Procedure
Participants were recruited from the outpatient clinic of the Department Psychiatry, Hiroshima University Hospital from 1995 to 2005. We excluded patients under 18 years of age, those with psychotic disorders, intellectual disability, personality disorder with self-destructive behavior, or those at high risk of suicide. We recruited patients whose treatment had started within the past year.
We interviewed each patient in advance, judged whether the patient did not fit the exclusion criteria, and introduced the research to the subjects. For the patients from whom consent was obtained, group therapy was conducted for 6 or 7 patients in the order of registration. Psychological measurements were taken before and after group therapy. We performed group therapy in parallel with outpatient consultation, but did not allow concurrent individual psychotherapy or nutritional counseling. However, 15 patients had received nutritional counseling before the group therapy started. Regular outpatient treatment consisted of a medical consultation that included simple counseling for about 15 min in the outpatient clinic and medication.
Those who completed group therapy with fewer than 3 absences were regarded as completers, and those who were absent 5 times or more were regarded as dropouts. All participants fell into one of these two groups. We investigated the prognosis after 1, 5, and 10 years after group therapy of completers and dropouts who we were able to follow up. We conducted the following assessments after 5 and 10 years: BMI, number of regular meals/day, instances of overeating (number of times and extent of overeating), frequency of vomiting, use of laxatives or diuretics, excessive exercise, alcohol and tobacco use, self-injurious behavior, other problem behaviors, comorbidities, symptoms such as depression and anxiety, interpersonal relationship situation, marriage and childbirth, work, and social activities. Based on these items, we evaluated the prognosis as described below.
Evaluation of prognosis
We used improvements in eating behavior and social adjustment as parameters for the prognostic evaluation. The conditions for determining improvements in eating behavior were: three meals per day were regularly eaten, the frequency of overeating was less than once a week, the BMI was 17.5 or more, and the behaviors were sustained for more than 1 year. Improvements in social adaptation were judged using the Global Assessment of Functioning (GAF). GAF is a component of the DSM-IV, not the DSM-5. However, GAF has been widely used and it is easy to administer. We considered a score of higher than 80 on the GAF to be an indicator of good social adaptation. We considered the patients whose eating disorder symptoms improved and who had adapted well to society as having made “good progress,” the patients whose symptoms did not change as having “no change,” and the patients whose symptoms got worse or were maladaptive (GAF score less than 50) as having “poor progress.”
This study received approval of Hiroshima University Medical Ethics Committee (No: E776). In addition, we retrospectively registered the study in University Hospital Medical Information Network in Japan (No.000028868, May 19th, 2017).
Participants
The participants were 65 adult patients with eating disorders diagnosed in accordance with the Diagnostic and Statistical Manual of Mental Disorders (DSM), 4th edition (DSM-IV) and re-diagnosed with DSM 5th edition (DSM-5) based on the medical records and discussion with the attending doctor. However, although The Global Assessment of Function (GAF) is not present in the DSM-IV, we used GAF because it is convenient. All patients were Japanese women. The average age (19–37) of the patients was 25.1 ± 3.8 years, age of onset was 17.8 ± 2.8 years, duration of illness was 6.8 ± 4.2 years, and the average body mass index (BMI) was 17.7 ± 2.0 kg/m2. The included cases were 18 cases of AN restricting type (AN-R), 12 cases of AN binge-eating/purging type (AN-BP), 24 cases of BN, 9 cases of BED, and 2 cases of other specified feeding or eating disorder (OSFED). According to comorbidities, 13 cases were of depressive disorder, 10 of panic disorder, 3 of obsessive-compulsive disorder, and 11 were of personality disorder (7 borderline personality disorder and 4 schizoid personality disorder).
Forty-eight patients completed the therapy sessions (they attended more than 8 sessions), and 17 patients (26.1%) dropped out of the study. Of the 17 patients, 3 dropped out initially, 8 within 3 weeks (3rd session) of the first session, and 6 within 1 month (4–5th session).
Intervention
The structure of the group therapy was as follows: 1) closed membership, 2) group size limited to no more than eight members, 3) weekly meetings (90 min, 10 sessions), and 4) 2–3 staff members (2 psychiatrists usually participated, sometimes a psychologist joined) present.
Session 1, 2: “What is an eating disorder?”
