What is multi-impulsive bulimia and can multi-impulsive patients benefit from supervised self-help?

European Eating Disorders ReviewEur. Eat. Disorders Rev. 10, 413–427 (2002)Published online 17 May 2002 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/erv.468

Paper

What Is Multi-Impulsive Bulimia andCan Multi-Impulsive Patients Benefitfrom Supervised Self-Help?

Lorraine Bell* and Kathryn NewnsEating Disorders Team, Civic Offices, Havant, Hampshire, UK

Definitions of multi-impulsivity and sample characteristics between studies ofimpulsivity vary widely leading to inconsistent results. Outcome data wasexamined to assess the comparative response of multi-impulsive and non multi-impulsive bulimic patients to a supervised self-help CBT programme. Multi-impulsivity was defined as the presence of two or more impulsive behaviours inthe last 2 months in addition to bulimia nervosa as reported with the Multi-Impulsivity Scale. Multi-impulsive patients reported similar levels of bulimicbehaviours but higher levels of depression at pre-treatment. They achievedsimilar levels of change by the end of treatment. However, despite improve-ments, their levels of depressive symptoms remain high and bulimic symptomssubclinical and may be at higher risk of relapse. Copyright # 2002 John Wiley& Sons, Ltd and Eating Disorders Association.

Keywords: multi-impulsivity; bulimia nervosa; supervised self-help;CBT; outcome

INTRODUCTION

What is multi-impulsive bulimia?

It has been suggested that bingeing and purging may sometimes beattributable to general problems with impulse regulation (Lacey, 1993;Steiger, Lehoux, & Gauvin, 1998; Vitousek & Manke, 1994). Impulsivityis characterized by a lack of deliberation and failure to consider the risksand consequences before acting upon an impulsive urge. Lacey andEvans (1986) suggested that multiple patterns of impulsivity are

European Eating Disorders ReviewCopyright # 2002 John Wiley & Sons, Ltd and Eating Disorders Association. 10(6), 413–427 (2002)

*Correspondence to: Dr L. Bell, Eating Disorders Team, Civic Offices, Civic Centre Road, Havant,Hampshire PO9 2AX, UK. Tell: 023 92499224. Fax: 023 92350005.

common in eating disorders. Lacey coined the term ‘multi-impulsivebulimia’ to describe the subgroup of patients whose bulimia is alsoassociated with at least one of the following: gross alcohol abuse, ‘streetdrug’ abuse, multiple overdoses, repeated self-damage, sexual disin-hibition, or shoplifting, where these behaviours are associated with asimilar sense of being out of control, are interchangeable and impulsive,and where suppression of these behaviours leads to depression andintense anger. They observed these patients place high demands uponpsychiatric and medical services, and stated they are ‘associated withpoor prognosis and particularly parasuicide’. Lacey (1993) found 80per cent of normal weight bulimic women from the same urbancatchment area gave a history of three or more self-damagingbehaviours. However, both the diagnostic definition of multi-impulsivebulimia, and the role of impulsivity in the maintenance and aetiology ofBN in this subgroup remains the subject of much contention.

Problems of definition

Other studies have used different criteria from those of Lacey.Matsunaga et al. (2000) observed that inconsistencies in diagnosticcriteria have produced rates of multi-impulsivity in bulimic patientsfrom 18–80 per cent. There are a range of differences in criteria betweenstudies (see Table 1). Firstly, the number of dyscontrol behavioursassessed varies from three to six behaviours. Secondly, the number ofthese behaviours which constitute multi-impulsivity varies. Thirdly,how long the patient has been exhibiting these behaviours for them to beconsidered present is variable. In some studies they require thebehaviour to have been experienced during the previous month oryear, in others an existence of the behaviour in the patient’s lifetime.Most studies use a lifetime history as the time criteria. This seems toolow a threshold as many young women (i.e. normal controls) wouldhave a history of episodic substance misuse or casual sex. Laceyproposes patients may substitute one impulsive behaviour for another.Identification of this phenomenon would require a tighter definitionthan merely a lifetime history.

