Psychothcr Psychosom 1991;56:56-63
© 1991 S. Karger AG, Basel 0033-3190/91/0562-0056S2.75/0
Therapy Outcome of Two Treatment Models for Bulimia nervosa: Preliminary Results of a Controlled Study Reinhard Liedtke, Burkhard Jäger, Wolfgang Lempa, Hans-Werner Künsebeck, Margret Gröne, Hellmuth Freyberger Department of Psychosomatic Medicine, Hannover Medical School, Hannover, FRG
Abstract. Beyond the reduction of the core symptoms, different modification patterns are expected due to differing emphases in two alternative types of treatment for bulimia nervosa: inpatient analytic and outpatient systemic therapy. The initial results of a study with a waiting-list control group are reported. Eating disorders of the bulimic women definitely improved in both therapy groups, the results for the inpatient group (n = 27) indicate a basic change in the attitude towards eating.
In order to explain the effect of different types of therapy for one particular disorder, therapy-induced changes have to be mea sured on a broad spectrum of symptomatic and psychological dimensions. Therefore, the assessment of effects of two alternative treatments for bulimia nervosa - inpatient analytically oriented or outpatient systemic - is the focal point of our therapy process evaluation. Beyond the reduction of core symptoms after either therapy, different modification patterns are expected due to differing emphases in the two therapy groups. So far there is little empirical proof in the literature on bulimia nervosa for either the efficacy of the conflict-centered inpatient analytic therapy or the outpatient
systemic one [ 1, 2], This report is based on the initial results of a study in which patients awaiting treatment served as controls.
The Two Types of Treatment Four psychoanalytic group sessions per week in closed heterogeneous groups are the main element in our 2-month inpatient treatment [3], The analytic group therapist allows the patient to become vividly aware of his unconscious defence, rejected desires, emotions and transference and helps him gain an insight into the importance of previous self-deceit. The initial interventions aim to show the patient that his symptoms and conflicts already con tain solutions which represent achievements. How ever, these are no longer experienced as satisfactory.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 11:15:46 PM
Introduction
Therapy Outcome of Two Treatment Models for Bulimia nervosa
In addition to the psychoanalytic groups, there are integrated, structured groups which are presented with a task or topic, and non verbal behavior is specifically encouraged. Male and female nurses conduct interactive exercises, creative therapy and use bodyoriented techniques. Our therapeutic ap proach also includes morning exercises, a symptom-centered round and the ward meeting as well as individual therapy where necessary. The systemic therapy which includes one or two longer treatment units per month and runs for 1 year is using the Milan Family Therapy Model. It is based on the assumption that a patient's somatic disorders are not primarily an expression of personal problems but have developed on the basis of intrafamiliar or interpersonal conflicts. Consequent ly, the patient is presenting a relationship system and his problem is fully embedded in this context. Any of his changes have to be concomitant with changes in his environment. The central question in systemic family therapy is not about the causes but about the effects of phenomena: of symptoms, on relevant rela tionships in the past but especially in the present and the future [4], In this therapy the guiding principle is instigation rather than working through [5]. Circular questions are a method of hypothetically playing with constructive alternatives to prevalent views and be havioral patterns. They also direct attention towards potential solutions to the problem or what may al ready have solved it temporarily [4],
Systemic therapy has also been intro duced lately as systemic individual therapy in the sense of ‘family therapy without a family’, whenever the family is not (yet?)
ready for family therapy or the patient not (yet?) inclined to address personal problems relating to his own family.
Patients, Indications, Measuring Instruments Within this project sponsored by the RobertBosch Foundation, Stuttgart, FRG, only female pa tients are accepted for therapy. They have to satisfy the following operational DSM-III-R criteria [6]: (1) A minimum average of two binge eating episodes a week for at least 3 months whereby bingeing is de fined as such by the patient; (2) a feeling of lack of control over eating behavior during the eating binges; (3) the ingested food is subsequently disgorged as a weight control measure, and (4) the patient is con stantly preoccupied with her figure and weight and wants to weigh at least 5% less than her current weight, keeps herself constantly at least 5% below normal or feels she is at least ‘a little too fat’ (inter view). The patients are not assigned to the two treatment conditions by randomization, which in our opinion would jeopardize the validity of our results for exter nal treatment settings. Each patient is seen alternately by one member of the two treatment teams for an initial interview and subsequently asked about her therapy expectations by a third member of the project during the standardized interview on eating behavior. A case conference decides on the indication. Criteria to be considered for choosing between the alternative treatment approaches arc: the capacity of the family therapy team and the psychosomatic ward; would the patient’s family and professional ties permit a 2month inpatient treatment; previous therapies and the patient’s choice of therapy. Patients with very serious neurotic symptoms or personality disorders with additional severe addictions (e.g. alcohol) or only minor eating problems are not included in the project. The therapy process is evaluated. Some of the patients are assessed at the end of the waiting period prior to therapy, and all again 1 month, 1 year and 2 years after termination of the therapy. The data col lected comprise standard diagnostics including an in ventory of complaints (B-L) [7], the Freiburg Person ality Inventory [8], disorder-specific diagnostics with
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 11:15:46 PM
and hence seem to be in need of change. In this way the patient can regain or maintain his self-esteem and more easily distance himself from previous solutions. This type of intervention usually reinforces positive transference and strengthens the working relation ship, opening up the possibility to approach relevant conflict areas.
