Dalle Grave

Seventeen patients meeting the DSM-IV criteria for bulimia nervosa were treated in a specialist setting according to the "guided self-help" approach as outlined in the self-help handbook "Overcoming Binge Eating" by Fairburn. This self-help manual is essentially a condensed version of the cognitive-behavioural therapy for bulimia nervosa developed by the same author. Every patient took part in 8 bimonthly sessions each lasting 20 minutes. All subjects were evaluated both before and after the treatment through a semi-structured interview. Overall, 10 patients (58.8%) did well; 6 of these 10 patients (35.3%) stopped binge-eating and vomiting altogether. Although the conclusions arising from this pilot study have yet to be confirmed by a controlled study, the preliminary findings seem to suggest that "guided self-help" in a specialist setting could, indeed, be not only sufficient in some cases but may also be the most accessible approach in treating many patients affected by bulimia nervosa.

ABSTRACT Cognitive behavioural therapy (CBT) is the most effective treatment for adults with bulimia nervosa (BN), but it is not effective enough; at best, only half of patients make a full remission and it has not been designed for treating patients with anorexia nervosa (AN) and eating disorder not otherwise specified (EDNOS). To address some of these limitations, an enhanced form of CBT for BN, named CBT-E, has been developed. CBT-E adopts modern procedures to address eating disorder psychopathology, and it is suitable for treating all forms of clinical eating disorders. The treatment was originally designed for adults in standard outpatient settings, but was then adapted for intense levels of care (e.g. intensive outpatient, day-hospital, and inpatient). In this article intensive CBT-E for treating eating disorders will be described. A brief summary of the data supporting this novel form of treatment will also be provided.

... Johan Vanderlinden Riccardo Dalle Grave Fernando Fernandez Walter Vandereycken Guido Pieters Chris Noorduin ... In het hier besproken onderzoek beogen we de uitlok-kers van eetbuien te bestuderen in een grote groep eet-stoornispatie¨nten aan de hand van de BETCH. ...

The aim of this study was to assess the possible relationship between the presence of a pathological family background and various eating disorders subgroups. A semi-structured interview was used to assess the socio-demographic and clinical characteristics and the presence of psychological complaints among family members of 79 subjects with anorexia nervosa (AN) and 34 subjects with bulimia nervosa (BN). The subjects were also administered the following self-assessment questionnaires: BITE, EDI, and HSCL-90. There were nonsignificant differences between AN and BN in terms of parental mental disorders. A further subdivision of the patients (as indicated in DSM-IV) revealed significant differences in the distribution of psychiatric family history. In particular, it seems that the presence of purgative behavior is associated with a higher incidence of a pathological family background. These results suggest that pathological family histories are not responsible for the development of ED, but they are an aggravating factor both in AN and BN.

The aim of this pilot study was to evaluate the efficacy of a new school-based eating disorder prevention program designed to reduce dietary restraint and the level of preoccupation with regard to shape and weight. One hundred and six (61 females and 45 males) 11 to 12-year-old students were evaluated, 55 of whom participated in the program (experimental group). An additional 51 students formed the control group. The program met for six sessions, two hours per session. After six months, the experimental group received two booster sessions of two hours in two consecutive weeks. Outcome measures included the Eating Disorder Examination Questionnaire (EDE-Q), the children's version of the Eating Attitudes Test (EAT), the Rosenberg Self-Esteem Scale (RSES), and a Knowledge Questionnaire (KQ) devised by the authors of the program. The questionnaires were administered in both the experimental and control groups, one week before the intervention, one week afterwards, and at six-month and 12-month follow-ups. Unlike a previous school-based eating disorder prevention program, in the experimental group both an increase in knowledge and a decrease in some attitudes were maintained at 12-month follow-up (Eating Concerns EDE-Q scores). Although more intensive interventions seem necessary to modify shape and weight concern and self-esteem, these findings suggest that the intervention had been useful since it led to both an increase in knowledge and a decrease in some dysfunctional eating attitudes.

... The coauthors are working at the same center: Patrizia Todisco, MD, as internist, Manuela Oliosi and Sabrina Marchi as clinical psychologists. Address corre-spondence to: Dr. R. Dalle Grave, Center for Eating Disorders, Casa di Cura Villa Garda, via Montebaldo 53, 1-37016 ...