Clinical features and incidence

Studies have found widely varying incidence rates for multi-impulsivebulimia (see Table 2) depending on definitions used and samplecharacteristics. Fitcher, Quadflieg, and Rief (1994) applied morestringent criteria i.e. at least three impulsive behaviours from: drugabuse; self-damage; alcohol abuse; shoplifting; overdoses; and sexual

L. Bell and K. Newns Eur. Eat. Disorders Rev. 10, 413–427 (2002)

Copyright # 2002 John Wiley & Sons, Ltd and Eating Disorders Association. 414

Tab

le1.

Defi

nitionsofmulti-im

pulsivebulimia

Study

Beh

aviours

included

Number

forthresh

old

Duration

How

assessed

Nag

ata

etal

.(2

000)

Hea

vy

reg

ula

ral

coh

ol;

suic

ide

>3

Inli

feti

me

Imp

uls

ive

Beh

avio

ur

atte

mp

t;se

lf-h

arm

;sh

op

lift

ing

;Q

ues

tio

nn

aire

(IB

Q)

sex

wit

h‘n

ot

wel

lk

no

wn

’su

bje

cts

and

sem

i-st

ruct

ure

din

terv

iew

Wie

der

man

Su

icid

eat

tem

pt;

self

-har

m;

>3

Inli

feti

me

Dia

gn

ost

icS

urv

eyfo

rE

atin

gan

dP

ryo

r(1

996)

stea

lin

g;

atle

ast

wee

kly

use

Dis

ord

ers-

Rev

ised

(DS

ED

-R)

of

alco

ho

lan

d/m

arij

uan

aF

itch

eret

al.

(199

4)S

uic

ide

atte

mp

t;se

lf-h

arm

;B

ing

eea

tin

gþ>

3In

life

tim

eS

elf-

rep

ort

stea

lin

g;

alco

ho

l;d

rug

s;p

rom

iscu

ity

Kee

lan

dS

uic

ide

atte

mp

ts;

sev

ere

>2

No

tsp

ecifi

edE

atin

gD

iso

rder

sM

itch

ell

(199

9)au

toag

gre

ssio

n;

stea

lin

g;

Qu

esti

on

nai

re(E

DQ

)al

coh

ol

abu

seN

ewto

net

al.

(199

3)A

lco

ho

lab

use

;st

reet

dru

gab

use

;B

Nþ>

1N

ot

spec

ified

Bar

rett

Imp

uls

iven

ess

mu

ltip

leo

ver

do

ses;

rep

eate

dS

cale

(BIS

10)

and

sem

i-se

lf-h

arm

;se

xu

ald

isin

hib

itio

n;

stru

ctu

red

inte

rvie

wsh

op

lift

ing

Mat

sun

aga

Su

icid

eat

tem

pt;

self

-har

m;

stea

lin

g;

Bu

lim

icIn

life

tim

eS

elf-

rep

ort

qu

esti

on

nai

reet

al.

(200

0)al

coh

ol;

dru

g;

pro

mis

cuit

ysy

mp

tom

sþ>

3F

ahy

and

Eis

ler

(199

3)A

lco

ho

lab

use

;d

rug

abu

se;

ov

erd

ose

s;B

Nþ>

1D

uri

ng

Inte

rvie

wse

lf-h

arm

;sh

op

lift

ing

;se

xu

alp

rev

iou

sd

isin

hib

itio

ny

ear

Wel

chan

dD

elib

erat

ese

lf-h

arm

;re

gu

lar

BNþ>

1D

uri

ng

Sem

i-st

ruct

ure

din

terv

iew

Fai

rbu

rn(1

996)

dru

gm

isu

se;

exce

ssiv

ep

rev

iou

sal

coh

ol

con

sum

pti

on

mo

nth

Eur. Eat. Disorders Rev. 10, 413–427 (2002) Multi-Impulsive Bulimia


disinhibition. Bulimic patients who met this definition did not differconcerning eating behaviours, attitudes and body weight, or socio-demographic characteristics (e.g. age, duration of eating disorder, andage of onset) from bulimics who did not exhibit other impulsivebehaviours. However, the multi-impulsive group had a higher severityof psychosocial stressors and a lower maximum level of adaptivefunctioning before inpatient admission. They also showed higher scoresin some dimensions of general psychopathology. Fitcher et al.concluded their data supported the notion that multi-impulsive bulimiacan be classified as a distinct subgroup.

