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Validity and clinical utility of the DSM-5 severity specifier for bulimia nervosa: results from a multisite sample of patients who received evidence-based treatment

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Abstract

A new “severity specifier” for bulimia nervosa (BN), based on the frequency of inappropriate weight compensatory behaviours (IWCBs), was added to the DSM-5 as a means of documenting heterogeneity and variability in the severity of the disorder. Yet, evidence for its validity in clinical populations, including prognostic significance for treatment outcome, is currently lacking. Existing data from 281 treatment-seeking patients with DSM-5 BN, who received the best available treatment for their disorder (manual-based cognitive behavioural therapy; CBT) in an outpatient setting, were re-analysed to examine whether these patients subgrouped based on the DSM-5 severity levels would show meaningful and consistent differences on (a) a range of clinical variables assessed at pre-treatment and (b) post-treatment abstinence from IWCBs. Results highlight that the mild, moderate, severe, and extreme severity groups were statistically distinguishable on 22 variables assessed at pre-treatment regarding eating disorder pathological features, maintenance factors of BN, associated (current) and lifetime psychopathology, social maladjustment and illness-specific functional impairment, and abstinence outcome. Mood intolerance, a maintenance factor of BN but external to eating disorder pathological features (typically addressed within CBT), emerged as the primary clinical variable distinguishing the severity groups showing a differential treatment response. Overall, the findings speak to the concurrent and predictive validity of the new DSM-5 severity criterion for BN and are important because a common benchmark informing patients, clinicians, and researchers about severity of the disorder and allowing severity fluctuation and patient’s progress to be tracked does not exist so far. Implications for future research are outlined.

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References

  1. Steinhausen H, Weber S (2009) The outcome of bulimia nervosa: findings from one-quarter century of research. Am J Psychiatry 166:1331–1341

    Article  PubMed  Google Scholar 

  2. Keel PK, Brown TA (2010) Update on course and outcome in eating disorders. Int J Eat Disord 43:195–204

    Article  PubMed  Google Scholar 

  3. Steinhausen H (2009) Outcome of eating disorders. Child Adolesc Psychiatr Clin N Am 18:225–242

    Article  PubMed  Google Scholar 

  4. American Psychiatric Association (1994) Diagnostic and statistical manual of mental disorders, 4th edn. American Psychiatric Association, Washington

    Google Scholar 

  5. Mond JM (2013) Classification of bulimic-type eating disorders: from DSM-IV to DSM-5. J Eat Disord. doi:10.1186/2050-2974-1-33

    Google Scholar 

  6. American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders, 5th edn. American Psychiatric Association, Washington

    Book  Google Scholar 

  7. Grilo CM, Ivezaj V, White MA (2015) Evaluation of the DSM-5 severity indicator for bulimia nervosa. Behav Res Ther 67:41–44

    Article  PubMed  PubMed Central  Google Scholar 

  8. Smink FR, van Hoeken D, Oldehinkel AJ, Hoek HW (2014) Prevalence and severity of DSM-5 eating disorders in a community cohort of adolescents. Int J Eat Disord 47:610–619

    Article  PubMed  Google Scholar 

  9. Regier DA, Kuhl EA, Kupfer DJ (2013) The DSM-5: classification and criteria changes. World Psychiatry 12:92–98

    Article  PubMed  PubMed Central  Google Scholar 

  10. Lock J, Agras WS, Le Grange D, Couturier J, Safer D, Bryson SW (2013) Do end of treatment assessments predict outcome at follow-up in eating disorders? Int J Eat Disord 46:771–778

    Article  PubMed  Google Scholar 

  11. Dakanalis A, Carrà G, Calogero R, Zanetti MA, Gaudio S, Caccialanza R, Riva G, Clerici M (2015) Testing the cognitive-behavioural maintenance models across DSM-5 bulimic-type eating disorder diagnostic groups: a multi-study. Eur Arch Psychiatry Clin Neurosci 265(8):663–776

    Article  PubMed  Google Scholar 

  12. Clerici M, Dakanalis A (2014) Effectiveness of cognitive cognitive-behavioural therapy for binge eating and bulimia nervosa: an Italian multisite study. In: Fairburn CG (ed) Overcoming binge-eating and bulimia nervosa, 1st edn. Raffaelo Cortina Editore, Milan, pp 213–232

    Google Scholar 

  13. Hay P (2013) A systematic review of evidence for psychological treatments in eating disorders: 2005–2012. Int J Eat Disord 46:462–469

    Article  PubMed  Google Scholar 

  14. Fairburn CG, Marcus MD, Wilson GT (1993) Cognitive-behavioral therapy for binge eating and bulimia nervosa: a comprehensive treatment manual. In: Fairburn CG, Wilson GT (eds) Binge eating: nature, assessment and treatment, 1st edn. Guilford Press, New York, pp 361–404

    Google Scholar 

  15. Fairburn CG, Cooper Z (1993) The eating disorder examination. In: Fairburn CG, Wilson GT (eds) Binge eating: nature, assessment, and treatment, 1st edn. Guilford Press, New York, pp 317–360