In these sessions, we used a psycho-educational approach. In addition, we adopted Fairburn’s “formulation” and self-monitoring. We created the “formulation” and learned about self-monitoring through real time meal, situation, and mood records. The participants were encouraged to perform real-time self-monitoring as homework, and in each session after that, we analyzed the records objectively and discussed countermeasures.
Session 3: “Thinking about body image and evaluating symptoms”
In this session, we evaluated body image and body checking behavior. We assessed the extent to which the patients were preoccupied by their weight.
Session 4, 5: “Tackling difficult problems”
In these sessions, we clarified the various general problems, especially interpersonal problems the patients faced, and discussed new ways of coping with the problems. The purpose of these sessions was to improve the coping skills of the patients.
Session 6, 7: “Asserting myself”
In these sessions, we discussed the scenarios in which the patients experienced difficulties in self-assertiveness, and trained the patients with regard to self-assertiveness through role-play. The purpose of the sessions was to improve the skills the patients needed to assert themselves.
Session 8, 9: “Thinking about cognition”
In these sessions, the patients learned about 1) common cognitive styles in eating disorders including working to reconsider the “formulation” created in the first session, 2) using a thought record list to examine their cognitive style, and 3) examining their perception of their weight and body shape, and their views of their interpersonal relationships.
Session 10: “If you recovered from your eating disorder?”
In this session, we encouraged the patients to imagine themselves as someone who recovered, discuss the merits and demerits of recovery, and uncover factors that may hinder their recovery. The purpose of this session was to reinforce the motivation to continue treatment.
In the last intervention, we directed the patients to continue using the content of the session by themselves, and to report the progress to their doctor at the time of consultation.
Measures
Eating attitudes Test-26 (EAT-26)
The Eating Attitudes Test-26 (EAT-26) is a 26-item self-reported measure of eating attitudes. The original scale consists of 40 items (EAT-40) but we used Garner’s modification, namely the shorter EAT-26. Garner reported that the EAT-26 was highly correlated with the EAT-40, and that the EAT-26 was a reliable, valid, and economical instrument [25]. It is scored using a six-point Likert-type scale, with options ranging from “not at all” to “extremely.” We used the Japanese version translated by Baba et al. in 1993. Cronbach’s alpha coefficient scores were 0.85–0.94 [25, 26].
Profile of mood states (POMS)
The Profile of Mood States (POMS) was developed by McNair et al. [27], and is administered to patients to assess their mood states. It is a 65-item self-report measure of six subscales comprising tension/anxiety, depression/dejection, anger/hostility, vigor/activity, fatigue/inertia, and confusion/bewilderment. It is scored using a five-point Likert-type scale, with options ranging from “not at all” to “extremely.” We used the Japanese version translated by Yokoyama et al. in 1994. Cronbach’s alpha coefficient scores were 0.76–0.95 [27, 28].
Coping inventory for stressful situations (CISS)
The Coping Inventory for Stressful Situations (CISS) was developed by Endler et al. [29]. It is a 48-item self-report measure that is scored using a five-point Likert-type scale, with options ranging from “not at all” to “extremely.” This scale evaluates three coping behavior patterns as follows: task-oriented, emotional-oriented, and avoidance-oriented coping. Task-oriented coping is considered to be an adaptive coping behavior; in contrast, emotion-oriented coping is considered to be a non-adaptive coping behavior, which includes self-criticism and anger. We used the Japanese version translated by Furukawa et al. in 1993. Cronbach’s alpha coefficient scores were 0.75–0.89 [30].
Rosenberg’s self-esteem scale (RSES)
Rosenberg’s Self Esteem Scale (RSES) was developed by Rosenberg [31]. It is a 10-item self-report measure that is scored on a four-point Likert-type scale, with options ranging from “not at all” to “extremely.” We used the Japanese version translated by Yamamoto et al. in 1982. Cronbach’s alpha coefficient scores were 0.82–0.86 [32].
Statistical analysis
We used IBM SPSS version 21 statistics for statistical analysis. We used paired t-tests to analyze the self-rating scales before and after intervention, Mann-Whitney U-tests to compare the self-rating scales between patients who completed therapy and those who dropped out of the study, and chi-square tests for comparing the frequencies of good outcome, no change, and poor outcome. We assumed p < 0.01 indicated significant differences.