Wiederman and Pryor (1996) compared the clinical features ofbulimics with and without impulsivity. They defined impulsivity asthe presence of at least three of four impulsive behaviours: a history ofattempted suicide; a history of self-harm; at least weekly use of alcoholand/or marijuana; and a history of stealing. Although multi-impulsivityappeared unrelated to the current frequency of vomiting or binge eating,the multi-impulsive group reported earlier onset of self-inducedvomiting, binge eating and sexual intercourse, and a greater incidenceof laxative abuse and of vomiting.

Others have questioned the case for a subtype of multi-impulsivebulimia. Welch and Fairburn (1996) compared 102 bulimic patients with204 normal controls and 102 controls with other psychiatric disorders.They measured only three areas of impulsive behaviour in additionto BN in a typical week within the last month: repeated deliberate

Table 2. Incidence of multi-impulsive bulimia

Study BN sample Sample Percentage withsize characteristics multi-impulsive bulimia

Wiederman 217 Outpatients 18.4and Pryor(1996)Nagataet al. (2000) 114 Outpatients 18Lacey (1993) 112 Outpatients 40

(community sample)Welch and 102 Outpatients 30 bi-impulsiveFairburn (1996) (community sample) 6 multi-impulsiveFahy and 39 Outpatient tertiary 51Eisler (1993) referralsFitcher et al. (1994) 64, 196 Inpatients 50Newton et al. (1993) 58 Inpatients 44Matsunaga 64 Inpatients (48% meet 30et al. (2000) criteria for AN)



self-harm; regular drug misuse; or excessive alcohol consumption . Onlysix out of 102 bulimic patients had two or more of these behavioursconcurrently. BN cases used more illicit drugs than either of the controlgroups and had a higher rate of deliberate self-harm. However, theyconcluded these cases were probably heterogeneous in character andthat it would be premature to classify them as a subgroup. Theysuggested self-harm, drug misuse and alcohol misuse might each have adifferent relationship to BN rather than reflecting underlying disordersof impulse control. They proposed that, although the difficulties ofpatients with BN and comorbid substance misuse or self-harm need tobe recognized, there was no justification for the subclassification ofbulimia nervosa (BN) into multi-impulsive and non-impulsive sub-types.

Fahy and Eisler (1993) studied 39 BN subjects using Lacey’s criteria(at least one of additional: alcohol abuse, ‘street drug’ abuse, multipleoverdoses, repeated self-damage, sexual disinhibition, or shoplifting).The Eysenck’s Impulsivity Questionnaire failed to distinguish multi-impulsive patients from those who were non multi-impulsive. How-ever, only one of their patients scored highly on the ImpulsivityQuestionnaire. Newton, Freeman, and Munro (1993) used Lacey’scriteria and the Barrett Impulsiveness Scale (BIS10, Barrett, 1985) todetermine multi-impulsivity among 28 bulimic patients. Of their patientcohort 44 per cent met Lacey’s criteria and there were significantpositive correlations between the BIS10 and the number of dyscontrolbehaviours reported. The BIS10 and the number of impulsivebehaviours reported positively correlated with measures of depression(Beck Depression Inventory, BDI; Beck, Ward, Mendelson, Mock, &Erbaugh, 1965), obsessionality (Maudsley Obsessive CompulsiveInventory, MOCI; Hodgson & Rachman, 1977) and BN (BulimicInvestigatory Test, Edinburgh, BITE; Henderson & Freeman, 1987).Their results indicated that impulsivity is associated with more severebulimic symptoms, leading them to suggest that multi-impulsivebulimia is not an independent phenomenon but is associated withmore severe clinical disturbance.

Cross-cultural studies such as those in Japan (Matsunaga et al., 2000;Nagata, Kawarada, Kiriike, & Iketani, 2000) support the existence of asubgroup of patients with a multi-impulsive form of bulimia nervosa.Matsunaga et al. found 30 per cent of inpatients with BN met Fitcheret al.’s (1994) criteria. Nagata et al. (2000) found 18 per cent ofoutpatients had three additional areas of impulsivity compared to2 per cent in anorectic patients (restricting subtype), 11 per cent inanorectic patients (binge-eating/purging subtype) and 2 per centin control subjects. They also found that, of the bulimic patients with



multi-impulsivity, 80 per cent had a history of suicide attempts or self-mutilation prior to the onset of their bulimia nervosa. This led them tosuggest primary impulsivity does exist and the impulsive behavioursdisplayed by these patients could be considered an expression of a morefundamental psychopathology rather than the consequence of chaoticeating behaviour.

