BRIEF REPORT
Predictors of Rapid Relapse in Bulimia Nervosa Marion P. Olmsted, PhD1,2* Danielle E. MacDonald, MA1,3 Traci McFarlane, PhD1,2,3 Kathryn Trottier, PhD1,2 Patricia Colton, MD1,2
ABSTRACT Objective: Relapse remains a significant concern in bulimia nervosa, with some patients relapsing within months of treatment completion. The purpose of the study was to identify predictors of relapse within the first 6 months following treatment. Method: The 116 participants were bingeing and/or vomiting 8 times per month before day hospital (DH), and had 2 episodes per month in the last month of DH and the first month after DH. Rapid relapse was defined as 8 episodes per month for 3 months starting within 6 months. Results: The rate of rapid relapse was 27.6%. Patients who relapsed soon after DH had higher frequencies of bingeing and vomiting before treatment,
Introduction Relapse is a significant concern in eating disorders, with estimates of relapse for bulimia nervosa (BN) ranging from 25 to 63%, depending on the definition of relapse and length of follow-up.1–8 The first six months following remission may be a peak period for relapse.2,4,7 Predictors of relapse in BN include: younger age; shorter duration of illness; fewer weeks of abstinence and slower interruption of binge/purge symptoms during treatment; higher shape and weight concerns, more eating disorder psychopathology, more residual symptoms, and poorer psychosocial functioning at the end of treatment; and more stressful negative life events related to work and social relationships following treatment.1–3,6,7
Accepted 8 December 2014 Disclosure of Conflicts: None of the authors have any conflicts of interest (financial or otherwise) to disclose. There is no funding source to disclose *Correspondence to: Dr. Marion P. Olmsted, PhD, Eating Disorder Program, Toronto General Hospital, University Health Network, 7 Eaton South, Room 413, 200 Elizabeth Street, Toronto, Ontario, Canada, M5G 2C4. E-mail: [email protected] 1 Department of Psychiatry, University Health Network, Toronto, Canada 2 Department of Psychiatry, University of Toronto, Toronto, Canada 3 Department of Psychology, Ryerson University, Toronto, Canada Published online 26 December 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/eat.22380 C 2014 Wiley Periodicals, Inc. V
International Journal of Eating Disorders 48:3 337–340 2015
engaged in less body avoidance before treatment and were more likely to be slow responders to treatment. Weight and shape concerns and body checking were not significant predictors. Discussion: More frequent bulimic symptoms accompanied by less body avoidance may indicate an entrenchment in the illness which in turn augurs a labored and transient response to DH treatment that is difficult to sustain after intensive treatment C 2014 Wiley Periodicals, Inc. ends. V Keywords: bulimia nervosa; relapse; rapid relapse; rapid response (Int J Eat Disord 2015; 48:337–340)
Residual psychopathology at the end of treatment for BN is one of the most commonly identified predictors of relapse and provides a parsimonious explanation for early relapse. Individuals who require day hospital (DH) treatment for BN fall at the more severe end of the spectrum, and some may achieve control of behavioral symptoms only with very intensive support. For many of these patients, the factors maintaining their eating disorder may have been temporarily sidestepped rather than resolved, and their new eating behaviors may be out of synchrony with their psychological functioning. These patients may be at significant risk for rapid relapse. The purpose of the current study was to identify predictors of rapid relapse within the first six months following DH treatment. It was hypothesized that patients with greater eating disorder psychopathology, more frequent binge/ purge symptoms, slower rate of symptom interruption, and more severe indicators of cognitive psychopathology would be more likely to experience a return of binge/purge symptoms within several months of completing DH treatment.
Method Participants and Procedure Participants were 116 female patients who participated in DH treatment from 2007 to 2013 and were bingeing and/or vomiting at least eight times per month
337
OLMSTED ET AL. TABLE 1.