57
Liedtke/Jäger/Lempa/Künsebeck/Gröne/Freyberger
the above-mentioned interview and a questionnaire on eating behavior (EAT-EDI-ANIS) [9-11], a de pression scale (D-S) [12], and treatment-specific di mensions such as the Family Assessment Measure [ 13, 14], Major changes were expected for the inpa tient group with regard to affective experience. In the systemic treatment group we felt that changes would affect primarily cognitive dimensions and the percep tion of significant others including the family. So far 27 patients have completed the psychoanalytically oriented inpatient group therapy. The results presented here mainly refer to their group. Follow-up was 1 month after therapy, i.c. about 3 months after the beginning of therapy. The average age of these patients was 23.1 years, the mean duration of illness about 3.6 ± 4.3 years. The first binge/purge episode was considered to be the onset of the disorder. Pa tients in systemic therapy were 23.3 years on average; the mean duration of illness was 5.2 ± 3.9 years; they were also reassessed 3 months after the beginning of therapy. At that time they had already had 3 or 4 of the 10-15 therapy sessions. For additional compari son, the data of the waiting group - which was with out therapy for an average of 2 months - is ana lyzed.
Results Based on data collected during the stan dardized interview about eating behavior and from the various questionnaires, mean values were calculated and tested for signifi cance with two-tailed t tests. At the follow up interview, 52% of the inpatient group were symptom-free by DSM-III-R criteria with regard to bingeing/purging, i.e. there was no case of bingeing with subsequent purging more often than once a week during the last 4 weeks (table 1). As for systemic therapy patients, 33% were symptom-free at the time. Using mean values, changes in the core symptoms are given in figures 1 and 2. The frequency of bingeing per week decreases to an average of 3.5 for inpatients, for systemic
therapy patients it is about 5.6, whereas the waiting group still binges approximately 11 times per week. Figure 2 shows similar changes for self-induced vomiting after food intake only for the two treatment groups. Table 2 represents further data collected during the interview on eating behavior. As you can see in this table, the number o f‘nor mal’ meals per day, defined as minimum consumption of half a roll or two apples within a certain time period, has increased for inpatients who have completed their therapy. The number of measures to control eating behavior, such as going without meals or taking laxatives, has decreased. During follow-up, inpatients also feel less restricted by bulimia, for instance in their ability to concentrate or in their sexuality. The actual weight remains practically constant in both therapy groups, the desired weight is clearly lower but increases in both groups so this can be seen as a therapeutic success. The first five dimensions in table 2 represent counting variables and were tested for normal distri bution using the Kolmogorov-Smirnov test. The hy pothesis of normal distribution could not be main tained for the frequency of bingeing and purging. Therefore, the sign test was used to check the results. No changes were found in the level of significance.
In addition to the interview questions the patients were given a questionnaire on eat ing behavior with seven scales derived from
Tabic 1. Frequency of binges/purges (interview) Times per week
Inpatient therapy Systemic therapy postT, % midT. % (n - 29) (n = 27)
0-1 >2
52 48
33 67
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 11:15:46 PM
58
59
Therapy Outcome of Two Treatment Models for Bulimia nervosa
the EAT [9], the EDI [ 10] and the ANIS [ 11 ]. In line with our expectations, table 3 shows a significant decrease in five out of seven di mensions for the inpatient group and in two out of seven dimensions for the outpatients. The variable 'dieting’ comprises fear of over weight and deliberate choice of low-calorie food, the preoccupation with food and vom iting is covered by the variable ‘bulimia and food preoccupation’. The variables ‘oral con trol’ (i.e. self-discipline during eating and the importance of food for others) and ‘interper sonal distrust’ (i.e. distrust in interpersonal relationships) are directed primarily at an orexia nervosa. Waiting group patients show
Fig. 1. Frequency of binges/week.----- = Inpatient group;----- -- systemic group; ....... ... waiting group. Fig. 2. Frequency of purges/week. ----- -- Inpa tient group;----- = systemic group.
Table 2. Interview on eating behavior Inpatient therapy (n = 27) preT Frequency of binges per week Frequency of purges per week Number of normal meals per day Measures to control eating behavior Sum of restrictions due to bulimia Actual weight, kg Desired weight, kg
postT
Systemic therapy (n = 29) preT
midT
11.9 ± 10.4
3.5 ±5.5**
10.8 ±7.6
5.6± 5.9**
11.9 ±13.4
3.7 ±7.4**
10.8 ±7.6
5.6±6.0**
2.0± 1.3
2.9 ±1.0**
2.0± 1.3
2.1 ±1.4
4.5 ± 1.7
2.6 ±2.4**
3.8 ± 1.7
3.2 ±1.9
7.0± 1.9 58.4 ± 9.1 54.7±6.8
4.2 ±2.9** 58.0±8.2 55.5 ± 7.2
5.7 ± 2.2 58.1 ±5.3 54.6 ± 5.3
5.0 ±2.4 58.3 ± 6.1 55.6 ±6.0*
Values are mean ± SD. * p < 0.05; ** p < 0.01.
Waiting group (n=ll) preW
preT
11.8 ± 7.6
11.3± 10.2
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 11:15:46 PM
Variable
60
Liedtke/'Jäger/Lempa/Künsebeck/Gröne/Freyberger
Table 3. Questionnaire on eating behavior (EAT-EDI-ANIS) Variable
Dieting EAT Bulimia and food pre occupation EAT Oral control EAT Ineffectivity EDI Interoceptive awareness EDI Interpersonal distrust EDI Anancastia ANIS
Inpatient therapy (n = 27)
Systemic therapy (n = 29)
Waiting group (n = II)
preT
postT
preT
mid I'
preW
preT
20.0 ±6.9
14.2 ±7.6**
20.8 ±6.6
18.0 ±7.4
19.4 ± 8.6
18.7±9.0
11.3 ±3.8 3.3 ±3.1 17.9± 5.7
3.9±4.6** 3.2 ±3.4 12.1 ±5.5**
10.1 ±3.9 3.6±3.7 13.5 ± 4.4
7.1 ±5.0** 3.0 ±3.7 12.7 ± 4.5
9.6 ±4.9 4.2 ±3.6 15.6 ±4.8
9.7 ± 5.6 3.7 ± 2.8 14.9 ± 5.5
14.0 ±6.0
8.9±6.3**
9.8 ±5.2
11,4± 7.3
11.0± 7.8
12.1 ±5.1 17.1 ±3.8
12.3 ± 4.2 15.1 ±3.1**
11.6 ± 4.7 18.2 ±4.2
10.6 ±5.6 18.0 ±4.0
12.2 ±5.5* 17.6 ±4.0
8.4 ±6.1 11.3 ± 3.9 16.5 ±3.7**
Values are means ± SD. * p < 0.05; ** p < 0.01.