Response to treatment

Drop-out

Newton et al. (1993) found multi-impulsive bulimic patients had higherdrop-out rates than non-impulsive patients. In a larger study by Agraset al. (2000), the best combination of predictors of drop-out was morefrequent bulimic thoughts and greater levels of impulsivity on theMultidimensional Personality Questionnaire (Tellegen & Waller, 1994).Fitcher et al. (1994) also found a trend for more premature terminationsof inpatient therapy among multi-impulsive patients.

Outcome

It has been suggested that the course of multi-impulsive bulimia islikely to differ from that of BN without additional impulsive features(Fitcher et al., 1994; Lacey, 1993; Lacey & Evans, 1986; Sohlberg, Norring,Holmgren, & Rosmark, 1989). Lacey (1993) proposed that specialisttreatment is required to deal with the interchangeable nature of thesymptoms in multi-impulsive bulimia, and that such treatment shouldgive importance to the management of delayed gratification and controlof impulsivity. Symptom substitution has been reported by Brismanand Segal (1984), who found a high prevalence of alcohol abuse inbulimic patients and observed the two symptoms appeared to beinterchangeable.

Studies measuring outcome have had mixed results (see Table 3).Fahy and Eisler (1993), found that at pre-treatment assessment and after8 weeks of CBT, the multi-impulsive group (51 per cent of subjects)reported a significantly higher frequency of bingeing than the non-impulsive group, and the non-impulsive group had a more rapidreduction in Eating Attitude Test (EAT; Garner & Garfinkel, 1979)scores. However, at 1-year follow-up there was no difference betweengroups in binge frequency, EAT scores, or BITE scores. They concludedthat there is no evidence of an association between high impulsivity andpoor treatment response. Other studies have also found no relationshipbetween impulsivity and outcome (Bossert, Schmolz, Wiegand, Junker,& Krieg, 1992; Keel & Mitchell, 1999).



Sohlberg et al. (1989) found impulsive behaviour was a strongpredictor of poor outcome. However their study used both anorecticand bulimic patients and considered bingeing to be an impulsivebehaviour, so the poor prognosis of severe bulimia may have beenwrongly attributed to impulsivity. Fitcher et al. (1994) found at 3-monthfollow-up there was no difference between the multi-impulsive groupand the non-impulsive group, but in the fourth to the 12th month afterdischarge, the multi-impulsive group began to show signs of moredisturbed eating behaviours. By 2 years, this difference was statisticallysignificant.

Supervised self-help

Abbreviated CBT programmes are an effective first line treatmentfor Bulimia Nervosa (Cooper, Coker, & Fleming, 1994, 1996; Schmidt,Tiller, & Treasure, 1993; Treasure et al., 1996) and Binge EatingDisorder (Carter & Fairburn, 1998; Loeb, Wilson, Gilbert, & Labouvie,2000). Wilson and Fairburn (1998) conclude that a subgroup of patientsrespond to abbreviated CBT but it is unknown which patients, ifany, should be excluded from such programmes. We examined

Table 3. Studies examining the relationship between multi-impulsivity andoutcome in treatment for bulimia nervosa

Study Sample End of Follow-upcharacteristics treatment

Agras et al. (2000) 194 o/p No difference N/AKeel and 173 o/p Not specified 11.5� 1.9 years:Mitchell (1999) Impulsiveness did not

predict outcomeFitcher et al. (1994) 64 i/p Both groups 3 months: no

32¼BNþMI showed difference32¼BN�MI improved eating 4–12 months:196 i/p behaviour. BNþMI more

BNþMI: more severe eatinganxious, depressed disturbancesand demoralized 2 years: significant

difference betweengroups

Fahy and Eisler 39 i/p BNþMI: more 1 year: no difference(1993) 51% BNþMI frequent bingeing between groupsBossert 31 i/p Impulsiveness did N/Aet al. (1992) not predict outcome

o/p, outpatient; i/p, inpatient.



the effectiveness of a supervised self-help programme for patientswho are multi-impulsive compared to those who are non-multi-impulsive.