Demographic and clinical features Mean (SD)
Age Duration of illness (years) BMI Pretreatment Post-treatment Binge frequency Pretreatment Post-treatment Vomit frequency Pretreatment Post-treatment Body Avoidancec Pretreatment Post-treatment % Slow response to DH Body checkingc Pretreatment Post-treatment Weight and shape concerns sumc Pretreatment Post-treatment Treatment duration (weeks)
Rapid Relapse (N 5 32)
No Rapid Relapse (N 5 84)
26.7 (9.9) 9.8 (10.3)
27.8 (9.0) 10.1 (8.8)
22.0 (3.2) 22.5 (3.1)
23.4 (5.0) 23.7 (4.4)
37.5 (32.6)a 0.3 (0.6)
25.8 (24.6) 0.2 (0.4)
66.1 (43.0)b 0.4 (0.7)
35.3 (39.0) 0.3 (0.5)
39.8 (9.3)a 40.5 (10.1) 34.4%a
44.8 (9.7) 42.1 (9.7) 16.7%
73.1 (18.9) 59.5 (21.6)
72.2 (19.3) 54.7 (18.4)
9.3 (2.6) 6.8 (3.0) 7.8 (1.0)
9.7 (2.3) 6.6 (2.9) 7.8 (1.4)
a
p < 0.05. p < 0.001. c N 5 31 for rapid relapse and N 5 79 for No rapid relapse. b
before DH, and who had a maximum of two episodes per month in each of the last month of DH and the first month after DH. Eighty patients treated in the same time interval did not meet this criterion for remission at the end of DH. Of the eligible patients, 71.2% met criteria for DSM-IV-TR BN, an additional 7.2% met criteria for DSM5 BN, and the remaining 21.6%% met criteria for EDNOS/OSFED (14.8% with a Purging Disorder profile, and 6.8% with regular bingeing and less frequent purging). Participants were assessed before and after treatment, and at 6- and 12-month follow-ups. In terms of participation in follow-up, an additional 54 patients appeared to meet inclusion criteria at post-treatment (i.e., had 2 episodes), but did not provide follow-up data, therefore precluding assessment of eligibility in the first month after treatment, and precluding relapse analysis. Thus, 68.2% of potentially eligible patients at posttreatment provided follow-up data and participated in the study. Patients who did not participate in follow-up assessments either declined or could not be reached. Measures This study was approved by the Toronto General Hospital Ethics Review board. Participants provided informed consent to participate, prior to beginning of treatment. Eating disorder symptom frequencies were assessed at pre- and post-DH, and at each follow-up, using an abbreviated Eating Disorder Examination9 (EDE) interview that focused only on diagnostic items. At
338
FIGURE 1 Timing and rate of relapse in the first 6 months after DH treatment. Relapse rates increased consistently for each month in the first 6 months following DH treatment, with 27% of the sample having relapsed by the 6-month follow-up.
6 and 12 month follow-up, symptom frequencies were assessed for each month since the last assessment.10 Eating disorder psychopathology and associated behaviors were also assessed at pre- and post-DH using the Eating Disorder Examination Questionnaire11 (EDE-Q) combined Weight Concerns and Shape Concerns subscales, Body Image Avoidance Questionnaire12 (BIAQ), and Body Checking Questionnaire13 (BCQ). Definitions Slow response to treatment was defined as 4 binge and/or vomit episodes during the first 4 weeks of DH, whereas rapid responders had three or fewer episodes in the first 4 weeks. Rapid relapse was defined as a mean of 8 episodes per month for three consecutive months starting within 6 months of DH discharge. Relapse was defined as occurring in the first of these three consecutive months. The DSM-IV-TR definition was used because the study was completed prior to the publication of DSM-5. Statistical Analysis Cox regression was used to model the rate and timing of relapse. Multivariate analyses of variance (MANOVA) were conducted to test potential predictors at pre- and post-treatment. Variables included binge episodes, vomit episodes, BMI, the combined weight and shape concerns subscales of the EDE, the BIAQ, and the BCQ assessed at pre- and post-treatment. v2 analysis was used to test rapid versus slow response to DH treatment. Findings were summarized in a forced entry Cox regression.
Results Demographic and symptom features are presented in Table 1. The rate of relapse within the first six International Journal of Eating Disorders 48:3 337–340 2015
PREDICTORS OF RAPID RELAPSE
months after DH was 27.6% (see Fig. 1 for a plot of the relapse rate over 6 months). MANOVA on the six predictor variables at pretreatment indicated a significant omnibus effect for group differences, Wilk’s k 5 0.86, F(6, 103) 5 2.73, p 5 .017. As indicated in Table 1, subsequent univariate comparisons were significant for binge and vomit frequencies and the BIAQ. MANOVA on the same six predictor variables measured at the end of treatment yielded no significant differences (p 5 .94). v2 analysis showed a significant association between slow response to treatment and subsequent rapid relapse, v2 (1) 5 4.26, p 5 .04. Therefore, more frequent binge and vomit episodes and lower body avoidance before treatment, and slow response to DH were associated with rapid relapse. The Cox regression model including these four variables was significant, v2(4, N 5 110) 5 19.53, p 5 .001. Together these four variables accounted for 15.2% of the variance in rapid relapse. Other features such as BMI, weight and shape concerns, and body checking, as well as post-treatment variables, were not significant predictors.
