Self-induced vomiting in eating disorders: Associated features and treatment outcome
Introduction
Self-induced vomiting is an unhealthy behavior included in the broad category of purging methods, also including misuse of laxatives and diuretics, frequently reported in individuals with eating disorders (ED). In clinical samples it has been found in more than 90% of patients with bulimia nervosa (BN) (Ben-Tovim et al., 1989, Reba et al., 2005), in 31%–39% of patients with anorexia nervosa (AN) (Ben-Tovim et al., 1989, Garner et al., 1993), and in 56% of patients with eating disorder not otherwise specified (EDNOS) (Reba et al., 2005). Although the results of the different methods of purging may be similar, the immediate effect of vomiting differs from the delayed effect of laxatives and diuretics misuse. It is conceivable that some features of personality and psychopathology may influence the preference for the method of purging (Reba et al., 2005).
Self-induced vomiting, with or without other methods of purging, has been associated with higher lifetime maximum and lifetime minimum BMI, earlier menarche, lower rates of laxative misuse, lower self-directedness, personal standards, organization, and higher novelty seeking (Reba et al., 2005). It seems to serve as a means to control shape and weight after bulimic episodes (objective or subjective), but in a subgroup of patients it may also serve as a strategy to modulate mood (Fairburn, Cooper, & Shafran, 2003). Laxative misuse seems to serve as a method of purging as well as a form of self-harm (Tozzi et al., 2006). It has been associated with more severe ED and general psychopathology (Bryant-Waugh, Turner, East, Gamble, & Mehta, 2006; Tozzi et al., 2006), but a study found no significant differences between individuals with vomiting and those with laxative misuse (Favaro & Santonastaso, 1996).
In several cases self-induced vomiting is associated with other methods of purging (multiple purging). The use of multiple purging methods has been associated with greater ED severity, and the purging frequency parallels with the frequency of bingeing, the severity of depression, impulsiveness, anxiety, and the presence of personality disorder (Edler, Haedt, & Keel, 2007). Individuals with multiple purging with vomiting reported a significantly higher frequency of self-injurious behaviors and suicide attempts than subjects using a single method of purging (Favaro & Santonastaso, 1996).
Finally, very few data are available on the role of vomiting on treatment outcome. The frequency of self-induced vomiting was associated with the rate of relapse in BN individuals (Olmsted, Kaplan, & Rockert, 1994), while an inpatient study in subjects with AN found a higher dropout rate in those with binge eating/purging type than in those without purging (Woodside, Carter, & Blackmore, 2004).
The aims of our study were to investigate the prevalence and the associated features of self-induced vomiting with/without multiple purging in a large group of in patients with ED and to assess their role on inpatient cognitive behavior treatment (CBT) outcome.
Section snippets
Participants
The sample consisted of 152 consecutive female patients admitted to the ED inpatient unit of Villa Garda Hospital (Northern Italy) between November 2003 and November 2006.
The patients were referred to from all over Italy by general practitioners or by ED specialists for their outpatients. Indications for admission were the failure of less intensive treatments (e.g., outpatient treatment) or the presence of an eating disorder of clinical severity not manageable in an outpatient setting. Patients
Participant characteristics
Study participants included 152 ED patients with a mean age of 25.8 years [SD = 8.1] and a mean baseline BMI of 16.9 kg/m2 [SD = 3.4]. Overall, the mean age of onset was 16.9 years [SD = 5.6], the mean pre-morbid BMI was 20.8 kg/m2 [SD = 3.5], and the mean maximum and minimum BMI was 22.4 kg/m2 [SD = 5.0] and 14.5 kg/m2 [SD = 2.3], respectively. 58 patients (38.2%) met criteria for AN, 26 (17.1%) for BN and 68 (44.6%) were classified as EDNOS. Among the EDNOS patients, 37 (54.4%) had a
Discussion
The principal finding of the study is that vomiting, although associated with more severe ED and general psychopathology, and with distinctive personality features, does not have any negative influence on dropout rates and inpatient CBT outcome.
The prevalence of vomiting in our sample (56.6%) is lower than the 71.3% reported by the Price Foundation Genetic Studies of Eating Disorders, the largest study that included subjects with all the ED diagnostic categories (AN, BN, and EDNOS) (Reba
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