Table 4. Autonomic complaints and depressivity (B-L, D-S) Variable
Autonomic complaints B-L Dcprcssivcncss D-S
Inpatient therapy (n = 27)
Systemic therapy (n = 29)
Waiting group (n = 11)
preT
preT
preW
postT
32.4 ± 12.9 25.5 ± 12.4* 22.2±9.8 11.0±9.2**
midT
30.6± 13.3 28.6 ± 11.3 15.4 ±6.4 13.8 ±8.1
preT
26.2 ± 1 1.8 29.7 ±14.4 15.6 ±9.2 15.4± 8.8
a significant increase of distrust in others. This may relate either to the fact that they have to wait for therapy to begin or it may be a random result. The ‘ineffectivity’ scale in cludes self-doubts which definitely decrease in the inpatient group just as insecurity and fear of personal feelings show a sharp decline on the 'interoceptive awareness’ scale. Com pulsiveness decreases in both groups as dem onstrated by the variable ‘anancastia’.
Table 4 reports results of the complaints list and the depression scale (B-L, D-S) [7, 12]. Our data indicate that, initially, com plaints and depressiveness are most pro nounced in the inpatient group, decreasing significantly during therapy. This does not apply either to the waiting group or the sys temic therapy group. The results of the Frei burg Personality Inventory [8], limited to the most relevant personality dimensions, are
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 11:15:46 PM
Values are means ± SD. *p < 0.05; **p < 0.01.
Therapy Outcome of Two Treatment Models for Bulimia nervosa
61
Table 5. Freiburg Personality Inventory Variable
Contentment Performance orientation Inhibition Excitability Aggressivity Bodily complaints Openness Extraversión Emotionality
Inpatient therapy (n = 27)
Systemic therapy (n = 29)
Waiting group ( n - 11)
preT
preT
preW
2.3 ± 1.8 5.0 ± 2.1 7.3 ±3.1 8.3 ±3.1 3.9 ±2.5 6.6±3.3 8.3 ± 1.8 5.2 ±3.2 10.7 ± 2.9
postT 3.2 ±2.4 6.2 ±2.4** 6.5±2.6 8.5 ±3.3 4.4 ±3.1 4.9 ±3.1** 8.2 ± 1.8 6.7 ± 3.1 * 9.5 ± 2.9*
midT
preT
2.2±2.4
2.4 ±2.0
2.8 ±2.1
2.8±2.5
5.1 ± 2.1
6.1 ±2.8 6.5 ± 3.1 8.6 ±2.6 4.4 ±2.4 4.8 ±2.6 7.2 ±2.0 6.5 ±3.5 10.2 ±2.8
5.3 ±2.9 7.3 ±3.4 8.3 ± 3.7 3.6±2.8 3.6 ±3.2 6.9±2.0 5.4 ±2.9 10.1 ±1.9
6.0±2.8* 6.9±3.6 9.9±2.7 4.1 ±3.2 3.9±2.7 6.6 ±2.0 6.3±2.7 10.4±3.0
6.8± 3.7 9.0± 2.8 4.2 ±2.1 5.2 ±3.2 7.5 ± 2.1 6.2±3.6 10.6 ±2.9
Values arc means ± SD. * p < 0.05; ** p < 0.01.
Table 6. Family Assessment Measure Variable
Task accomplishment Role performance Communication Affective involvement Affective expression Control Values and norms
Inpatient therapy (n - 27)
Systemic therapy (n - 29)
Waiting group (n = 11)
preT
postT
preT
midT
preW
preT
9.9±2.8 11.0 ± 2.5 12.0 ±2.5 8.3 ± 2.8 10.7 ± 2.8 10.5 ±2.5 10.4±2.6
9.7 ± 2.3 10.5 ±2.9 11.2 ±2.2 8.4±2.7 10.2 ±2.5 10.6 ±1.9 10.2 ±2.5
11.7 ±2.7 11.1 ±2.9 12.4 ±2.3 8.7 ±3.0 11.4 ±2.6 11.4±2.5 10.7 ±3.5
11.1 ±2.4 11.1 ±2.5 12.6 ±2.1 9.3 ±2.4 11.0± 2.5 1 1,0± 2.2 10.5 ± 2.8
11.5 ± 2.4 12.2 ± 3.1 13.1 ±2.1 10.0 ±2.6 11.8 ± 2.8 11.3 ± 2.8 12.1 ±2.7
10.8 ± 2.4 11.9 ± 3.2 12.7 ± 2.2 9.9 ±2.5 12.2 ± 1.9 11.0 ± 2.9 12.4 ±2.9
presented in table 5. According to the selfassessment in this questionnaire, perfor mance and competitiveness (‘performance orientation’) increase in the inpatient group. In accordance with the list of complaints, inpatients mention fewer ‘bodily com plaints’ during follow-up. The significant
changes in the dimensions ‘extraversión’ and ‘emotionality’ indicate that the patients see themselves as more sociable and lively fol lowing inpatient treatment and have fewer emotional problems. Performance also in creases in the waiting group, for which there is no plausible explanation. The Family As
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 11:15:46 PM
Values are means ± SD. * p < 0.05; ** p < 0.01.
