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Effect of positive reinforcement, informational feedback, and contingency contracting on a bulimic anorexic female
BEHAVIOR THERAPY 8, 258-263 (1977)
Effect of Positive Reinforcement, Informational Feedback, and Contingency Contracting on a Bulimic Anorexic Female PETER M . M O N T I , BARBARA S. M C C R A D Y , AND DAVID H . BARLOW
Brown University and Butler Hospital Effects of reinforcement and feedback on the weight and caloric intake of a bulimic anorexic female were studied in a modified reversal design. Also studied was the effect of instructions on vomiting and effects of desensitization and conU'acting on weight and intake. The following phases were run: baseline, reinforcement, reinforcement plus feedback, reinforcement, reinforcement plus feedback plus desensitization, and desensitization plus contingency contracting. Results showed that feedback had a powerful influence. Also, instructions were effective in eliminating vomiting. When desensitization to thoughts which the patient had (which led her to feel as though she was a "bad person") was initiated, there was an increase in intake and weight. Interpretation of weight data was complicated because the patient developed edema which required treatment. This complication emphasized the importance of making reinforcement contingent on both weight gain and intake. A 6-month outpatient follow-up treatment period, during which desensitization and contracting were employed, suggested that treatment results were maintained. The discussion emphasizes this study's uniqueness in that it reports treatment of a bulimic anorxic. The fact that data for a 6-month follow-up period are reported is particularly important in light of recent criticisms of behavioral treatment of anorexia nervosa.
Behavior modification procedures incorporating selective positive reinforcement have proven effective in treating anorexia nervosa (Blinder, Freeman, & Stunkard, 1970; Leitenberg, Agras, & Thomson, 1968). Although most studies suggest that reinforcement leads to weight gain, only two studies have attempted to isolate the role of reinforcement. In the first study, Leitenberg et al. (1968) demonstrated that although positive reinforcement increased caloric intake and weight gain, weight gain continued after withdrawal of reinforcement. In the second, Agras, Barlow, Chapin, Abel, and Leitenberg (1974) demonstrated, in a series of single-case experiments, that reinforcement, informational feedback, and meal size all contribute to increased eating. Although the above studies have demonstrated the effectiveness of behavioral treatment for anorexia nervosa, none of the patients in the studies cited were bulimic anorexics. This is unfortunate since bulimia Reprint requests should be sent to Peter M. Monti, Brown University Medical School/ V.A. Hospital, Providence, RI 02908. 258 Copyright(~ 1977by the Associationfor Advancementof BehaviorTherapy. All rightsof reproductionin any formreserved.
ISSN 0005-7894
CASE REPORTS
AND
STUDIES
259
( m o r b i d l y i n c r e a s e d a p p e t i t e ) is o f t e n a p r o b l e m w h i c h a l t e r n a t e s w i t h anorexia. Also absent from the literature are reports of posthospitalization follow-up on anorexic cases treated with behavior m o d i f i c a t i o n ( F e i n s t e i n , 1974). L a c k o f f o l l o w - u p d a t a h a s m a d e e v a l u a tion o f t h e l o n g - t e r m e f f e c t i v e n e s s o f b e h a v i o r a l t r e a t m e n t f o r a n o r e x i a n e r v o s a i m p o s s i b l e . S u c h d a t a a r e p a r t i c u l a r l y c r u c i a l in v i e w o f r e c e n t c r i t i c i s m s o f t h e b e h a v i o r m o d i f i c a t i o n o f a n o r e x i a n e r v o s a ( B r u c h , 1974; S p e c t o r , 1975). T h e p r e s e n t c a s e differs f r o m p r e v i o u s r e p o r t s in s e v e r a l i m p o r t a n t dimensions. First, the patient was a bulimic anorexic. The patient would overeat and then induce vomiting and take laxatives and/or diuretics. Overeating/vomiting alternated with periods of decreased eating. Second, a b e h a v i o r a l a n a l y s i s r e v e a l e d t h a t t h o u g h t s w h i c h l e d t h e p a t i e n t to feeling as t h o u g h she w a s a " b a d p e r s o n " u s u a l l y p r e c e d e d h e r m a l a d a p tire behavior. The consequences of these bad feelings were either that the p a t i e n t w o u l d n o t eat, o r w o u l d o v e r e a t , feel " d i s g u s t i n g , " a n d t h e n t a k e o v e r d o s e s o f l a x a t i v e s a n d / o r d i u r e t i c s a n d i n d u c e v o m i t i n g . T h e s e intrusive t h o u g h t s w h i c h f o r m e d an e a r l y c o m p o n e n t in the b e h a v i o r a l a n d c o g n i t i v e c h a i n l e a d i n g to t h e m a l a d a p t i v e t a r g e t b e h a v i o r s d e s c r i b e d above also required treatment. Finally, data for a 6-month, outpatient, follow-up period are also reported.