METHOD

Patients were referred to the programme in a 24-month period (August1998–August 2000) following initial assessments in community mentalhealth teams. Patients referred met criteria for Bulimia Nervosa, BingeEating Disorder or Eating Disorder Not Otherwise Specified andincluded both males and females. They were 17 to 58 years old, with amean age of 30 years. Data presented are only those for female bulimicclients who reported bingeing and purging at least twice a week at initialassessment. Some patients with major psychological disturbance(notably Borderline Personality Disorder) are not allocated to theprogramme but are offered more intensive comprehensive psychologi-cal treatment.

Design and measures

Patients were assessed at the beginning and end of treatment usingmeasures selected for their previous well-documented validity andreliability, the Bulimic Investigatory Test (BITE; Henderson & Freeman,1987), BDI and Multi-Impulsivity Scale (MIS; Evans, Searle, & Dolan,1998).

The BITE is a 33-item self-report measure and consists of twosubscales: the Symptom Scale, which measures the degree of symptomspresent, and the Severity Scale, which provides an index of severity ofbingeing and purging behaviours as defined by their frequency. On theSymptom Scale scores of 20 or more indicate a highly disordered eatingpattern and the presence of binge eating. There is a high probability thata subject who achieves such a score would fulfil the DSM criteria for adiagnosis of bulimia nervosa. On the Severity Scale a score of 5 or moreis considered to be clinically significant, a score of 10 or more isindicative of a high degree of severity.

The MIS includes 11 domains: bingeing, drinking alcohol, shoplifting,gambling, behavioural aggression, self-harm, overdosing, illicit drugabuse, promiscuity, starting fires and provoking fights. Responses arescored on a 6-point scale (‘never’, ‘occasionally’, ‘sometimes’, ‘often’,‘very often’ and ‘always’). Multi-impulsivity is considered present if the



subject responds at or above ‘sometimes’ on the behavioural items forbingeing and two or more non-food items.

Procedure

Patients used the manual Getting Better Bit(e) by Bit(e) (Treasure &Schmidt, 1993) and were supervised by an assistant psychologist.Supervision sessions took place weekly and lasted approximately30 min each. The mean number of session for subjects who completedtreatment was 9.48, ranging from 4 to 15.

RESULTS

Of the 46 patients included in this study, 11 were multi-impulsive,reporting at or above ‘sometimes’ on bingeing and two or more non-food items on the MIS. The remaining 35 were considered to be nonmulti-impulsive. A total of 16 patients dropped out of treatment, a t-testrevealed that multi-impulsivity did not predict drop-out (5/16 multi-impulsive, 11/16 non multi-impulsive, p-value 0.505, n.s).

An independent t-test on the pre-treatment scores for the multi-impulsive and non-multi-impulsive patients indicated that there wereno significant differences in their scores for BITE symptom, BITEseverity, and BITE bingeing, purging and fasting behaviours. Howeverthe multi-impulsive group scored significantly higher on the BDI thanthe non-multi-impulsive group (t¼ 2.94, p> 0.005) (see Table 4).

Table 5 shows that multi-impulsive patients reported higher levels ofdepression at pre-treatment, but not of bulimic behaviours. Althoughboth groups made significant changes in depression and bulimicbehaviours, the multi-impulsive group remained moderately to severely

Table 4. t-Test to investigate whether there is statistical significance betweenmulti-impulsive and non-impulsive patients pre-treatment

t-value p-value

BDI 2.94 0.005*BITE–Symptom �1.08 0.292BITE–Severity �0.84 0.404BITE–Fasting �0.68 0.500BITE–Bingeing �0.81 0.422BITE–Purging �0.39 0.699

*Statistically significant (p< 0.05).



depressed (mean 24.33), and their BITE symptom scores remained at asubclinical level (mean 15.33).

Related t-tests were carried out to see if the two groups improvedwith treatment. There were significant differences in pre- and post-treatment scores in multi-impulsive patients. Reduction in fastingbehaviours did not reach significance and bingeing behaviours almostreached significance (see Table 6).

