23
ORIGINAL
ARTICLE
The use of a manual-driven group cognitive behavior
therapy in a Brazilian sample of obese individuals
with binge-eating disorder
Utilização de terapia cognitivo-comportamental em
grupo baseada em manual em uma amostra
brasileira de indivíduos obesos com transtorno da
compulsão alimentar periódica
Mônica Duchesne,1,2 José Carlos Appolinario,1,2
Bernard Pimentel Rangé,3 Julia Fandiño,1,2
Tatiana Moya,2 Silvia R Freitas2
Abstract
Objective: To assess the effectiveness of a manual-based cognitive behavior therapy adapted to a group format in a sample of
Brazilian obese subjects with binge-eating disorder. Method: In an open trial, 21 obese subjects with binge-eating disorder
received a group cognitive-behavioral therapy program. Changes in binge-eating frequency, weight, body shape concerns, and
depressive symptoms were compared between baseline and the end of the study. Results: The mean frequency of binge-eating
episodes significantly decreased from baseline to post-treatment (p < 0.001), with a binge eating remission rate of 76.1% at the
end of the trial. Depressive symptoms and body shape concern also improved (p < 0.001). In addition, weight loss was statistically
and clinically significant. Conclusion: The use of this adapted manual-based cognitive behavior therapy in this sample resulted
in a marked improvement in binge-eating, weight, body shape concern, and depressive symptoms related to binge-eating disorder.
Descriptors: Eating disorders; Binge-eating; Obesity; Cognitive-behavior therapy; Behavior therapy
Resumo
Objetivo: Avaliar a efetividade da terapia cognitivo-comportamental baseada em um manual adaptado para o formato de
grupo em uma amostra brasileira de obesos com transtorno da compulsão alimentar periódica. Método: Em um estudo
aberto, 21 pacientes obesos com transtorno da compulsão alimentar periódica participaram de um programa da terapia
cognitivo-comportamental em grupo. A freqüência da compulsão alimentar, o peso corporal, o grau de satisfação com a forma
corporal e os sintomas depressivos foram avaliados no início do tratamento e no final do estudo. Resultados: Houve uma
redução estatisticamente significativa da freqüência média de episódios de compulsão alimentar entre a linha de base e o final
do tratamento (p < 0,001), com uma taxa de remissão de episódios no final do estudo de 76,1%. Foi observada, também,
uma redução significativa dos sintomas depressivos e da insatisfação com a forma corporal (p < 0,001). Adicionalmente, a
perda de peso foi clínica e estatisticamente significativa. Conclusão: A utilização de terapia cognitivo-comportamental baseada
em um manual adaptado para o transtorno da compulsão alimentar periódica resultou em melhora significativa da compulsão
alimentar, do peso corporal, da preocupação com a forma corporal e dos sintomas depressivos associados ao transtorno da
compulsão alimentar periódica nessa amostra.
Descritores: Transtornos alimentares; Compulsão alimentar; Obesidade; Terapia cognitivo-comportamental; Terapia comportamental
1
2
3
Institute of Psychiatry, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro (RJ), Brazil
Obesity and Eating Disorders Group (Grupo de Obesidade e Transtornos Alimentares - GOTA), State Institute of Diabetes and
Endocrinology of Rio de Janeiro, Rio de Janeiro (RJ), Brazil
Graduate Program in Psychology, Institute of Psychology, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro (RJ), Brazil
Financing: This research was supported by grants of Coordenação
de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)
Conflict of interests: None
Submitted: July 10, 2006
Accepted: October 23, 2006
Correspondence
Mônica Duchesne
Rua Marquês de São Vicente 124, sala 239 – Gávea
22451-040 Rio de Janeiro, RJ, Brazil
Phone: (55 21) 2540-0367 Fax: (55 21) 2249-3512
E-mail: [email protected]
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Cognitive behavior therapy in binge-eating 24
Introduction
Binge-eating disorder (BED) is characterized by recurrent
binge-eating episodes, without the inappropriate compensatory
weight control methods found in bulimia nervosa.1-2 Although
obesity is not a criterion for BED, it is a condition frequently
associated with this diagnosis.3 Compared to matched obese
subjects who do not binge, obese binge-eaters experience
higher levels of general and eating-related psychopathology.4
For example, they show more concerns with body shape, and
some authors found that binge-eating is significantly correlated
with the perception that body weight is above the ideal.4-5
Cognitive behavior therapy (CBT) is a semi-structured focal
therapy, especially focused on the present and the future of the
patient. It can be delivered by a therapist or in a self-help format.6
In the treatment of obese subjects with BED, the main aims of
CBT are to increase the patient’s control over eating and to improve
the associated psychopathological symptoms.7 CBT is regarded
as the best-established intervention for BED and has been
increasingly used in the usual clinical practice.8 The present
open study aims to investigate the effectiveness of a manualbased CBT adapted to a group format in reducing binge-eating
and weight in a sample of Brazilian obese subjects with BED.