Liedtke/Jäger/Lempa/Künsebeck/Gröne/Frcybcrger
sessment Measure [13, 14] served as a fami ly-specific dimension. The results which did not meet with our expectations are con densed in table 6. The variable ‘task accom plishment’ refers to the question of who takes over problem solving in the family. ‘Role performance’ also includes expecta tions of the patient’s role in the family. ‘Communication’ covers the ability or in ability to communicate. The other variables will have to remain undiscussed for lack of space. They show no important changes either in the two therapy groups or the wait ing group. Additionally, it should be men tioned that for about 90% of the patients in systemic therapy, family members partici pated in therapy sessions. Discussion In conclusion we can state that eating dis orders of bulimic inpatients definitely im proved [compare 2, 15-18], which also seems to apply to patients in the systemic therapy which is still continuing. Only some of the inpatients are persistently symptom-free after discharge as far as bingeing and purging are concerned. However, the results indicate a basic change in the attitude towards eating up to a stabilization of self-confidence. As might be expected, the analytically oriented group therapy has partially led to major changes in dimensions comprising affective experience, whereas no changes in the family-specific di mensions have been detected in the group receiving systemic therapy. Our next assess ment after completion of this type of therapy will provide better answers as to its effective ness. Only the scheduled catamneses of 1-2 years will contribute further information on the stability of our results.
References 1 Fairburn CG: The current status of the psycholog ical treatments for bulimia nervosa. J Psychosom Res 1988;32:635-645. 2 Garner DM: Psychotherapy outcome research with bulimia nervosa. Psychother Psychosom 1987:48:129-140. 3 Liedtke R: Strukturelle Grundlagen und therapeu tische Praxis in der stationären Psychotherapie psychosomatisch erkrankter Patienten. Gruppcnpsychother Gruppendynamik 1986;22:138— 150. 4 Schmidt G: Bulimie aus der Perspektive der Syste mischen Familientherapie; in Kämmerer A, Klin genspor B (eds): Bulimie. Stuttgart, Kohlkammer, 1989. pp 49-70. 5 Weber G, Stierlin H: In Liebe entzweit. Die Hei delberger Familientherapie der Magersucht. Rein bek, Rowohlt. 1989. 6 American Psychiatric Association (APA): Diag nostic and Statistical manual of mental disorders, ed 3 revised (DSM-III-R). Washington, American Psychiatric Association, 1987. 7 Zerssen D von: Klinische Selbstbeurteilungsska len (KSb-S) aus dem Münchener Psychiatrischen Informations-System (PSYCH1S München). Die Beschwerden-Liste - Manual. Weinheim, Beltz, 1976. 8 Fahrenberg J, Hampel R, Selg H: Das Freiburger Persönlichkeitsinventar FPL Handanweisung, ed 4 . Göttingen. Hogrefe. 1984. 9 Garner DM, Olmstedt MP. Bohr Y, Garfinkel PE: The Eating Attitudes Test: Psychometric and clin ical correlates. Psychol Med 1982;12:871-878. 10 Garner DM, Olmstedt MP. Polivy J: The Eating Disorders Inventory: A measure of cognitive-be havioral dimensions of anorexia nervosa and bu limia; in Darby PL, Garfinkel PE, Garner DM, Coscina DV (eds): Anorexia nervosa. Recent De velopments in Research. New York, Riss, 1983, pp 173-184. 11 Fichter MM. Kecscr W: Das Anorexia-nervosaInventar zur Selbstbeurteilung (ANIS). Arch Psychiatr Nervenkr 1980;228:67-89. 12 Zerssen D von: Klinische Selbstbeurteilungsska len (KSb-S) aus dem Münchener Psychiatrischen Informations-System (PSYCHIS München). Paranoid-Depressivitäts-Skala sowie DepressivitätsSkala-Manual. Weinheim, Beltz, 1976.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 11:15:46 PM
62
Therapy Outcome of Two Treatment Models for Bulimia nervosa
17 Laessle RG, Waadt S, Schindler L, Schweiger U, Pirke KM: Strukturierte ambulante Gruppenthe rapie bei Bulimie - Vorläufige Ergebnisse einer kontrollierten Therapiestudie. Psychother Med Psychol 1988;38:324-327. 18 Freeman CPL, Barry F, Dunkeld-Turnbull J, Hen derson A: Controlled trial of psychotherapy for bulimia nervosa. Br Med J 1988;296:521-525.
PD Dr. med. Reinhard Liedtke Department of Psychosomatic Medicine Hannover Medical School Konstanty-Gutschow-Strasse 8 D-W-3000 Hannover 61 (FRG)
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 11:15:46 PM
13 Skinner HA, Steinhauer PD, Santa-Barbara J: The family assessment measure. Can J Comm Ment Health 1983;2:91-105. 14 Cierpka M. Rahm R, Schulz H: Die Testgiitekriterien des ‘Family-Assessment-Measure’ (FAM-version III): in Cierpka M, Nordmann E (eds): Me thoden in der Familienforschung. Berlin, Sprin ger, 1987. pp 83-100. 15 Bosscrt S, Schnabel E. Krieg JC: Effects and limi tations of cognitive behavior therapy in bulimia inpatients. Psychother Psychosom 1989;51:77— 82. 16 Dedman PA, Numa SF, Wakcling A: A cognitive behavioural group approach for the treatment of bulimia nervosa - a preliminary study. J Psycho som Res 1988,32:285-290.