METHOD Subject The patient was a 28-year-old female registered nurse, referred for admission because she had been losing weight and abusing medications such as diuretics and laxatives for the past 6 months. She had been taking an average of 30 Ex-Lax daily for the 2 months prior to admission. Six months prior to admission the patient had been overweight (79.38 kg and 1.75 m tall), had begun to diet, and ceased menstruating. Gradually she took more medications to lose weight, ate less, and when she overate, she induced vomiting. Vomiting occurred daily for several weeks prior to hospitalization. Upon admission she was severely emaciated, weighing 49.90 kg. Criteria used in making the diagnosis for anorexia nervosa in the present case were those generally accepted (Russell, 1971), namely, (1) behaviors leading to at least 20% loss of body weight; (2) cessation of menstruation in the patient above the age of puberty occurring before weight loss was extreme; (3) a fear of becoming obese, with marked resistance to the idea of gaining weight; and (4) no evidence of psychosis, but with other psychopathology usually similar to that described as hysterical personality. Measures Two measures of eating behavior were employed, caloric intake and weight. Caloric intake. Immediately after meals, caloric intake was calculated and charted by one of several nurses who had been trained to use a calorie counting booklet to calculate caloric intake. Weight. Each morning, at 10:00 AM, the patient was weighed by a nurse and her weight was recorded.
260
CASE REPORTS AND STUDIES
Vomiting. The patient was asked to report each time she vomited. Also, staff and other patients observed and reported vomiting, which was recorded by a staff member. Procedure Procedures involving positive reinforcement and informational feedback which were employed in this study were chosen in light of the data reported by Agras et al. (1974). However, these procedures were modified because of medical complications and the specific psychological complexities of the patient. The patient was treated on an inpatient unit for 44 days. Three daily meals were served to the patient who ate on the unit except when she earned the privilege of eating in the cafeteria. Eating in the cafeteria occurred only after baseline. Meals consisted of choices which the patient selected. No food was available other than that served at meals. Meal size was gradually increased by the therapist. The study consisted of six phases which were completed sequentially: baseline, reinforcement, reinforcement plus feedback, reinforcement, reinforcement plus feedback plus systematic desensitization and systematic desensitization plus contingency contracting. 1. Baseline. Therapeutic instructions communicated that we were interested in the patient, that she should eat as much as possible, that weight gain was expected, that she should vomit only in a specific toilet, and that she should report each time she vomited. The patient was given a minimum of nursing attention and was restricted to the unit. 2. Reinforcement. In this phase the patient was told that each 0.5-1b (0.2-kg) increase in her weight beyond the previous day's weight would earn her one of the following privileges which she had selected: dining in the cafeteria for a given day's meals; a 0.5-hr individual therapy session; attending a movie; or an accompanied walk outside. In addition, the patient was asked not to induce vomiting. Other procedures remained as in baseline. 3. Reinforcement plus feedback. In this phase the patient was asked by her therapist to calculate her caloric intake after meals and to plot these data as well as her daily weight on a wall graph in her room. These data were checked by a nurse daily. Reinforcement was as in Phase 2. 4. Reinforcement. This consisted of a return to reinforcement as in the second phase. In addition, since weight gain was occurring due to edema rather than increased caloric intake, reinforcers were made contingent on consumption of a minimum of 2000 calories per day. The patient was told that in order to earn her rewards she would have to consume a minimum of 2000 calories per day in addition to gaining 0.5 lb beyond her previous day's weight. 5. Reinforcement plus feedback plus systematic desensitization. Reinforcement conditions of Phase 4 plus feedback conditions of Phase 3 were reintroduced and daily sessions of deep muscle relaxation and systematic desensitization were initiated. Desensitization focussed on thoughts which led the patient to feel as though she was a "bad person." The rationale for desensitizing the patient to the content of these thoughts was that if the patient could learn to relax in the presence of these thoughts, they would eventually extinguish since their source of reinforcement (anxiety and its subsequent reduction by suppressing the thoughts) would be absent. 6. Post-hospital systematic desensitization plus contingency contracting. Sessions of muscle relaxation and desensitization were continued on a weekly outpatient basis. In addition, the patient consented to and signed (on a weekly basis) a behavioral contingency contract stipulating that she would consume between 1800 and 2300 calories per day, that she would not induce vomiting, and that she would not take nonprescribed drugs. The contract was considered broken if the patient consumed any less than 1800 or any more than 2300 calories in any given day, if she induced vomiting one or more times during a given day, or if she took any nonprescribed drugs during the course of any given day. Thus, the