Independent t-tests were then carried out to see if multi-impulsivitysignificantly effected outcome. The multi-impulsive group did not doless well statistically in any area, i.e. the two groups made similar ratesof improvement in depression, BITE symptom and severity scores, andin bingeing, purging and fasting behaviours (see Table 7).

Table 5. Pre- and post-treatment scores for multi-impulsive and non-multi-impulsive patients

Multi-impulsive Non-impulsive

Pre-treatment Post-treatment Pre-treatment Post-treatmentmean mean mean mean

BDI 40.09* 24.33* 26.97* 5.36BITE–Symptom 24.59* 15.33y 22.91* 8.35BITE–Severity 10.45* 3.83 11.97 1.92BITE–Fasting 1.36 0.17 1.71 0.38BITE–Bingeing 3.55 2.17 3.95 0.83BITE–Purging 5.91 1.50 5.44 0.75

*Clinically significant.ySubclinical.BDI: 30–36 severe; 19–29 moderate to severe; 10–18 mild–moderate; <10 minimal–none.BITE symptom: >20 highly disordered; 10–20 subclinical; <10 normal range.BITE severity: <5 not clinically significant.

Table 6. t-Test to investigate significance of change scores in multi-impulsive patients

Change scores t-value p-value

BDI �19.83 �3.90 0.011*BITE–Symptom �10.08 �3.15 0.025*BITE–Severity �7.67 �3.56 0.016*BITE–Fasting �2.00 �2.15 0.084BITE–Bingeing �2.33 �2.50 0.054BITE–Purging �4.67 �4.43 0.007*

*Statistically significant (p< 0.05).



DISCUSSION

Patients were classified as multi-impulsive with the aid of the Multi-Impulsivity Scale. This scale was selected as it includes the widest rangeof impulsive behaviours and operationally defines their presence. (Therange of behaviours is not however exhaustive. It does not for exampleinclude impulsive spending, a behaviour not uncommonly reported bybulimic women.)

Multi-impulsive and non-multi-impulsive patients reported similarBITE symptom and severity scores pre-treatment. The two groups didnot differ significantly in their pre-treatment BITE binge, purge andfasting frequencies, but the multi-impulsive group had a significantlyhigher BDI score. In our sample both the multi-impulsive and non-multi-impulsive groups reported significant improvements in all areas,with the exception of fasting behaviours. Changes in scores for fastingand bingeing did not reach statistical significance in the multi-impulsivegroup. Drop-out rates were not significantly different.

Mean pre-treatment scores on the BDI indicated patients on theprogramme were severely depressed, with the multi-impulsive groupsignificantly more so. After completing the programme, the mean for thenon-multi-impulsive group had fallen within the range of the normalpopulation. Although the post-treatment scores for the multi-impulsivegroup indicated moderate to severe depression, they too had experi-enced significant reduction in depressive features. The programme waseffective at reducing levels of depression, but medication was notcontrolled for and is likely to have also influenced outcome. The fact thatthe multi-impulsive group still displayed clinically significant depres-sive features may indicate that they are at higher risk of relapse (Keller,Herzog, Lovori, Bradburn, & Mahoney, 1991). A recent studyquestioned the value of routine prescriptions of antidepressantsconcurrent with CBT (Bacalchuck et al., 2000). However, given the rate

Table 7. t-Test to investigate statistical significance between change scores ofmulti-impulsive and non-multi-impulsive patients

MI�NMI change scores t-value p-value

BDI �2.67 �0.54 0.592BITE–Symptom �6.19 �1.95 0.062BITE–Severity �1.54 �0.61 0.547BITE–Fasting 0.83 1.18 0.249BITE–Bingeing �0.77 �1.24 0.227BITE–Purging 0.028 0.49 0.635



of depression reported by multi-impulsive patients, supplementarymedication should perhaps be routinely considered.

Similarly, mean scores on the BITE symptom and severity scales weresignificantly reduced after treatment for both groups. Importantly therewas no significant difference between the change scores of the twogroups in any area. Although the multi-impulsive group did not reportless improvement than the non-multi-impulsive group, bulimicsymptoms remained subclinical, which again may indicate increased riskof relapse (Mussell et al., 2000). If this is the case it may be that theprogramme should be expanded to address impulsivity or associatedproblems with mood disturbance or interventions offered to addresspossible trauma sequelae. Many patients presenting with bulimia nervosahave additional problems identified at assessment which they do notalways want necessarily to address. It is not clear whether cliniciansshould always offer more comprehensive psychological treatment. Theseissues should be explored with patients before commitment to aprogramme which focuses solely on their eating disorder.