63
© 1991 S. Karger AG, Basel 0033-3190/91/0562-0056S2.75/0
Therapy Outcome of Two Treatment Models for Bulimia nervosa: Preliminary Results of a Controlled Study Reinhard Liedtke, Burkhard Jäger, Wolfgang Lempa, Hans-Werner Künsebeck, Margret Gröne, Hellmuth Freyberger Department of Psychosomatic Medicine, Hannover Medical School, Hannover, FRG
Abstract. Beyond the reduction of the core symptoms, different modification patterns are expected due to differing emphases in two alternative types of treatment for bulimia nervosa: inpatient analytic and outpatient systemic therapy. The initial results of a study with a waiting-list control group are reported. Eating disorders of the bulimic women definitely improved in both therapy groups, the results for the inpatient group (n = 27) indicate a basic change in the attitude towards eating.
In order to explain the effect of different types of therapy for one particular disorder, therapy-induced changes have to be mea sured on a broad spectrum of symptomatic and psychological dimensions. Therefore, the assessment of effects of two alternative treatments for bulimia nervosa - inpatient analytically oriented or outpatient systemic - is the focal point of our therapy process evaluation. Beyond the reduction of core symptoms after either therapy, different modification patterns are expected due to differing emphases in the two therapy groups. So far there is little empirical proof in the literature on bulimia nervosa for either the efficacy of the conflict-centered inpatient analytic therapy or the outpatient
systemic one [ 1, 2], This report is based on the initial results of a study in which patients awaiting treatment served as controls.
The Two Types of Treatment Four psychoanalytic group sessions per week in closed heterogeneous groups are the main element in our 2-month inpatient treatment [3], The analytic group therapist allows the patient to become vividly aware of his unconscious defence, rejected desires, emotions and transference and helps him gain an insight into the importance of previous self-deceit. The initial interventions aim to show the patient that his symptoms and conflicts already con tain solutions which represent achievements. How ever, these are no longer experienced as satisfactory.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 11:15:46 PM
Introduction
Therapy Outcome of Two Treatment Models for Bulimia nervosa
In addition to the psychoanalytic groups, there are integrated, structured groups which are presented with a task or topic, and non verbal behavior is specifically encouraged. Male and female nurses conduct interactive exercises, creative therapy and use bodyoriented techniques. Our therapeutic ap proach also includes morning exercises, a symptom-centered round and the ward meeting as well as individual therapy where necessary. The systemic therapy which includes one or two longer treatment units per month and runs for 1 year is using the Milan Family Therapy Model. It is based on the assumption that a patient's somatic disorders are not primarily an expression of personal problems but have developed on the basis of intrafamiliar or interpersonal conflicts. Consequent ly, the patient is presenting a relationship system and his problem is fully embedded in this context. Any of his changes have to be concomitant with changes in his environment. The central question in systemic family therapy is not about the causes but about the effects of phenomena: of symptoms, on relevant rela tionships in the past but especially in the present and the future [4], In this therapy the guiding principle is instigation rather than working through [5]. Circular questions are a method of hypothetically playing with constructive alternatives to prevalent views and be havioral patterns. They also direct attention towards potential solutions to the problem or what may al ready have solved it temporarily [4],
Systemic therapy has also been intro duced lately as systemic individual therapy in the sense of ‘family therapy without a family’, whenever the family is not (yet?)
ready for family therapy or the patient not (yet?) inclined to address personal problems relating to his own family.
Patients, Indications, Measuring Instruments Within this project sponsored by the RobertBosch Foundation, Stuttgart, FRG, only female pa tients are accepted for therapy. They have to satisfy the following operational DSM-III-R criteria [6]: (1) A minimum average of two binge eating episodes a week for at least 3 months whereby bingeing is de fined as such by the patient; (2) a feeling of lack of control over eating behavior during the eating binges; (3) the ingested food is subsequently disgorged as a weight control measure, and (4) the patient is con stantly preoccupied with her figure and weight and wants to weigh at least 5% less than her current weight, keeps herself constantly at least 5% below normal or feels she is at least ‘a little too fat’ (inter view). The patients are not assigned to the two treatment conditions by randomization, which in our opinion would jeopardize the validity of our results for exter nal treatment settings. Each patient is seen alternately by one member of the two treatment teams for an initial interview and subsequently asked about her therapy expectations by a third member of the project during the standardized interview on eating behavior. A case conference decides on the indication. Criteria to be considered for choosing between the alternative treatment approaches arc: the capacity of the family therapy team and the psychosomatic ward; would the patient’s family and professional ties permit a 2month inpatient treatment; previous therapies and the patient’s choice of therapy. Patients with very serious neurotic symptoms or personality disorders with additional severe addictions (e.g. alcohol) or only minor eating problems are not included in the project. The therapy process is evaluated. Some of the patients are assessed at the end of the waiting period prior to therapy, and all again 1 month, 1 year and 2 years after termination of the therapy. The data col lected comprise standard diagnostics including an in ventory of complaints (B-L) [7], the Freiburg Person ality Inventory [8], disorder-specific diagnostics with
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 11:15:46 PM
and hence seem to be in need of change. In this way the patient can regain or maintain his self-esteem and more easily distance himself from previous solutions. This type of intervention usually reinforces positive transference and strengthens the working relation ship, opening up the possibility to approach relevant conflict areas.