Discussion One of the most surprising findings in the current study was that the predictors of rapid relapse were features assessed before DH treatment, along with a variable that reflected how the treatment process unfolded. In contrast, indicators of the severity of eating disorder psychopathology at the end of DH treatment were not significantly associated with relapse during the following six months. This is consistent with Lock et al.’s finding that cognitive psychopathology at end of treatment was not strongly related to future recovery in adult BN.14 However, it is inconsistent with two previous studies which have identified overconcern with weight and shape at the end of treatment as predictors of subsequent relapse.1,6 Importantly, weight and shape concerns before treatment, as measured by the EDE-Q, were comparable to those reported in other research, but weight and shape concerns at the end of treatment were somewhat lower in our sample.15 This is to be expected from a highly intensive treatment such as DH and may also help to explain the failure to observe an association between weight and shape concerns at the end of treatment and subsequent relapse. Perhaps the immersion in treatment for 35 h weekly that facilitates control of bingeing and vomiting also encourages identification with healthier cognitive psychopathology. Rather than conceptualizing the DH as simply a controlling environment which International Journal of Eating Disorders 48:3 337–340 2015
prohibits behavioral symptoms, it may be more helpful to consider participants’ engagement in an “other world” not governed by the same rules and patterns of interaction as their usual environments. The theme for this journey is change and recovery and some participants may be carried along in the current created by others. In this homogenizing context, it may be difficult to identify prognostic indicators. When intensive treatment ends and individuals re-engage more fully with their own lives, differences may become more apparent. Patients who relapsed soon after DH were more symptomatic and engaged in less body avoidance before treatment and were slow responders to treatment. This suggests that for these individuals, relatively high frequencies of bingeing and vomiting may have been accompanied by some degree of accommodation or comfort with their bodies. Perhaps their slower response to treatment reflects a process of being swept along in the current of the intensive treatment experience. When this ended, the momentum may have diminished over the following few months until it was outweighed by the entrenchment of their eating disorder in their everyday life. Increased therapeutic attention to the function served by the eating disorder and the development of alternative means of having these needs met may help these patients make a more enduring foray into recovery. It is also possible that intensified efforts to support rapid response to treatment may ameliorate rates of rapid relapse. Individuals who achieve symptom control early in intensive treatment may progress more quickly to consideration of maintaining factors. Study limitations included a relatively small sample size and a potential lack of generalizability of the findings to non-DH treatment settings. The 68% rate of participation in follow-up was another limitation of the study, especially related to the validity of the rate of rapid relapse. The participation rate is less problematic related to the identification of predictors of relapse, but could still result in a biased sample. Strengths included the conduct of face-toface interviews at follow-up assessments.
References 1. Fairburn CG, Peveler RC, Jones R, Hope A, Doll H. Predictors of 12-month outcome in bulimia nervosa and the influence of attitudes to weight and shape. J Consult Clin Psychol 1993;61:696–698. 2. Grilo CM, Pagano ME, Stout RL, Markowitz JC, Ansell EB, Pinto A, et al. Stressful life events predict eating disorder relapse following remission: Six-year prospective outcomes. Int J Eat Disord 2012;45:185–192. 3. Halmi K, Agras W, Mitchell J, Wilson G, Crow S, Bryson S, et al. Relapse predictors of patients with bulimia nervosa who achieved abstinence
339
OLMSTED ET AL.
4. 5.
6.