Method
This study was carried out in the eating disorders’ outpatient
clinic at the State Institute of Endocrinology and Diabetes of
Rio de Janeiro, Brazil. The protocol was approved by the
institutional review board of the hospital and a written informed
consent was obtained from patients prior to the accomplishment
of any study procedure.
All subjects who spontaneously sought treatment at the clinic
were evaluated. Subjects were eligible for the study if they
met the following inclusion criteria: 1) diagnosis of BED
according to DSM-IV criteria,1 2) age between 18-60 years,
3) a minimum of 6 years of schooling, 4) body mass index
[BMI: weight (kg)/height2 (m2)] between 30-45 kg/m 2, and 5)
score in the Binge-Eating Scale (BES) 9 > 17, suggesting at
least a moderate severity level of binge-eating. Of the 60 obese
patients initially interviewed, 21 subjects met all eligible criteria
and were included in the study. Of note, seven patients (33%
of 21) had a current major depressive disorder and were treated
with fluoxetine 20 mg/day during the course of the study.
The Structured Clinical Interview for DSM-IV Axis I Disorders,
Patient Version (SCID I/P)10 was used for BED diagnosis. Eligible
subjects were asked to complete a self-monitoring register of
their daily food intake (highlighting the occurrence of bingeeating episodes). They also fulfilled the BES, 9 the Beck
Depression Inventory (BDI)11 and the Body Shape Questionnaire
(BSQ). 12-13 The BES was chosen because it is a self-reported
questionnaire, specifically designed to measure, in a
dimensional way, behaviors, feelings and cognitions associated
with binge eating.
The study was a single center open trial. Subjects were
assigned to one of three groups of seven patients each, and
received 19 sessions of group CBT for 22 weeks. They were
assessed at baseline and immediately following completion of
treatment. CBT groups were conducted by a therapist and a
co-therapist experienced in the treatment of eating disorders.
They underwent a previous extensive training in the manualbased treatment used in this study.
All CBT sessions were videotaped and therapists received
ongoing supervision to ensure adherence to the CBT manual
and standardized administration of the treatment.
The primary outcome measure was frequency of binge-eating
assessed as the number of days per week in which patients
had at least one binge-eating episode according to DSM-IV
criteria, considering the seven days prior to the beginning of
CBT and the seven days following completion of treatment.
Secondary outcome measures included the scores of BES,9
BDI11 and BSQ,12 besides changes in weight and BMI.
The CBT used in this study was based on the manual for
binge-eating and bulimia nervosa of Fairburn et al.7 After the
author’s written approval, this manual was independently
translated by two CBT professionals and one eating disorders
specialist. Afterwards, these three translators adapted the
manual to a group format, including some weight loss
strategies. Cognitive-behavioral therapy groups were composed
by nineteen 90-minute sessions. It was a three-stage
intervention weekly conducted over the two first stages and
biweekly in the third stage.
Demographic and clinical data variables were described as
means and standard deviations. Wilcoxon14 and Mann-Whitney
Tests14 were applied to assess the treatment effect. Mann-Whitney
Tests14 were performed comparing subjects taking fluoxetine to
those without fluoxetine, and no significant differences were
found. Thus, they were included in the final analysis. Treatment
outcomes were analyzed using the last observation carried
forward as the end-point (intention-to-treat analysis). All
statistical tests were interpreted at the 5% significance level.