To study the different factors (external, emotional, cognitive, and physiological) which may trigger binge eating in eating disorder patients and to make a comparison of binge eating triggers in different eating disorder samples, i.e. anorexia nervosa bingeing-purging type and bulimia nervosa (BN). A total of 242 eating disorder patients filled out the Binge Eating Trigger Checklist (BETCH), a new screening device to evaluate the type of situations (and their experienced discomfort) which subjects identify as antecedents of a binge eating episode. Eating disorder patients report a combination of negative emotions, physiological states (urge for sweets) and negative cognitions as most important antecedents for their bingeing episodes. External stimuli were only reported by a small number of patients and provoked significantly lower levels of discomfort. A comparison of binge eating triggers in bingeing anorexia nervosa patients and bulimic patients showed only a few significant differences. Binge eating, as perceived and reported by eating disorder patients, seems to be provoked by a combination of different antecedents, both emotional, cognitive and physiological. Remarkably enough, binge eating triggers did not differ between bingeing anorectic patients and patients suffering from BN.

Demographic, psychopathological and hormonal parameters of 22 women with previous anorexia nervosa (AN) presently recovered, in a state of stabilized nutritional normalization for 3 months to 2 years but with persistent amenorrhoea, and of 20 psychophysically healthy age- and sex-matched normally menstruating controls were studied. Body mass index (BMI) values did not differ in patients and controls. Psychological examination, monitored by Eating Disorder Inventory 1, Bulimic Investigation Test Edinburgh, Yale-Brown-Cornell Eating Disorder Scale, and Tridimensional Personality Questionnaire rating scales, showed the persistence of some of the psychopathological symptoms of AN. Hormonal examinations included basal plasma concentrations of follicle stimulating hormone, luteotropic hormone, estrogens (E), progesterone, thyrotropic hormone, FT(3), FT(4) (immunoradiometric assays), leptin (LEP) (enzymatic-linked-immunosorbent assay) and 24 h urinary free cortisol (immunoradiometric assay). Hormone values were the same in patients and controls, except for E and LEP levels, which were significantly lower in patients than in controls. The concentrations of the two hormones were not correlated with the BMI of the patients, but LEP values were correlated negatively with the difference between the present BMI and the preanorexic one. The values of both hormones correlated negatively with some of the psychopathological aspects typical of AN, in particular with high 'body dissatisfaction', 'ineffectiveness', and 'interpersonal distrust' and with low 'interoceptive awareness'.

Weight-loss maintenance remains a problematic issue in lifestyle modification programmes, but a small percentage of individuals are able to maintain a significant long-term weight loss. This means cognitive mechanisms may effectively contrast the biological pressures to regain weight arising from an obesiogenic environment. Aims of this review were to summarizes and synthesizes the data on the cognitive factors associated with program attrition, weight loss and weight maintenance derived from the QUOVADIS (QUality of life in Obesity: eVAluation and DIsease Surveillance), an observational study on quality of life in 1944 obese patients seeking treatment in 25 medical centres in Italy, and discuss its results in light of other literature. The data obtained suggest that some cognitive factors are associated with treatment discontinuation (namely higher weight-loss expectations, appearance-based primary motivation for weight loss, and unsatisfactory progress), while others with the amount of weight lost (i.e., increased dietary restraint and reduced disinhibition) or with long-term weight loss maintenance in patients who interrupted the treatment (i.e., satisfaction with results achieved, confidence in being able to lose weight without professional help). All these findings have important clinical implications.

Underweight patients with eating disorder not otherwise specified without the over-evaluation of shape and weight (EDNOS-W) represent a diagnostic challenge. We aimed to evaluate their clinical characteristics and treatment outcome, compared with anorexia nervosa (AN) cases. Eighty-eight consecutive patients (81 females; age range 13-50 years, 71 AN, and 17 EDNOS-W) were studied. The differential diagnosis of AN and EDNOS-W was based on the eating disorder examination. Compared with AN, EDNOS-W cases had a milder eating disorder psychopathology, but no differences in anthropometric and clinical data. The response to inpatient cognitive behavioral treatment was good and similar between groups, and no differences in the dropout rate or time-to-dropout were observed. The normalization of body weight in EDNOS-W cases was not associated with the appearance of the over-evaluation of shape and weight. The data gives preliminary support to the proposal to include EDNOS-W in the diagnosis of AN.