7. 8. 9.
through cognitive behavioral therapy. Arch Gen Psychiatry 2002;59: 1105–1109. Halmi K, Agras W, Mitchell J, Wilson G, Crow S. Relapse in bulimia nervosa—In reply. Arch Gen Psychiatry 2003;60:850–851. Herzog DB, Dorer DJ, Keel PK, Selwyn SE, Ekeblad ER, Flores AT, et al. Recovery and relapse in anorexia and bulimia nervosa: A 7.5 year follow-up study. J Am Acad Child Adolesc Psychiatry 1999;388:29–837. Keel PK, Dorer DJ, Franko DL, Jackson SC, Herzog DB. Postremission predictors of relapse in women with eating disorders. Am J Psychiatry 2005;162: 2263–2268. Olmsted MP, Kaplan AS, Rockert W. Rate and prediction of relapse in bulimia nervosa. Am J Psychiatry 1994;151:738–743. Olmsted MP, Kaplan AS, Rockert W. Defining remission and relapse in bulimia nervosa. Int J Eat Disord 1995;38:1–6. Fairburn CG, Cooper Z, O’Connor ME. Eating disorder examination (Edition 16.0D). In: Fairburn CG, editor. Cognitive Behavior Therapy and Eating Disorders. New York: Guilford, 2008, pp. 265–308.
340
10. Ravaldi C, Vannacci A, Truglia E, Zucchi T, Mannucci E, Rotella CM, et al. The eating disorder examination as a retrospective interview. Eat Weight Disord 2004;9:228–231. 11. Fairburn CG, Beglin SJ. Assessment of eating disorders: Interview or selfreport questionnaire? Int J Eat Disord 1994;16:363–370. 12. Rosen JC, Srebnik D, Saltzberg E, Wendt S. Development of a body image avoidance questionnaire. Psychol Assessment 1991;3:32–37. 13. Reas DL, Whisenhunt BL, Netemeyer R, Williamson DA. Development of the body checking questionnaire: A self-report measure of body checking behaviors. Int J Eat Disord 2002;31:324–333. 14. Lock J, Agras WS, LeGrange D, Courturier J, Safer D, Bryson SW. Do end of treatment assessments predict outcome at follow-up in eating disorders? Int J Eat Disord 2013;46:771–778. 15. Sysko R, Walsh BT, Fairburn CG. Eating disorder examination-questionnaire as a measure of change in patients with bulimia nervosa. Int J Eat Disord 2005;37:100–106.
International Journal of Eating Disorders 48:3 337–340 2015
Copyright of International Journal of Eating Disorders is the property of John Wiley & Sons, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Predictors of Rapid Relapse in Bulimia Nervosa Marion P. Olmsted, PhD1,2* Danielle E. MacDonald, MA1,3 Traci McFarlane, PhD1,2,3 Kathryn Trottier, PhD1,2 Patricia Colton, MD1,2
ABSTRACT Objective: Relapse remains a significant concern in bulimia nervosa, with some patients relapsing within months of treatment completion. The purpose of the study was to identify predictors of relapse within the first 6 months following treatment. Method: The 116 participants were bingeing and/or vomiting 8 times per month before day hospital (DH), and had 2 episodes per month in the last month of DH and the first month after DH. Rapid relapse was defined as 8 episodes per month for 3 months starting within 6 months. Results: The rate of rapid relapse was 27.6%. Patients who relapsed soon after DH had higher frequencies of bingeing and vomiting before treatment,
Introduction Relapse is a significant concern in eating disorders, with estimates of relapse for bulimia nervosa (BN) ranging from 25 to 63%, depending on the definition of relapse and length of follow-up.1–8 The first six months following remission may be a peak period for relapse.2,4,7 Predictors of relapse in BN include: younger age; shorter duration of illness; fewer weeks of abstinence and slower interruption of binge/purge symptoms during treatment; higher shape and weight concerns, more eating disorder psychopathology, more residual symptoms, and poorer psychosocial functioning at the end of treatment; and more stressful negative life events related to work and social relationships following treatment.1–3,6,7
Accepted 8 December 2014 Disclosure of Conflicts: None of the authors have any conflicts of interest (financial or otherwise) to disclose. There is no funding source to disclose *Correspondence to: Dr. Marion P. Olmsted, PhD, Eating Disorder Program, Toronto General Hospital, University Health Network, 7 Eaton South, Room 413, 200 Elizabeth Street, Toronto, Ontario, Canada, M5G 2C4. E-mail: [email protected] 1 Department of Psychiatry, University Health Network, Toronto, Canada 2 Department of Psychiatry, University of Toronto, Toronto, Canada 3 Department of Psychology, Ryerson University, Toronto, Canada Published online 26 December 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/eat.22380 C 2014 Wiley Periodicals, Inc. V
