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Background: The aims of this study were to explore the role of life events and difficulties in the onset of anorexia nervosa and bulimia nervosa and to find out whether events and difficulties with a specific meaning, i.e. those of a certain sexual nature, are important in the onset of anorexia nervosa., Methods: Seventy-two patients with anorexia nervosa (AN) and 29 with bulimia nervosa (BN) were assessed with the life events and difficulties schedule (Brown & Harris, 1978), the year before onset was studied. A new dimension to measure specific meaning of life events and difficulties called 'pudicity' was developed. Subjects from two community cohorts were used as comparison groups (Brown & Harris, 1978; Andrews et al. 1990)., Results: Anorexic patients, bulimic patients and community controls did not differ in proportion of patients with at least one severe event; however, significantly more AN and BN patients than community controls had experienced a major difficulty. Sixty-seven per cent of anorexics and 76% of bulimia nervosa patients had either a severe event or a marked difficulty during the year before onset. In AN and BN the most common serious life stresses before onset concerned close relationships with family and friends with BN patients being significantly more often than AN patients directly involved in the problem (interpersonal events). Patients with anorexia nervosa had significantly more pudicity events before onset than BN patients or community controls., Conclusion: While serious life stresses commonly precede the onset of anorexia nervosa and bulimia nervosa, problems with sexuality seem to be specific in triggering the onset of anorexia nervosa.

Objective: To investigate the social support networks of patients with anorexia nervosa (AN) and bulimia nervosa (BN)., Method: Social support was measured using the Significant Others Scale for 44 patients with AN, 81 patients with BN, and 86 polytechnic students., Results: Eating disorder patients had smaller social networks than the students. AN patients were significantly less likely than BN patients to have a spouse or partner as a support figure. Both AN and BN patients reported less actual emotional and practical support than students. AN patients perceived their social support to be adequate, whereas BN patients were dissatisfied with their support. Patients set lower ideals for support than the students. Social support was not correlated with duration of illness., Discussion: AN and BN patients have deficient social networks. In BN patients there is disturbance in both the size and perceived adequacy of social relationships.

Objective: This study examined pretreatment variables to predict outcome in two treatments for bulimia nervosa., Method: Patients were offered either 16 weeks of cognitive-behavioral therapy (CBT) or a self-treatment manual followed by up to 8 weeks of CBT (sequential group). Using complete data, stepwise regression analyses were performed., Results: It was found that a longer duration of illness and lower binge frequency predicted a better outcome both at the end of treatment (p < .001) and at 18 months of follow-up (p < .005). In the sequential group, lower pretreatment binge frequency predicted better outcome at the end of treatment (p < .05) and at 18 months of follow-up (p < .05). In the CBT group, longer duration of illness predicted better outcome at the end of treatment (p < .02)., Discussion: It is concluded that (1) those with more frequent binging may require a more intense intervention and (2) those who have been ill longer may be more motivated to respond to treatment.

Self-directed treatment has been shown to be effective in the treatment of bulimia nervosa. This paper shows that compliance with a manual is related to outcome. Forty per cent of high compliers achieved full remission after eight weeks with a manual, compared with only 5 per cent of low compliers. Furthermore, patients with greater weight and shape concerns were less likely to use a manual while those with a longer duration of illness were more likely to use it.

Background: The aim of this study was to evaluate the effectiveness of a stepped care approach to the treatment of bulimia nervosa: a self-care manual followed, if necessary, by a course of attenuated cognitive behavioural treatment (CBT) in comparison with standard CBT., Method: One hundred and ten patients, presenting at a tertiary referral centre with ICD-10 bulimia nervosa or atypical bulimia nervosa, were randomly assigned to one of two treatment conditions; a) a sequential treatment group: 8 weeks with a self-care manual followed by up to eight sessions of CBT (if still symptomatic) or b) 16 sessions of CBT., Results: Bulimic symptoms improved significantly in both groups with no significant differences between the two groups on any of the measures at the end of treatment or at 18 months follow-up. At end of treatment 30% (95% CI: 18-46%) of the sequential group and 30% (95% CI: 17-47%) of the standard treatment group were free from all bulimic symptoms. Sixteen of those in the sequential group improved significantly with self-care and did not require additional treatment. The median number of sessions taken by the sequential group was three (95% CI: 0-6). At 18 months follow-up 40% (95% CI: 23-59%) of the sequential group and 41% (95% CI: 25-59%) of the CBT group were symptom free., Conclusions: A sequential approach to the treatment of bulimia may be as effective as standard CBT and can considerably reduce the amount of therapist contact required.

The level and direction of hostility in patients with bulimia nervosa, anorexia nervosa and a comparison group were measured using the the Hostility and Direction of Hostility Questionnaire. A semistructured interview developed by Harris, Brown, and Bifulco (Psychological Medicine, 16, 641-659, 1986) was used to assess childhood care to examine whether a link exists between childhood exposure to aggression or parental neglect and adult hostility. Patients with eating disorders had significantly higher hostility levels and were significantly more intropunitive than the comparison group. Patients with bulimia nervosa were significantly more intropunitive than the comparison group. Patients with bulimia nervosa were significantly more hostile than patients with anorexia nervosa. Anorexia nervosa patients were more likely to direct hostility inwardly, rather than outwardly, when compared with bulimia nervosa patients. Impulsivity was associated with extrapunitiveness whereas intropunitiveness was associated with depression. Although some measures of poor childhood care correlated with adult hostility levels no clear pattern emerged.