Our sample size was small which may have contributed to thoseresults which did not reach statistical significance. MIS scores post-treatment could also have been measured to examine the impact of theprogramme on levels of other impulsive behaviours. A further merit ofthe MIS is that separate measures are taken of the urge to carry outimpulsive behaviours as well as their action, giving a more detailedpicture of change. Reassessment at follow-up is needed to examinewhether multi-impulsive patients are more likely to relapse in bulimicbehaviours.

CONCLUSION

Definitions of multi-impulsivity and sample characteristics betweenstudies of impulsivity vary widely leading to inconsistent results. On asupervised self-help programme, multi-impulsive patients reportedsimilar levels of bulimic behaviours but higher levels of depression atpre-treatment and achieved similar levels of change by the end oftreatment. However, despite improvements, their levels of depressivesymptoms remain high and bulimic symptoms subclinical. This couldmean they are at higher risk of relapse but this cannot be assessedwithout follow-up. When multi-impulsive patients are identifiedtreatment goals should be carefully considered and the benefit ofconcurrent medication explored with patients. Patients who still bingeor purge at the end of treatment could be offered further follow-up orsupplementary treatment (Mussell et al, 2000).



REFERENCES

Agras, W., Crow, S., Halmi, K., Mitchell, J., Wilson, G., & Kraemer, H. (2000).Outcome predictors for cognitive behaviour treatment of bulimianervosa: data from a multi-site study. American Journal of Psychiatry,157, 1302–1308.

Bacalchuck, J., Trefiglio, R., Oliverira, I., Hay, P., Lima, M., & Mari, J. (2000).Combination of antidepressants and psychological treatments forbulimia nervosa: a systematic review. Acata Psychiatrica Scandinavica,101, 256–264.

Barrett, E. (1985). Impulsiveness subtraits, arousal and information processing.In J. Spence, & C. Izzard (Eds.), Motivation, emotion and personality.Amsterdam: Elsevier Science Publishers.

Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1965). Aninventory for measuring depression. Archives of General Psychiatry 4,561–571.

Bossert, S., Schmolz, U., Wiegand, M., Junker, M., & Krieg, J. C. (1992).Predictors of short-term treatment outcome in bulimia nervosainpatients. Behaviour Research and Therapy 30, 193–199.

Brisman, J., & Siegal, M. (1984). Bulimia and alcoholism: two sides of the samecoin? Journal of Substance Abuse Treatment 1, 113–118.

Carter, J., & Fairburn, C. (1998). Cognitive behavioural self-help for bingeeating disorder: a controlled effectiveness study. Journal of Consultingand Clinical Psychology, 66, 616–623.

Cooper, P., Coker, S., & Fleming, C. (1994). Self-help for bulimia nervosa:a preliminary report. International Journal of Eating Disorders, 16,401–404.

Cooper, P., Coker, S., & Fleming, C. (1996). An evaluation of the efficacy ofsupervised cognitive behavioural self-help for bulimia nervosa. Journalof Psychosomatic Research, 40, 281–287.

Evans, C., Searle, Y., & Dolan, B. (1998). Two new tools for the assessment ofmulti-impulsivity: the ‘MIS’ and the ‘CAM’. European Eating DisordersReview, 6, 48–57.

Fahy, T., & Eisler, I. (1993). Impulsivity and eating disorders. British Journal ofPsychiatry, 162, 193–197.

Fitcher, M., Quadflieg, N., & Rief, W. (1994). Course of multi-impulsivebulimia. Psychological Medicine, 24, 591–604.

Garner, D., & Garfinkel, P. E. (1979). The eating attitudes test: an index of thesymptoms of anorexia nervosa. Psychological Medicine, 9, 273–279.

Henderson, M., & Freeman, C. (1987). A self-rating scale for bulimia—the BITE.British Journal of Psychiatry, 150, 18–24.

Hodgson, R., & Rachman, S. (1977). Obsessional compulsive complaints.Behavioural Research and Therapy, 15, 185–189.