International Journal of Eating Disorders 48:3 337–340 2015
engaged in less body avoidance before treatment and were more likely to be slow responders to treatment. Weight and shape concerns and body checking were not significant predictors. Discussion: More frequent bulimic symptoms accompanied by less body avoidance may indicate an entrenchment in the illness which in turn augurs a labored and transient response to DH treatment that is difficult to sustain after intensive treatment C 2014 Wiley Periodicals, Inc. ends. V Keywords: bulimia nervosa; relapse; rapid relapse; rapid response (Int J Eat Disord 2015; 48:337–340)
Residual psychopathology at the end of treatment for BN is one of the most commonly identified predictors of relapse and provides a parsimonious explanation for early relapse. Individuals who require day hospital (DH) treatment for BN fall at the more severe end of the spectrum, and some may achieve control of behavioral symptoms only with very intensive support. For many of these patients, the factors maintaining their eating disorder may have been temporarily sidestepped rather than resolved, and their new eating behaviors may be out of synchrony with their psychological functioning. These patients may be at significant risk for rapid relapse. The purpose of the current study was to identify predictors of rapid relapse within the first six months following DH treatment. It was hypothesized that patients with greater eating disorder psychopathology, more frequent binge/ purge symptoms, slower rate of symptom interruption, and more severe indicators of cognitive psychopathology would be more likely to experience a return of binge/purge symptoms within several months of completing DH treatment.
Method Participants and Procedure Participants were 116 female patients who participated in DH treatment from 2007 to 2013 and were bingeing and/or vomiting at least eight times per month
337
OLMSTED ET AL. TABLE 1.
Demographic and clinical features Mean (SD)
Age Duration of illness (years) BMI Pretreatment Post-treatment Binge frequency Pretreatment Post-treatment Vomit frequency Pretreatment Post-treatment Body Avoidancec Pretreatment Post-treatment % Slow response to DH Body checkingc Pretreatment Post-treatment Weight and shape concerns sumc Pretreatment Post-treatment Treatment duration (weeks)
Rapid Relapse (N 5 32)
No Rapid Relapse (N 5 84)
26.7 (9.9) 9.8 (10.3)
27.8 (9.0) 10.1 (8.8)
22.0 (3.2) 22.5 (3.1)
23.4 (5.0) 23.7 (4.4)
37.5 (32.6)a 0.3 (0.6)
25.8 (24.6) 0.2 (0.4)
66.1 (43.0)b 0.4 (0.7)
35.3 (39.0) 0.3 (0.5)
39.8 (9.3)a 40.5 (10.1) 34.4%a
44.8 (9.7) 42.1 (9.7) 16.7%
73.1 (18.9) 59.5 (21.6)
72.2 (19.3) 54.7 (18.4)
9.3 (2.6) 6.8 (3.0) 7.8 (1.0)
9.7 (2.3) 6.6 (2.9) 7.8 (1.4)
a
p < 0.05. p < 0.001. c N 5 31 for rapid relapse and N 5 79 for No rapid relapse. b
before DH, and who had a maximum of two episodes per month in each of the last month of DH and the first month after DH. Eighty patients treated in the same time interval did not meet this criterion for remission at the end of DH. Of the eligible patients, 71.2% met criteria for DSM-IV-TR BN, an additional 7.2% met criteria for DSM5 BN, and the remaining 21.6%% met criteria for EDNOS/OSFED (14.8% with a Purging Disorder profile, and 6.8% with regular bingeing and less frequent purging). Participants were assessed before and after treatment, and at 6- and 12-month follow-ups. In terms of participation in follow-up, an additional 54 patients appeared to meet inclusion criteria at post-treatment (i.e., had 2 episodes), but did not provide follow-up data, therefore precluding assessment of eligibility in the first month after treatment, and precluding relapse analysis. Thus, 68.2% of potentially eligible patients at posttreatment provided follow-up data and participated in the study. Patients who did not participate in follow-up assessments either declined or could not be reached. Measures This study was approved by the Toronto General Hospital Ethics Review board. Participants provided informed consent to participate, prior to beginning of treatment. Eating disorder symptom frequencies were assessed at pre- and post-DH, and at each follow-up, using an abbreviated Eating Disorder Examination9 (EDE) interview that focused only on diagnostic items. At
338
FIGURE 1 Timing and rate of relapse in the first 6 months after DH treatment. Relapse rates increased consistently for each month in the first 6 months following DH treatment, with 27% of the sample having relapsed by the 6-month follow-up.