In order to assess the relationship pubertal development, sexual milestones and childhood sexual abuse in women with eating disorders, 44 patients with restricting anorexia nervosa (RAN), 26 with bulimic anorexia nervosa (BAN), 29 with bulimia nervosa and also with a history of anorexia nervosa (BN/HistAN), and 69 with bulimia nervosa but without a history of anorexia nervosa (BN) completed questionnaires on pubertal and sexual development and unpleasant sexual experiences. Forty-four female college students complete the sexual development questionnaire only. Different eating disorder groups were found to be similar in terms of their pubertal development. All eating disorder groups showed delays in aspects of their psychosexual development (age at first kiss, masturbation, genital fondling and first sexual intercourse) compared with the control group, although to a different degree. The RAN group was delayed on almost all sexual milestones whereas the other groups were delayed on only some. On some variables, most noticeably on first sexual intercourse, restricters also were more delayed than the other eating disorder groups. Similarly, the median number of sexual partners differed significantly between groups (RAN = 1, BAN = 2, BN/HistAN = 4, BN = 4, controls = 5, P < 0.0001). Eating disorder patients, in particular RAN patients, were less positive about sexual relationships than controls, but did not differ from controls in attitudes to masturbation, marriage, children or pregnancy. Of the eating disorder patients 22-31% had been sexually abused during childhood. A history of abuse affected attitudes to masturbation, but did not appear to affect sexual development.

Objective: To test the short term efficacy of a self directed treatment manual for bulimia nervosa., Design: Randomised controlled trial of the manual against cognitive behavioural therapy and a waiting list., Setting: Tertiary referral centre., Subjects: 81 consecutive referrals presenting with bulimia nervosa or atypical bulimia nervosa., Main Outcome Measures: Frequency of binge eating, vomiting, and other behaviours to control weight as well as abstinence from these behaviours., Results: Cognitive behavioural treatment produced a significant reduction in the frequency of binge eating, vomiting, and other behaviours to control weight. The manual significantly reduced frequency of binge eating and weight control behaviours other than vomiting, and there was no change in the group on the waiting list. Full remission was achieved in five (24%) of the group assigned to cognitive behavioural treatment, nine (22%) of the group who used the manual, and two (11%) of the group on the waiting list., Conclusions: A self directed treatment manual may be a useful first intervention in the treatment of bulimia nervosa.

The aims of the study were (1) to compare the defence style of patients with anorexia nervosa with that of patients with bulimia nervosa and of female controls; (2) to establish whether a link exists between childhood adversity and adult defence style in eating disorder patients. Twenty-six patients with restricting anorexia nervosa (RAN), 61 patients with bulimia nervosa (BN), 37 patients with bulimic anorexia nervosa or bulimia nervosa with a history of anorexia nervosa (BAN/BN-HistAN) and 88 female controls were given the short Defense Style questionnaire (Andrews, Pollock & Stewart, 1989). Eating disorder patients were asked about their childhood care using a semi-structured interview (Harris, Brown & Bifulco, 1986). Bulimia nervosa patients had a significantly less mature defence style than the other groups and like the BAN/BN-HistAN group more immature defences than the control group. In the RAN group no childhood predictors of adult defence style were found, whereas in bulimia nervosa, excessive parental control during childhood was a negative predictor of mature defences and physical abuse a positive predictor of immature defence style. These results provide some evidence that childhood adversity may constitute a vulnerability factor for the later development of bulimia nervosa, mediated by personality development.

The aim of this study was to determine whether the childhood experiences of patients with anorexia nervosa and bulimia nervosa differ and affect the course of the illness. A semistructured interview developed by Harris et al. (1986) was used to assess the childhood family environment of 64 patients with restricting anorexia nervosa (RAN), 23 patients with bulimic anorexia nervosa (BAN), 37 bulimic patients with a history of anorexia nervosa (BN/HistAN) and 79 patients with normal weight bulimia nervosa (BN). There were no significant differences between groups in terms of parental mental disorder, low parental control or childhood sexual abuse. BN patients had had significantly more family arrangements and had experienced more parental indifference, excessive parental control, physical abuse, and violence against other family members than RAN patients with the BAN and BN/HistAN group being intermediate. There was a trend for BN-patients to have had more intra-familial discord than the other groups. Different aspects of adversity tended to cluster in the same patients and 65% of the bulimic group had experienced two or more types of childhood adversity. These results suggest that childhood experiences contribute to the form of eating disorder which later develops.

Twenty-eight patients with ICD-10 bulimia nervosa or atypical bulimia nervosa were given a cognitive-behavioral treatment handbook and were reassessed 4-6 weeks later. On a clinician-rated global improvement scale 12 patients had much improved and 8 patients had somewhat improved. Fifteen patients were abstinent of vomiting or laxatives at reassessment as opposed to five patients before treatment. Of the 21 patients who were bringing before treatment, 7 had a 75-100% reduction of binges and 5 had a 50-75% reduction of binges. Patients' nutritional knowledge increased significantly. A patient-administered hand-book may be a useful first intervention in the treatment of patients with bulimia nervosa.