The effects of cognitive-behavioral therapy (CBT) on central dopamine (DA), noradrenaline (NE) and serotonin (5-HT) secretion were studied in a group of 50 female inpatients, of which 14 suffered from anorexia nervosa restricted type (AN-R), 14 from anorexia nervosa bingeing-purging type (AN-BP), and 22 from bulimia nervosa (BN). The aim of the study was to see whether or not CBT modifies the secretion of central DA (blood homovanillic acid=HVA), NE (blood 3-methoxy-4-hydroxy-phenylglycol=MHPG) and the 5-HT transporter (as evaluated by the platelet paroxetine binding=[(3)H]-Par-binding), if the physical and psychological effects of CBT correlate with changes of the neurotransmitter secretion; and if the biological effects of CBT are linked to specific psychopathological aspect of the disorders. The treatment lasted 20 weeks. Body-mass Index, bingeing and purging, specific AN-BN psychopathological (EDE 12-OD), depression (Beck Inventory), anxiety (STAY Form-Y-1), impulsiveness (Barratt Impulsiveness Scale), self-esteem (Rosenberg Self-Biochemical Scale) and temperament (Temperament and Character Inventory, Cloninger Scale) were assessed at baseline and at the end of the treatment. CBT significantly improved the psychophysical aspects of the diseases. HVA and MHPG concentrations did not change. The [(3)H]-Par-binding parameters, the maximum binding capacity (B(max)) and dissociation constant (K(d)) values did not change in either AN-R or AN-BP patients, while the [(3)H]-Par B(max) (and not the K(d)) increased significantly in BN patients. Correlations emerged between basal and final [(3)H]-Par B(max) values and psychopathological scores, but not between CBT-induced differences between basal and final values. Our data suggest that only in BN CBT may act through changes in 5-HT system function.

The aim of this study was to compare the immediate and long-term effect of a cognitive-behavior therapy program for anorexia nervosa inpatients with and without concomitant Major Depressive Episodes (MDE). The program has been adapted from the "enhanced" form of Cognitive Behavior Therapy (CBT) for eating disorders. Sixty-three consecutive underweight adult patients with severe eating disorder were treated with inpatient CBT. MDE was assessed with the structured clinical interview for DSM-IV. The Eating Disorder Examination, and the Brief Symptom Inventory were recorded at entry, at the end of treatment, and 6 and 12 months later. MDE was present in 60.3% of participants. No significant differences were observed in the demographic and baseline clinical variables between patients with and without MDE. Significant improvements in weight, and in eating disorder and general psychopathology were showed. There were no differences between participants with and without MDE in terms of treatment outcome, and the severity of depression was not associated with changes in global Eating Disorder Examination score. These findings suggest that a diagnosis of MDE does not influence the outcome of inpatient treatment for anorexia nervosa patients, and that the severity of depression cannot be used to predict the success or failure of such treatment.

Personality traits can affect eating behaviors, the development of obesity, and obesity treatment failure. We investigated the personality characteristics and their relation with disordered eating in 586 obese women consecutively seeking treatment at eight Italian medical centers (age, 47.7±9.8 years) and 185 age-matched, normal weight women without symptoms of eating disorders (Eating Attitude Test<20). The assessment included anthropometry, the Temperament and Character Inventory (TCI), the Binge Eating Scale (BES) and the Night Eating Questionnaire (NEQ). Logistic regression analyses were carried out in different models with BES score≥27 and NEQ≥30 as dependent variables and TCI scores as independent factors. Personality traits of obese individuals included significantly lower self-directedness and cooperativeness on TCI. BES and NEQ scores were higher in obese women, and values above the defined cut-offs were present in 77 and 18 cases (14 with high BES), respectively. After controlling for age and BMI, high BES values were associated with high novelty seeking and harm avoidance and low self-directedness, the last two scales being also associated with high NEQ. We conclude that personality traits differ between obese patients seeking treatment and controls, and the presence of disordered eating is associated with specific personality characteristics.

Large weight losses are rarely achieved through non-surgical procedures, but are also possible without professional help. A massive weight loss may be complicated by the development of an eating disorder psychopathology, followed by weight regain. We report the case of a male patient with super obesity (BMI, 86.2 kg/m(2)), who achieved a massive weight loss (170 kg in 2 years) largely without professional help and without surgery. The final body weight (∼ 100 kg; BMI, 32.6) has now been maintained for nearly 2 years. After weight loss, the patient had massive skin redundancy in several areas including the breasts, arms, abdomen, back, and thighs and a true body weight probably in the normal range. All laboratory tests were normal, with the exception of low free testosterone. Sonographic examination showed gall bladder microlithiasis. No eating disorders and other axis I and axis II psychiatric disorders were present. The case illustrates how much weight loss and weight-loss maintenance can be exceptionally achieved without surgery and without developing an eating disorder of clinical severity or other psychiatric disorders.