57
Liedtke/Jäger/Lempa/Künsebeck/Gröne/Freyberger
the above-mentioned interview and a questionnaire on eating behavior (EAT-EDI-ANIS) [9-11], a de pression scale (D-S) [12], and treatment-specific di mensions such as the Family Assessment Measure [ 13, 14], Major changes were expected for the inpa tient group with regard to affective experience. In the systemic treatment group we felt that changes would affect primarily cognitive dimensions and the percep tion of significant others including the family. So far 27 patients have completed the psychoanalytically oriented inpatient group therapy. The results presented here mainly refer to their group. Follow-up was 1 month after therapy, i.c. about 3 months after the beginning of therapy. The average age of these patients was 23.1 years, the mean duration of illness about 3.6 ± 4.3 years. The first binge/purge episode was considered to be the onset of the disorder. Pa tients in systemic therapy were 23.3 years on average; the mean duration of illness was 5.2 ± 3.9 years; they were also reassessed 3 months after the beginning of therapy. At that time they had already had 3 or 4 of the 10-15 therapy sessions. For additional compari son, the data of the waiting group - which was with out therapy for an average of 2 months - is ana lyzed.
Results Based on data collected during the stan dardized interview about eating behavior and from the various questionnaires, mean values were calculated and tested for signifi cance with two-tailed t tests. At the follow up interview, 52% of the inpatient group were symptom-free by DSM-III-R criteria with regard to bingeing/purging, i.e. there was no case of bingeing with subsequent purging more often than once a week during the last 4 weeks (table 1). As for systemic therapy patients, 33% were symptom-free at the time. Using mean values, changes in the core symptoms are given in figures 1 and 2. The frequency of bingeing per week decreases to an average of 3.5 for inpatients, for systemic
therapy patients it is about 5.6, whereas the waiting group still binges approximately 11 times per week. Figure 2 shows similar changes for self-induced vomiting after food intake only for the two treatment groups. Table 2 represents further data collected during the interview on eating behavior. As you can see in this table, the number o f‘nor mal’ meals per day, defined as minimum consumption of half a roll or two apples within a certain time period, has increased for inpatients who have completed their therapy. The number of measures to control eating behavior, such as going without meals or taking laxatives, has decreased. During follow-up, inpatients also feel less restricted by bulimia, for instance in their ability to concentrate or in their sexuality. The actual weight remains practically constant in both therapy groups, the desired weight is clearly lower but increases in both groups so this can be seen as a therapeutic success. The first five dimensions in table 2 represent counting variables and were tested for normal distri bution using the Kolmogorov-Smirnov test. The hy pothesis of normal distribution could not be main tained for the frequency of bingeing and purging. Therefore, the sign test was used to check the results. No changes were found in the level of significance.
In addition to the interview questions the patients were given a questionnaire on eat ing behavior with seven scales derived from
Tabic 1. Frequency of binges/purges (interview) Times per week
Inpatient therapy Systemic therapy postT, % midT. % (n - 29) (n = 27)
0-1 >2
52 48
33 67
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 11:15:46 PM
58
59
Therapy Outcome of Two Treatment Models for Bulimia nervosa
the EAT [9], the EDI [ 10] and the ANIS [ 11 ]. In line with our expectations, table 3 shows a significant decrease in five out of seven di mensions for the inpatient group and in two out of seven dimensions for the outpatients. The variable 'dieting’ comprises fear of over weight and deliberate choice of low-calorie food, the preoccupation with food and vom iting is covered by the variable ‘bulimia and food preoccupation’. The variables ‘oral con trol’ (i.e. self-discipline during eating and the importance of food for others) and ‘interper sonal distrust’ (i.e. distrust in interpersonal relationships) are directed primarily at an orexia nervosa. Waiting group patients show
Fig. 1. Frequency of binges/week.----- = Inpatient group;----- -- systemic group; ....... ... waiting group. Fig. 2. Frequency of purges/week. ----- -- Inpa tient group;----- = systemic group.
Table 2. Interview on eating behavior Inpatient therapy (n = 27) preT Frequency of binges per week Frequency of purges per week Number of normal meals per day Measures to control eating behavior Sum of restrictions due to bulimia Actual weight, kg Desired weight, kg
postT
Systemic therapy (n = 29) preT
midT
11.9 ± 10.4
3.5 ±5.5**
10.8 ±7.6
5.6± 5.9**
11.9 ±13.4
3.7 ±7.4**
10.8 ±7.6
5.6±6.0**
2.0± 1.3
2.9 ±1.0**
2.0± 1.3
2.1 ±1.4
4.5 ± 1.7
2.6 ±2.4**
3.8 ± 1.7
3.2 ±1.9
7.0± 1.9 58.4 ± 9.1 54.7±6.8
4.2 ±2.9** 58.0±8.2 55.5 ± 7.2
5.7 ± 2.2 58.1 ±5.3 54.6 ± 5.3
5.0 ±2.4 58.3 ± 6.1 55.6 ±6.0*
Values are mean ± SD. * p < 0.05; ** p < 0.01.
Waiting group (n=ll) preW
preT
11.8 ± 7.6
11.3± 10.2
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 11:15:46 PM
Variable
60
Liedtke/'Jäger/Lempa/Künsebeck/Gröne/Freyberger
Table 3. Questionnaire on eating behavior (EAT-EDI-ANIS) Variable
Dieting EAT Bulimia and food pre occupation EAT Oral control EAT Ineffectivity EDI Interoceptive awareness EDI Interpersonal distrust EDI Anancastia ANIS
Inpatient therapy (n = 27)
Systemic therapy (n = 29)
Waiting group (n = II)
preT
postT
preT
mid I'
preW
preT
20.0 ±6.9
14.2 ±7.6**
20.8 ±6.6
18.0 ±7.4
19.4 ± 8.6
18.7±9.0
11.3 ±3.8 3.3 ±3.1 17.9± 5.7
3.9±4.6** 3.2 ±3.4 12.1 ±5.5**
10.1 ±3.9 3.6±3.7 13.5 ± 4.4
7.1 ±5.0** 3.0 ±3.7 12.7 ± 4.5
9.6 ±4.9 4.2 ±3.6 15.6 ±4.8
9.7 ± 5.6 3.7 ± 2.8 14.9 ± 5.5
14.0 ±6.0
8.9±6.3**
9.8 ±5.2
11,4± 7.3
11.0± 7.8
12.1 ±5.1 17.1 ±3.8
12.3 ± 4.2 15.1 ±3.1**
11.6 ± 4.7 18.2 ±4.2
10.6 ±5.6 18.0 ±4.0
12.2 ±5.5* 17.6 ±4.0
8.4 ±6.1 11.3 ± 3.9 16.5 ±3.7**
Values are means ± SD. * p < 0.05; ** p < 0.01.