    Google Scholar 

  16. Lampard AM, Sharbanee JM (2015) The cognitive-behavioural theory and treatment of bulimia nervosa: an examination of treatment mechanisms and future directions. Aust Psychol 50:6–13

    Article  Google Scholar 

  17. Mazure CM, Halmi KA, Sunday SR, Romano SJ, Einhorn AM (1994) The Yale–Brown–Cornell eating disorder scale: development, use, reliability and validity. J Psychiatr Res 28:425–445

    Article  CAS  PubMed  Google Scholar 

  18. First MB, Spitzer RL, Gibbon M, Williams JBW (1996) Structured clinical interview for DSM-IV Axis I disorders-patient edition (SCID-I/P, Version 2.0). New York State Psychiatric Institute, Biometrics Research Department, New York

    Google Scholar 

  19. First MB, Gibbon M, Spitzer RL, Williams JBW, Benjamin LS (1997) Structured clinical interview for DSM-IV Axis II personality disorders (SCID-II). American Psychiatric Press, Washington

    Google Scholar 

  20. Derogatis LR (1993) The Brief Symptom Inventory (BSI): administration, scoring and procedures manual. Clinical Psychometric Research, Baltimore

    Google Scholar 

  21. Gameroff MJ, Wickramaratne P, Weissman MM (2012) Testing the short and screener versions of the Social Adjustment Scale-Self-report (SAS-SR). Int J Methods Psychiatr Res 21:52–65

    Article  PubMed  Google Scholar 

  22. Bohn K, Doll HA, Cooper Z, O’Connor M, Palmer RL, Fairburn CG (2008) The measurement of impairment due to eating disorder psychopathology. Behav Res Ther 46:1105–1110

    Article  PubMed  PubMed Central  Google Scholar 

  23. Garner DM (2004) Eating disorder inventory-3 professional manual. Psychological Assessment Resources, Odessa

    Google Scholar 

  24. Dickie L, Surgenor LJ, Wilson M, McDowall J (2012) The structure and reliability of the clinical perfectionism questionnaire. Pers Individ Differ 52:865–869

    Article  Google Scholar 

  25. Mitchell JE, Agras S, Crow S, Halmi K, Fairburn CG, Bryson S, Kraemer H (2011) Stepped care and cognitive-behavioural therapy for bulimia nervosa: randomised trial. Br J Psychiatry 198:391–397

    Article  PubMed  PubMed Central  Google Scholar 

  26. le Grange D, Crosby RD, Rathouz PJ, Leventhal BL (2007) A randomized controlled comparison of family-based treatment and supportive psychotherapy for adolescent bulimia nervosa. Arch Gen Psychiatry 64:1049–1056

    Article  PubMed  Google Scholar 

  27. Agüera Z, Riesco N, Jiménez-Murcia S, Islam MA, Granero R, Vicente E, Peñas-Lledó E, Arcelus J, Sánchez I, Menchon JM, Fernández-Aranda F (2013) Cognitive behaviour therapy response and dropout rate across purging and nonpurging bulimia nervosa and binge eating disorder: DSM-5 implications. BMC Psychiatry 13:285. doi:10.1186/1471-244X-13-285

    Article  PubMed  PubMed Central  Google Scholar 

  28. Reid HM (2014) Introduction to statistics: fundamental concepts and procedures of data analysis. Sage, London

    Google Scholar 

  29. Goldschmidt AB, Peterson CB, Wonderlich SA, Crosby RD, Engel SG, Mitchell JE, Crow SJ, Cao L, Berg KC (2013) Trait-level and momentary correlates of bulimia nervosa with a history of anorexia nervosa. Int J Eat Disord 46:140–146

    Article  PubMed  Google Scholar 

  30. Caslini M, Bartoli F, Crocamo C, Dakanalis A, Clerici M, Carrà G (2016) Disentangling the association between child abuse and eating disorders: a systematic review and meta-analysis. Psychosom Med 78(1):79–90

    Article  PubMed  Google Scholar 

  31. Dakanalis A, Timko A, Serino S, Riva G, Clerici M, Carrà G (2016) Prospective psychosocial predictors of onset and cessation of eating pathology amongst college women. Eur Eat Disord Rev 24(3):251–256

    Article  PubMed  Google Scholar 

  32. Dakanalis A, Clerici M, Caslini M, Gaudio S, Serino S, Riva G, Carrà G (2016) Predictors of initiation and persistence of recurrent binge eating and inappropriate weight compensatory behaviors in men. Int J Eat Disord 49(6):581–590

    Article  PubMed  Google Scholar 

  33. Colleen Stiles-Shields E, Labuschagne Z, Goldschmidt AB, Doyle AC, Le Grange D (2012) The use of multiple methods of compensatory behaviors as an indicator of eating disorder severity in treatment-seeking youth. Int J Eat Disord 45:704–710