6 and 12 month follow-up, symptom frequencies were assessed for each month since the last assessment.10 Eating disorder psychopathology and associated behaviors were also assessed at pre- and post-DH using the Eating Disorder Examination Questionnaire11 (EDE-Q) combined Weight Concerns and Shape Concerns subscales, Body Image Avoidance Questionnaire12 (BIAQ), and Body Checking Questionnaire13 (BCQ). Definitions Slow response to treatment was defined as 4 binge and/or vomit episodes during the first 4 weeks of DH, whereas rapid responders had three or fewer episodes in the first 4 weeks. Rapid relapse was defined as a mean of 8 episodes per month for three consecutive months starting within 6 months of DH discharge. Relapse was defined as occurring in the first of these three consecutive months. The DSM-IV-TR definition was used because the study was completed prior to the publication of DSM-5. Statistical Analysis Cox regression was used to model the rate and timing of relapse. Multivariate analyses of variance (MANOVA) were conducted to test potential predictors at pre- and post-treatment. Variables included binge episodes, vomit episodes, BMI, the combined weight and shape concerns subscales of the EDE, the BIAQ, and the BCQ assessed at pre- and post-treatment. v2 analysis was used to test rapid versus slow response to DH treatment. Findings were summarized in a forced entry Cox regression.
Results Demographic and symptom features are presented in Table 1. The rate of relapse within the first six International Journal of Eating Disorders 48:3 337–340 2015
PREDICTORS OF RAPID RELAPSE
months after DH was 27.6% (see Fig. 1 for a plot of the relapse rate over 6 months). MANOVA on the six predictor variables at pretreatment indicated a significant omnibus effect for group differences, Wilk’s k 5 0.86, F(6, 103) 5 2.73, p 5 .017. As indicated in Table 1, subsequent univariate comparisons were significant for binge and vomit frequencies and the BIAQ. MANOVA on the same six predictor variables measured at the end of treatment yielded no significant differences (p 5 .94). v2 analysis showed a significant association between slow response to treatment and subsequent rapid relapse, v2 (1) 5 4.26, p 5 .04. Therefore, more frequent binge and vomit episodes and lower body avoidance before treatment, and slow response to DH were associated with rapid relapse. The Cox regression model including these four variables was significant, v2(4, N 5 110) 5 19.53, p 5 .001. Together these four variables accounted for 15.2% of the variance in rapid relapse. Other features such as BMI, weight and shape concerns, and body checking, as well as post-treatment variables, were not significant predictors.
Discussion One of the most surprising findings in the current study was that the predictors of rapid relapse were features assessed before DH treatment, along with a variable that reflected how the treatment process unfolded. In contrast, indicators of the severity of eating disorder psychopathology at the end of DH treatment were not significantly associated with relapse during the following six months. This is consistent with Lock et al.’s finding that cognitive psychopathology at end of treatment was not strongly related to future recovery in adult BN.14 However, it is inconsistent with two previous studies which have identified overconcern with weight and shape at the end of treatment as predictors of subsequent relapse.1,6 Importantly, weight and shape concerns before treatment, as measured by the EDE-Q, were comparable to those reported in other research, but weight and shape concerns at the end of treatment were somewhat lower in our sample.15 This is to be expected from a highly intensive treatment such as DH and may also help to explain the failure to observe an association between weight and shape concerns at the end of treatment and subsequent relapse. Perhaps the immersion in treatment for 35 h weekly that facilitates control of bingeing and vomiting also encourages identification with healthier cognitive psychopathology. Rather than conceptualizing the DH as simply a controlling environment which International Journal of Eating Disorders 48:3 337–340 2015
prohibits behavioral symptoms, it may be more helpful to consider participants’ engagement in an “other world” not governed by the same rules and patterns of interaction as their usual environments. The theme for this journey is change and recovery and some participants may be carried along in the current created by others. In this homogenizing context, it may be difficult to identify prognostic indicators. When intensive treatment ends and individuals re-engage more fully with their own lives, differences may become more apparent. Patients who relapsed soon after DH were more symptomatic and engaged in less body avoidance before treatment and were slow responders to treatment. This suggests that for these individuals, relatively high frequencies of bingeing and vomiting may have been accompanied by some degree of accommodation or comfort with their bodies. Perhaps their slower response to treatment reflects a process of being swept along in the current of the intensive treatment experience. When this ended, the momentum may have diminished over the following few months until it was outweighed by the entrenchment of their eating disorder in their everyday life. Increased therapeutic attention to the function served by the eating disorder and the development of alternative means of having these needs met may help these patients make a more enduring foray into recovery. It is also possible that intensified efforts to support rapid response to treatment may ameliorate rates of rapid relapse. Individuals who achieve symptom control early in intensive treatment may progress more quickly to consideration of maintaining factors. Study limitations included a relatively small sample size and a potential lack of generalizability of the findings to non-DH treatment settings. The 68% rate of participation in follow-up was another limitation of the study, especially related to the validity of the rate of rapid relapse. The participation rate is less problematic related to the identification of predictors of relapse, but could still result in a biased sample. Strengths included the conduct of face-toface interviews at follow-up assessments.