Table 4. Autonomic complaints and depressivity (B-L, D-S) Variable
Autonomic complaints B-L Dcprcssivcncss D-S
Inpatient therapy (n = 27)
Systemic therapy (n = 29)
Waiting group (n = 11)
preT
preT
preW
postT
32.4 ± 12.9 25.5 ± 12.4* 22.2±9.8 11.0±9.2**
midT
30.6± 13.3 28.6 ± 11.3 15.4 ±6.4 13.8 ±8.1
preT
26.2 ± 1 1.8 29.7 ±14.4 15.6 ±9.2 15.4± 8.8
a significant increase of distrust in others. This may relate either to the fact that they have to wait for therapy to begin or it may be a random result. The ‘ineffectivity’ scale in cludes self-doubts which definitely decrease in the inpatient group just as insecurity and fear of personal feelings show a sharp decline on the 'interoceptive awareness’ scale. Com pulsiveness decreases in both groups as dem onstrated by the variable ‘anancastia’.
Table 4 reports results of the complaints list and the depression scale (B-L, D-S) [7, 12]. Our data indicate that, initially, com plaints and depressiveness are most pro nounced in the inpatient group, decreasing significantly during therapy. This does not apply either to the waiting group or the sys temic therapy group. The results of the Frei burg Personality Inventory [8], limited to the most relevant personality dimensions, are
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 11:15:46 PM
Values are means ± SD. *p < 0.05; **p < 0.01.
Therapy Outcome of Two Treatment Models for Bulimia nervosa
61
Table 5. Freiburg Personality Inventory Variable
Contentment Performance orientation Inhibition Excitability Aggressivity Bodily complaints Openness Extraversión Emotionality
Inpatient therapy (n = 27)
Systemic therapy (n = 29)
Waiting group ( n - 11)
preT
preT
preW
2.3 ± 1.8 5.0 ± 2.1 7.3 ±3.1 8.3 ±3.1 3.9 ±2.5 6.6±3.3 8.3 ± 1.8 5.2 ±3.2 10.7 ± 2.9
postT 3.2 ±2.4 6.2 ±2.4** 6.5±2.6 8.5 ±3.3 4.4 ±3.1 4.9 ±3.1** 8.2 ± 1.8 6.7 ± 3.1 * 9.5 ± 2.9*
midT
preT
2.2±2.4
2.4 ±2.0
2.8 ±2.1
2.8±2.5
5.1 ± 2.1
6.1 ±2.8 6.5 ± 3.1 8.6 ±2.6 4.4 ±2.4 4.8 ±2.6 7.2 ±2.0 6.5 ±3.5 10.2 ±2.8
5.3 ±2.9 7.3 ±3.4 8.3 ± 3.7 3.6±2.8 3.6 ±3.2 6.9±2.0 5.4 ±2.9 10.1 ±1.9
6.0±2.8* 6.9±3.6 9.9±2.7 4.1 ±3.2 3.9±2.7 6.6 ±2.0 6.3±2.7 10.4±3.0
6.8± 3.7 9.0± 2.8 4.2 ±2.1 5.2 ±3.2 7.5 ± 2.1 6.2±3.6 10.6 ±2.9
Values arc means ± SD. * p < 0.05; ** p < 0.01.
Table 6. Family Assessment Measure Variable
Task accomplishment Role performance Communication Affective involvement Affective expression Control Values and norms
Inpatient therapy (n - 27)
Systemic therapy (n - 29)
Waiting group (n = 11)
preT
postT
preT
midT
preW
preT
9.9±2.8 11.0 ± 2.5 12.0 ±2.5 8.3 ± 2.8 10.7 ± 2.8 10.5 ±2.5 10.4±2.6
9.7 ± 2.3 10.5 ±2.9 11.2 ±2.2 8.4±2.7 10.2 ±2.5 10.6 ±1.9 10.2 ±2.5
11.7 ±2.7 11.1 ±2.9 12.4 ±2.3 8.7 ±3.0 11.4 ±2.6 11.4±2.5 10.7 ±3.5
11.1 ±2.4 11.1 ±2.5 12.6 ±2.1 9.3 ±2.4 11.0± 2.5 1 1,0± 2.2 10.5 ± 2.8
11.5 ± 2.4 12.2 ± 3.1 13.1 ±2.1 10.0 ±2.6 11.8 ± 2.8 11.3 ± 2.8 12.1 ±2.7
10.8 ± 2.4 11.9 ± 3.2 12.7 ± 2.2 9.9 ±2.5 12.2 ± 1.9 11.0 ± 2.9 12.4 ±2.9
presented in table 5. According to the selfassessment in this questionnaire, perfor mance and competitiveness (‘performance orientation’) increase in the inpatient group. In accordance with the list of complaints, inpatients mention fewer ‘bodily com plaints’ during follow-up. The significant
changes in the dimensions ‘extraversión’ and ‘emotionality’ indicate that the patients see themselves as more sociable and lively fol lowing inpatient treatment and have fewer emotional problems. Performance also in creases in the waiting group, for which there is no plausible explanation. The Family As
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 11:15:46 PM
Values are means ± SD. * p < 0.05; ** p < 0.01.