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  34. National Institute for Clinical Excellence (2004) Eating disorders: core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. NICE clinical guideline, no. 9. National Institute for Clinical Excellence, London

    Google Scholar 

  35. Dakanalis A, Timko CA, Carrà G, Clerici M, Zanetti MA, Riva G, Caccialanza R (2014) Testing the original and the extended dual-pathway model of lack of control over eating in adolescent girls. A two-year longitudinal study. Appetite 82:180–193

    Article  PubMed  Google Scholar 

  36. Goldschmidt AB, Wonderlich SA, Crosby RD, Engel SG, Lavender JM, Peterson CB, Crow SJ, Cao L, Mitchell JE (2014) Ecological momentary assessment of stressful events and negative affect in bulimia nervosa. J Consult Clin Psychol 82:30–39

    Article  PubMed  Google Scholar 

  37. Cooper Z, Fairburn CG (2011) The evolution of “Enhanced” cognitive behavior therapy for eating disorders: learning from treatment nonresponse. Cogn Behav Pract 18:394–402

    Article  PubMed  PubMed Central  Google Scholar 

  38. Fairburn CG, Cooper Z, Doll HA, O’Connor ME, Bohn K, Hawker DM, Wales JA, Palmer RL (2009) Transdiagnostic cognitive-behavioral therapy for patients with eating disorders: a two-site trial with 60-week follow-up. Am J Psychiatry 166:311–319

    Article  PubMed  Google Scholar 

  39. Dakanalis A, Carrà G, Clerici M, Riva G (2015) Efforts to make clearer the relationship between body dissatisfaction and binge eating. Eat Weight Disord 20(1):145–146

    Article  PubMed  Google Scholar 

  40. Dakanalis A, Zanetti MA, Clerici M, Madeddu F, Riva G, Caccialanza R (2013) Italian version of the Dutch eating behavior questionnaire. Psychometric proprieties and measurement invariance across sex, BMI-status age. Appetite 71:187–195

    Article  PubMed  Google Scholar 

  41. Dakanalis A, Riva G (2013) Mass media, body image and eating disturbances: the underlying mechanism through the lens of the objectification theory. In: Sams LB, Keels JA (eds) Body image: gender differences sociocultural influences and health implications. Nova Science, New York, pp 217–235

    Google Scholar 

  42. Dakanalis A, Clerici M, Caslini M, Favagrossa L, Prunas A, Volpato C, Riva G, Zanetti MA (2014) Internalization of sociocultural standards of beauty and disordered eating behaviours: the role of body surveillance, shame and social anxiety. J Psychopathol 20(1):33–37

    Google Scholar 

  43. Pla-Sanjuanelo J, Ferrer-García M, Gutiérrez-Maldonado J, Riva G, Andreu-Gracia A, Dakanalis A, Fernandez-Aranda F, Forcano L, Ribas-Sabaté J, Riesco N, Rus-Calafell M, Sánchez I, Sanchez-Planell L (2015) Identifying specific cues and contexts related to bingeing behavior for the development of effective virtual environments. Appetite 87:81–89

    Article  PubMed  Google Scholar 

  44. Allen KL, Byrne SM, McLean NJ (2012) The dual-pathway and cognitive-behavioural models of binge eating: prospective evaluation and comparison. Eur Child Adolesc Psychiatry 21:51–62

    Article  PubMed  Google Scholar 

  45. Dakanalis A, Timko CA, Riva G, Madeddu F, Clerici M, Zanetti MA (2014) A comprehensive examination of the transdiagnostic cognitive behavioral model of eating disorders in males. Eat Behav 15(1):63–67

    Article  PubMed  Google Scholar 

  46. Dakanalis A, Carrà G, Calogero R, Fida R, Clerici M, Zanetti MA, Riva G (2015) The developmental effects of media-ideal internalization and self-objectification processes on adolescents’ negative body-feelings, dietary restraint, and binge eating. Eur Child Adolesc Psychiatry 24(8):997–1010

    Article  PubMed  Google Scholar 

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Acknowledgments

The authors would like to thank the psychiatric staff of all Italian specialised care centres/sites (detailed in [11, 12]) for their help in the acquisition of pre-treatment and EOT data.

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This research received no specific grant from any funding agency, commercial or not for-profit sectors.

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Correspondence to Antonios Dakanalis.

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Ethical standards

All participants provided written informed consent [11, 12]. The study was performed in compliance with the Helsinki Declaration of 1975, as revised in 2008, and the study protocol was approved by the ethics review board of each local institution (recruitment/treatment site [11, 12]) and of the co-ordinating body of the project (University of Pavia).

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Dakanalis, A., Bartoli, F., Caslini, M. et al. Validity and clinical utility of the DSM-5 severity specifier for bulimia nervosa: results from a multisite sample of patients who received evidence-based treatment. Eur Arch Psychiatry Clin Neurosci 267, 823–829 (2017). https://doi.org/10.1007/s00406-016-0712-7

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  • DOI: https://doi.org/10.1007/s00406-016-0712-7

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