Self-induced vomiting in eating disorders: Associated features and treatment outcome

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Abstract

Self-induced vomiting is adopted by people with a variety of eating disorders (ED) to control body shape and weight. We tested the prevalence, the associated features and the role on treatment outcome of self-induced vomiting in 152 ED patients consecutively admitted to an inpatient cognitive-behavioral treatment (CBT), based on the transdiagnostic CBT for ED. The Eating Disorder Examination, together with the Beck Depression Inventory, the State-Trait Anxiety Inventory and the Temperament and Character Inventory were recorded at entry and at end of treatment. Self-induced vomiting was reported in 35.5% of cases, and 21.1% had multiple purging with vomiting. Individuals with vomiting and those with multiple purging had significantly higher BMI and a higher frequency of bulimic episodes, but individuals with multiple purging were also characterized by higher levels of depression, longer ED duration, more severe ED psychopathology and lower self-directness. Individuals with vomiting had higher eating concern and novelty seeking compared with those without purging behaviors. However, the three groups had similar dropout rates and outcomes in response to inpatient CBT, in keeping with the transdiagnostic theory of EDs.

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

References (27)

  • C.M. Bulik et al.

    Predictors of 1-year treatment outcome in bulimia nervosa

    Comprehensive Psychiatry

    (1998)
  • C.G. Fairburn et al.

    Cognitive behaviour therapy for eating disorders: a “transdiagnostic” theory and treatment

    Behaviour Research and Therapy

    (2003)
  • A. Baggio et al.

    Il Beck Depression Inventory per la valutazione della depressione nel dolore cronico. Il contributo degli “item” somatici

    International Journal of Pain Therapy

    (1997)
  • A.T. Beck et al.

    An inventory for measuring depression

    Archives of General Psychiatry

    (1961)
  • D.I. Ben-Tovim et al.

    Bulimia: symptoms and syndromes in an urban population

    Australian and New Zeland Journal of Psychiatry

    (1989)
  • R. Bryant-Waugh et al.

    Misuse of laxatives among adult outpatients with eating disorders: prevalence and profiles

    International Journal of Eating Disorders

    (2006)
  • C.M. Bulik et al.

    Temperament, character, and personality disorder in bulimia nervosa

    Journal of Nervous and Mental Diseases

    (1995)
  • C.R. Cloninger et al.

    The temperament and character inventory (TCI): A guide to its development and use

    (1994)
  • R. Dalle Grave

    A multi-step cognitive behaviour therapy for eating disorders

    European Eating Disorders Review

    (2005)
  • R. Dalle Grave et al.

    Inpatient, day patient and two forms of outpatient CBT-E

  • C. Edler et al.

    The use of multiple purging methods as an indicator of eating disorder severity

    International Journal of Eating Disorders

    (2007)
  • C.G. Fairburn

    Cognitive behavior therapy and eating disorders

    (2008)
  • C.G. Fairburn et al.

    The eating disorder examination

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