Prior hospitalization failures (less than 2 kg gain)0.400.54Prior outpatient failures (less than 2kg failed0.090.28Prior hospitalization of adequate duration that failed0.220.42Pretreatment out-patient treatment of adequate duration that hyperactivity on ward (1 = no, 2 = yes)1 .420.33Sleep disturbance (self-rated, 1 absent, 4 = severe)2. 190.98Denial* 1 —¿@ absent, 4 = severe)1 .790.68Loss(self-rated, of appetite (self-rated, I absent, 4 = severe)2 .630.63Psychosexual

.880.51Body

immaturity*

From

Anorectic

Attitude

size :actual

Scale

ficant (P = .20). However, it must be noted that patients overall gained a fair amount of weight in both groups over 35 days.

BEHAVIOR @@L@DD@N 32@ NO

Q

.

(self-rated, 1 = absent, 4 = severe)1

size,sumof5measures606.73136.41 image distortion (N 79) perceived

*

.05

In order

MOD(N@?€l

to test whether

of patients modification, pretreatment predictors

@1i@

(Goldberg NONE

ONEORMORE

NUMBER OF PRIOR OUTPATIENT TREATMENTS OF ADEQUATE DURATION

variables, standard

a specific

subgroup

responded selectively to behaviour social and psychiatric history and variables shown to he possible of weight gain in prior research

et al, together deviations,

1977)

were

assessed.

with their are presented

These

means and in Table I.

Tests for homogeneity of regressionbetween FIG 1.—Interaction number of prior

between behaviour modification and outpatient treatments of adequate (12 weeks) duration. (P = .065: N = 81).

change. This analysis revealed the average weight gain for the 35-day treatment period was 5.0 kg for patients treated with behaviour modification, and 4. 1 kg for patients without behaviour modification. Although patients with

behaviour modificationgained somewhat more weight, this resultwas not statistically signi

behaviour modification and non-behaviour modification for the regression of weight gain on each of these variables revealed an interaction approaching significance between behaviour

modification patient

1 shows

and

treatments

the

the

number

of adequate

interaction

of prior duration.

between

out Figure

behaviour

modification and the number of prior outpatient treatments of adequate duration. An outpatient treatment was considered adequate if it was at least 12 weeks in duration. There was a differ

BEHAVIOUR THERAPY IN ANOREXIA NERVOSA

58

ence

approaching

significance

(P

favouring behaviour modification with no prior out-patient treatment

=

.065)

in patients of adequate

duration. Of all patients with no prior outpatient treatment, patients with behaviour modification gained an average of 4.9 kg during the 35-day treatment period, while patients not treated with

effective than a schedule of delayed reinforce ments given only every fifth day. It is known that the longer the time between the completion of a behaviour and the delivery of a reinforcing

consequence,

the less effect the reinforcer

will

have (Rimm and Masters, 1974). A preliminary analysis of an uncontrolled study at the Uni behaviour modification gained an average of versity of Minnesota indicates that anoretic 3.3 kg. For allpatientswith one or more prior patients may gain more weight on a daily reinforcement schedule than on a delayed out-patient treatments of adequate duration, schedule (Eckert, in preparation). there was a negligible difference between In this study there was no difference in the treatments: those on behaviour modification gained 5.3 kg and the non-behaviour modi efficacyof behaviour therapy and the ward fication group gained 5.8 kg. milieu programmes for inducing weight gain. It isconceivablethat our variousward milieu Discussion programmes and isolation may have produced a maximal possible weight gain so that behaviour This is the first controlled randomized therapy could not be expected to do any better. treatment study testing the efficacy of behaviour

modification nervosa.

in

These

preliminary

the

treatment

results

must

of anorexia be

References

considered

since they are based on only 80 per

AGRAS, W. S., BARLOW, D. H. & CHAPIN, H. N. et at (1974)

Behaviour modification of anorexia of General P@yc/natry,30,279-86.

cent of the total expected sample and the

consistency of the results among the three collaborating hospitals has not been examined. Behaviour modification for anorexia nervosa has been widely supported as producing rapid weight gain in the acute phase of the illness. This study shows that there was weight gain in both behaviour modification and non-behaviour modification groups. However, contrary to our expectations, although patients on behaviour modification gained somewhat more weight than patients not on behaviour modification, the difference was not significant. It will be interesting to seeifanalysisof the totalexpected sample of 106 patients will change this differ ence to significant levels in the expected directions.

Possible explanations for our results must be considered. It may be that another behaviour modification programme would be more effec tive than the operant conditioning programme

used in this study. Individualized reinforcers, rather than constant reinforcers in all patients have been used and may

(Brady and Rieger, Bhanji 1973).

and The

be more effective

1972; Blinder et al, 1970;

Thompson, 1974; Garfinkel ci al, schedule of reinforcements can be

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*Elke D. Eckert, M.D.,Assistant Professor of Psychiatry, Department of Psychiatry, University of Minnesota Hospitals, Box 393 Mayo Bldg, Minneapolis, Solomon

C. Goldberg,

Minnesota 55455

Ph.D. Acting Chief, Psychopharmacology

Research Branch,

National

institutes

of

Mental Health, 5600 Fishers Lane, Rm. 9—105,Rockville, Maryland 20852, Katherine

A. Halmi,

M.D., Associate Professor of Psychiatry,

University of Iowa College of Medicine,

500 Newton Road, Iowa City, Iowa 52242, Regina C. Casper, M.D..Assistant Professor of Psychiatry, University of illinois, Illinois StatePsychiatric

institute, West Side Medical Center, 1601 W. Taylor Street, Chicago, Illinois 60625, John

M. Davis, M.D., Professor of Psychiatry, University of Chicago, Illinois State Psychiatric Institute, West Side Medical Center, 1601 W. Taylor Street, Chicago, Illinois 60625

*

Responsible

(Received]

for

reprint

requests.

August 1977; revised 15 March 1978)