Keel, P., & Mitchell, J. (1999). Long-term outcome of bulimia nervosa. Archivesof General Psychiatry, 56, 63–69.



Keller, M., Herzog, D., Lovori, P., Bradburn, I., & Mahoney, E. (1991). Thenaturalistic history of bulimia nervosa: extraordinarily high rates ofchronicity, relapse, recurrence, and psychosocial morbidity. Interna-tional Journal of Eating Disorders, 12, 1–9.

Lacey, J. H. (1993). Self-damaging and addictive behaviour in bulimia nervosa.A catchment area study. British Journal of Psychiatry, 162, 190–194.

Lacey, J. H., & Evans, C. (1986). The impulsivist: a multi-impulsive personalitydisorder. British Journal of Addiction, 81, 715–723.

Loeb, K., Wilson, G., Gilbert, J., & Labouvie, E. (2000). Guided and unguidedself-help for binge eating. Behaviour Research and Therapy, 38, 259–272.

Matsunaga, H., Kiriike, N., Iwasaki, Y., Miyata, A., Matsui, T., Nagata, T.,Yamagami, S., & Kaye, W. (2000). Multi-impulsivity among bulimicpatients in Japan. International Journal of Eating Disorders, 27, 348–352.

Mussell, M., Mitchell, J., Crosby, R., Fulkerson, J., Hoberman, H., & Romano J.(2000). Commitment to treatment goals in prediction of groupcognitive-behavioural therapy treatment outcome in women withbulimia nervosa. Journal of Consulting and Clinical Psychology, 68, 432–437.

Nagata, T., Kawarada, Y., Kiriike, N., & Iketani, T. (2000). Multi-impuslivity ofJapanese patients with eating disorders: primary and secondaryimpulsivity. Psychiatry Research, 94, 239–250.

Newton, J., Freeman, C., & Munro, J. (1993). Impulsivity and dyscontrol inbulimia nervosa: is impulsivity an independent phenomenon or amarker of severity? Acta Psychiatrica Scandinavica, 87, 389–394.

Schmidt, U., Tiller, J., & Treasure, J. (1993). Self-treatment of bulimia nervosa: apilot study. International Journal of Eating Disorders, 13, 273–277.

Sohlberg, S., Norring, C., Holmgren, S., & Rosmark, B. (1989). Impulsivity andlong-term prognosis of psychiatric patients with anorexia nervosa/bulimia nervosa. Journal of Nervous and Mental Disease, 177, 249–258.

Steiger, H., Lehoux, P., & Gauvin, L. (1998). Impulsivity, dietary control and theurge to binge in bulimic syndromes. International Journal of EatingDisorders, 26, 261–274.

Tellegan, A., Waller, N. (1994). Exploring personality through test construction:development of the multidimensional personality questionnaire. InS. Briggs, & J. Cheek (Eds.), Personality measures: development andevaluation, Vol. 1. Greenwich, CT: JAI Press.

Treasure, J., & Schmidt, U. (1993). Getting Better Bit(e) by Bit(e). Hove:Psychology Press.

Treasure, J., Schmidt, U., Troop, N., Tiller, J., Todd, G., & Turnbull, S. (1996).Sequential treatment for bulimia nervosa incorporating a self-caremanual. British Journal of Psychiatry, 168, 94–98.

Vitousek, K., & Manke, F. (1994). Personality variables and disorders inanorexia nervosa and bulimia nervosa. Journal of Abnormal Psychology,103, 137–147.

Welch, S., & Fairburn, C. (1996). Impulsivity or comorbidity in bulimia nervosa.A controlled study of deliberate self-harm and alcohol and drug



misuse in a community sample. British Journal of Psychiatry, 169,451–458.

Wiederman, M., & Pryor, T. (1995). Multi-impulsivity among women withbulimia nervosa. International Journal of Eating Disorders, 20, 359–365.

Wilson, G. T., & Fairburn, C. T. (1998). In P. E. Nathan, & J. M. Gorman (Eds.),Guide to treatments that work. USA: Oxford University Press, inc.



What is multi-impulsive bulimia and can multi-impulsive patients benefit from supervised self-help?

Documents

Transcript of What is multi-impulsive bulimia and can multi-impulsive patients benefit from supervised self-help?