Results
Most participants were women (85.7%), married (52.4%), and
had at least 11 years of schooling (61.9%). On average, subjects
were 37.2 (SD = 10.8) years old, and had a mean weight and
BMI of 103.0 kg (SD = 13.3) and 39.4 kg/m² (SD = 3.8),
respectively. Eighteen patients completed the trial (85.8%). Subjects
were considered completers if they attended at least 15 group
meetings and completed end-of-treatment assessments.
Intention-to-treat analysis showed that the mean frequency
of binge-eating significantly decreased from baseline to posttreatment (p < 0.001). The number of binge-eating days
showed a mean reduction of 86% following treatment. For
completers, end-of-treatment rate of remission was 76.1% (16
subjects), whereas 9.5% (2 subjects) presented one bingeday during the post-treatment assessment week. Dimensional
evaluation of binge-eating behavior showed a marked reduction
in binge severity. In addition, depressive symptoms and body
shape concerns were also significantly reduced, in the end of
CBT. Moreover, over the course of treatment weight loss was
significant (p < 0.001), with a mean weight loss of 6.1 kg.
Among completers, 7 subjects (33.3%) have attained a weight
loss of at least 5% of their initial weight, and 4 subjects
(19.0%) have reduced at least 10%. Detailed information of
changes in all outcomes measures is available in Table 1.
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Discussion
The trial has revealed that this manual-based group CBT
produced significant improvements in binge-eating, body shape
concerns and depressive symptoms, along with a marked
decrease in body weight. Quite similar to other studies that
found remission rates ranging from 47%15 to 82%, 16 in this
study it was observed a binge eating remission rate of 76.1%.
Additionally, our treatment completion rates (85.8%) were
comparable to those reported in other trials involving obese
individuals with BED treated with group CBT.16-17
Of note, contrasting to previous findings,16 this study revealed
clinically and statistically significant reduction in body weight.
Completer analyses showed that 52.3% of the sample lost at
least 5% of their initial body weight. Although Ricca et al.17
also reported significant weight loss with CBT in obese patients
with BED, most of the studies with this intervention reported
no clinically significant weight loss.4,16
To better understand this lack of effect observed on body
weight it is important to consider some of the theoretical basis
of CBT. The initial CBT model for BED assumed that because
ongoing binge-eating could interfere with weight loss treatment,
patients should first learn to control binge-eating in order to
adhere to a weight loss regimen. In this model it was also
assumed that the focus on weight loss would increase dietary
restriction and that, in turn, would trigger binge-eating.
Considering these assumptions, weight loss strategies were
not included in the initial CBT protocols for BED patients.
Conversely, in our study, some weight loss strategies were
added to the treatment. The inclusion of these techniques
may have played an important role in the weight loss observed
in this trial, and apparently have not necessarily undermined
binge-eating control, as expected by those initial CBT
assumptions. Other studies support this finding, once traditional
behavioral weight control programs have reported success in
treating obesity without increasing binge-eating in obese
patients with BED in the short-term.4
A different aspect of this study is that, as mood disorders are
a prevalent comorbidity in BED patients,4 we decided to include
patients with major depression in order to have a sample that
is not much different from the general population of BED
patients. However, there are several limitations in this study.
The sample size was small and most participants were women
with at least 6 years of schooling. Therefore, generalization of
findings is limited. Another limitation is that binge/days have
been assessed for one week, and a longer period of assessment
could provide a more consistent measure. Additionally, there
was no control treatment condition able to differentiate the
effect of non-specific influences, such as intensity of
therapeutic contact. Given the high placebo response observed
in studies with BED,4 for a better assessment of the manual’s
efficacy, a randomized controlled trial comparing TCC with
another intervention is advisable.
Conclusions
This study suggests that the Fairburn’s CBT manual adapted
to a group format may be an effective treatment in Brazilian
obese patients with BED. The treatment produced significant
improvement in binge-eating, body shape concern and
depressive symptoms, along with a relevant weight loss.
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Acknowledgments
The authors gratefully acknowledge Christopher G. Fairburn for
authorizing the use of his manual.
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