Liedtke/Jäger/Lempa/Künsebeck/Gröne/Frcybcrger
sessment Measure [13, 14] served as a fami ly-specific dimension. The results which did not meet with our expectations are con densed in table 6. The variable ‘task accom plishment’ refers to the question of who takes over problem solving in the family. ‘Role performance’ also includes expecta tions of the patient’s role in the family. ‘Communication’ covers the ability or in ability to communicate. The other variables will have to remain undiscussed for lack of space. They show no important changes either in the two therapy groups or the wait ing group. Additionally, it should be men tioned that for about 90% of the patients in systemic therapy, family members partici pated in therapy sessions. Discussion In conclusion we can state that eating dis orders of bulimic inpatients definitely im proved [compare 2, 15-18], which also seems to apply to patients in the systemic therapy which is still continuing. Only some of the inpatients are persistently symptom-free after discharge as far as bingeing and purging are concerned. However, the results indicate a basic change in the attitude towards eating up to a stabilization of self-confidence. As might be expected, the analytically oriented group therapy has partially led to major changes in dimensions comprising affective experience, whereas no changes in the family-specific di mensions have been detected in the group receiving systemic therapy. Our next assess ment after completion of this type of therapy will provide better answers as to its effective ness. Only the scheduled catamneses of 1-2 years will contribute further information on the stability of our results.
References 1 Fairburn CG: The current status of the psycholog ical treatments for bulimia nervosa. J Psychosom Res 1988;32:635-645. 2 Garner DM: Psychotherapy outcome research with bulimia nervosa. Psychother Psychosom 1987:48:129-140. 3 Liedtke R: Strukturelle Grundlagen und therapeu tische Praxis in der stationären Psychotherapie psychosomatisch erkrankter Patienten. Gruppcnpsychother Gruppendynamik 1986;22:138— 150. 4 Schmidt G: Bulimie aus der Perspektive der Syste mischen Familientherapie; in Kämmerer A, Klin genspor B (eds): Bulimie. Stuttgart, Kohlkammer, 1989. pp 49-70. 5 Weber G, Stierlin H: In Liebe entzweit. Die Hei delberger Familientherapie der Magersucht. Rein bek, Rowohlt. 1989. 6 American Psychiatric Association (APA): Diag nostic and Statistical manual of mental disorders, ed 3 revised (DSM-III-R). Washington, American Psychiatric Association, 1987. 7 Zerssen D von: Klinische Selbstbeurteilungsska len (KSb-S) aus dem Münchener Psychiatrischen Informations-System (PSYCH1S München). Die Beschwerden-Liste - Manual. Weinheim, Beltz, 1976. 8 Fahrenberg J, Hampel R, Selg H: Das Freiburger Persönlichkeitsinventar FPL Handanweisung, ed 4 . Göttingen. Hogrefe. 1984. 9 Garner DM, Olmstedt MP. Bohr Y, Garfinkel PE: The Eating Attitudes Test: Psychometric and clin ical correlates. Psychol Med 1982;12:871-878. 10 Garner DM, Olmstedt MP. Polivy J: The Eating Disorders Inventory: A measure of cognitive-be havioral dimensions of anorexia nervosa and bu limia; in Darby PL, Garfinkel PE, Garner DM, Coscina DV (eds): Anorexia nervosa. Recent De velopments in Research. New York, Riss, 1983, pp 173-184. 11 Fichter MM. Kecscr W: Das Anorexia-nervosaInventar zur Selbstbeurteilung (ANIS). Arch Psychiatr Nervenkr 1980;228:67-89. 12 Zerssen D von: Klinische Selbstbeurteilungsska len (KSb-S) aus dem Münchener Psychiatrischen Informations-System (PSYCHIS München). Paranoid-Depressivitäts-Skala sowie DepressivitätsSkala-Manual. Weinheim, Beltz, 1976.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 11:15:46 PM
62
Therapy Outcome of Two Treatment Models for Bulimia nervosa
17 Laessle RG, Waadt S, Schindler L, Schweiger U, Pirke KM: Strukturierte ambulante Gruppenthe rapie bei Bulimie - Vorläufige Ergebnisse einer kontrollierten Therapiestudie. Psychother Med Psychol 1988;38:324-327. 18 Freeman CPL, Barry F, Dunkeld-Turnbull J, Hen derson A: Controlled trial of psychotherapy for bulimia nervosa. Br Med J 1988;296:521-525.
PD Dr. med. Reinhard Liedtke Department of Psychosomatic Medicine Hannover Medical School Konstanty-Gutschow-Strasse 8 D-W-3000 Hannover 61 (FRG)
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/5/2018 11:15:46 PM
13 Skinner HA, Steinhauer PD, Santa-Barbara J: The family assessment measure. Can J Comm Ment Health 1983;2:91-105. 14 Cierpka M. Rahm R, Schulz H: Die Testgiitekriterien des ‘Family-Assessment-Measure’ (FAM-version III): in Cierpka M, Nordmann E (eds): Me thoden in der Familienforschung. Berlin, Sprin ger, 1987. pp 83-100. 15 Bosscrt S, Schnabel E. Krieg JC: Effects and limi tations of cognitive behavior therapy in bulimia inpatients. Psychother Psychosom 1989;51:77— 82. 16 Dedman PA, Numa SF, Wakcling A: A cognitive behavioural group approach for the treatment of bulimia nervosa - a preliminary study. J Psycho som Res 1988,32:285-290.
63