References 1. Fairburn CG, Peveler RC, Jones R, Hope A, Doll H. Predictors of 12-month outcome in bulimia nervosa and the influence of attitudes to weight and shape. J Consult Clin Psychol 1993;61:696–698. 2. Grilo CM, Pagano ME, Stout RL, Markowitz JC, Ansell EB, Pinto A, et al. Stressful life events predict eating disorder relapse following remission: Six-year prospective outcomes. Int J Eat Disord 2012;45:185–192. 3. Halmi K, Agras W, Mitchell J, Wilson G, Crow S, Bryson S, et al. Relapse predictors of patients with bulimia nervosa who achieved abstinence
339
OLMSTED ET AL.
4. 5.
6.
7. 8. 9.
through cognitive behavioral therapy. Arch Gen Psychiatry 2002;59: 1105–1109. Halmi K, Agras W, Mitchell J, Wilson G, Crow S. Relapse in bulimia nervosa—In reply. Arch Gen Psychiatry 2003;60:850–851. Herzog DB, Dorer DJ, Keel PK, Selwyn SE, Ekeblad ER, Flores AT, et al. Recovery and relapse in anorexia and bulimia nervosa: A 7.5 year follow-up study. J Am Acad Child Adolesc Psychiatry 1999;388:29–837. Keel PK, Dorer DJ, Franko DL, Jackson SC, Herzog DB. Postremission predictors of relapse in women with eating disorders. Am J Psychiatry 2005;162: 2263–2268. Olmsted MP, Kaplan AS, Rockert W. Rate and prediction of relapse in bulimia nervosa. Am J Psychiatry 1994;151:738–743. Olmsted MP, Kaplan AS, Rockert W. Defining remission and relapse in bulimia nervosa. Int J Eat Disord 1995;38:1–6. Fairburn CG, Cooper Z, O’Connor ME. Eating disorder examination (Edition 16.0D). In: Fairburn CG, editor. Cognitive Behavior Therapy and Eating Disorders. New York: Guilford, 2008, pp. 265–308.
340
10. Ravaldi C, Vannacci A, Truglia E, Zucchi T, Mannucci E, Rotella CM, et al. The eating disorder examination as a retrospective interview. Eat Weight Disord 2004;9:228–231. 11. Fairburn CG, Beglin SJ. Assessment of eating disorders: Interview or selfreport questionnaire? Int J Eat Disord 1994;16:363–370. 12. Rosen JC, Srebnik D, Saltzberg E, Wendt S. Development of a body image avoidance questionnaire. Psychol Assessment 1991;3:32–37. 13. Reas DL, Whisenhunt BL, Netemeyer R, Williamson DA. Development of the body checking questionnaire: A self-report measure of body checking behaviors. Int J Eat Disord 2002;31:324–333. 14. Lock J, Agras WS, LeGrange D, Courturier J, Safer D, Bryson SW. Do end of treatment assessments predict outcome at follow-up in eating disorders? Int J Eat Disord 2013;46:771–778. 15. Sysko R, Walsh BT, Fairburn CG. Eating disorder examination-questionnaire as a measure of change in patients with bulimia nervosa. Int J Eat Disord 2005;37:100–106.
International Journal of Eating Disorders 48:3 337–340 2015
Copyright of International Journal of Eating Disorders is the property of John Wiley & Sons, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