261
CASE REPORTS A N D S T U D I E S
contract could be broken as m a n y as three times daily. The c o n s e q u e n c e for each time the contract was broken was a $5.00 check to an organization disfavored by the patient (the President Ford Re-election Committee),
RESULTS Weight decreased over the first 5 days of hospitalization (Fig. 1). Mean baseline caloric intake was 292 calories. Vomiting occurred once daily during baseline and occurred only twice more during treatment. Following reinforcement, weight increased (0.17 kg/day). However, there was no parallel increase in intake. This discrepancy was clarified after discovering the patient had developed edema and was retaining an excess of fluid for which Diuril, 500 mg, qid, was prescribed on Day 17. Reinforcement plus feedback began on Day 19. Increased caloric intake occurred immediately. Edema had not substantially improved until Day 22 when Diuril was reduced to 250 mg, qid. Unfortunately, until Day 22 the patient was very concerned that she was gaining weight too fast. Edema was eliminated by Day 23 and Diuril was discontinued until Day 27 when some edema reappeared and Hydrodiuril, 50 mg, qid, was prescribed for the duration of hospitalization. Following the return to reinforcement, caloric intake gradually increased while weight stabilized. When desensitization was added to reinforcement plus feedback, there was a continued gain in caloric intake and weight (0.35 kg/day) followed by a stabilization. During the first week of outpatient treatment, there was a slight increase in both caloric intake and weight. This was followed by a decrease in both these measures and then a stabilization. -
kNII~
I~TI|NT
QUTPATIENT TltiATMEN T
TIIATMEklT
In~rce~f
~nfor~nt
~ &
OmNmlitlzatton F4US¢ c m t i n g ~ y C o n t ~ t i n l l
26OO weight eeJorI¢ intakl
2500
22OO 2OOO
~S "~
IS00
~,
S4
i" so
"
t¢ ~,, ,,,,
I %5, ',,=4 . .72. . S~. . .100. . .114. . .12S. . ~.:. .1st. . .1.7 0.: 5. . .Wt. . .~.1 : 2 2 0 : 5 0
5oo
2S5
DAYS
FIG. 1. M e a n weight and caloric intake as a function of t r e a t m e n t p h a s e s for inpatient treatment ( m e a n of two days) and outpatient t r e a t m e n t ( m e a n of 7 days).
262
CASE REPORTS AND STUDIES
DISCUSSION Results support those of Agras et al. (1974) which suggest feedback plays a most important role in treatment. In the present case, as in two cases reported by Agras et al. (1974), the initial reinforcement phase produced little weight gain or caloric intake. The addition of feedback led to gains in caloric intake but not weight. This discrepancy can be explained by noting that the patient's edema and its treatment complicated data on weight. Initially, the patient's weight gain, due to water retention rather than increased caloric intake, was reinforced. When the edema was treated by diuretics the patient lost this excess water. When her caloric intake did increase, the increase did not immediately result in weight gain. It is possible that the patient was drinking more fluids so as to increase her weight (thus fulfilling reinforcement contingencies). Although when questioned the patient denied this, the importance of reinforcing caloric intake in addition to weight gain is apparent. The method of reinforcing caloric intake and weight gain has not been reported in previous studies of anorexia nervosa. The change from reinforcing weight gain to reinforcing both weight gain and caloric intake was made in Phase 4 when reinforcement was contingent on both a 0.2-kg weight increase and consumption of a minimum of 2000 calories per day. This combination had a powerful effect on caloric intake. It is not possible, due to the design of the present study, to assess the effect of adding desensitization to reinforcement plus feedback. However, there was a continued gain in caloric intake and weight when desensitization was added to the treatment. Although no data supporting the effectiveness of desensitization to thoughts are reported, some preliminary data (SUDS ratings) and the first author's clinical impressions suggest that this may be a promising approach to a complicated clinical problem. Follow-up outpatient treatment involved a continuation of systematic desensitization in conjunction with the behavioral contract regarding eating, vomiting, and pill-taking behaviors. After 3 weeks of outpatient treatment there was a leveling off of both weight and caloric intake. The contract was broken only six times during a 6-month treatment period, suggesting that the contract was effective in maintaining treatment successes. It is important to point out that follow-up treatment and effective maintenance are essential in treating anorexia nervosa since many anorexics reportedly redevelop severe symptoms after relatively shortterm successes (Bruch, 1974). REFERENCES Agras, W. S., Barlow, D. H., Chapin, H. N., Abel, G. G., & Leitenberg, H. Behavior modification of anorexia nervosa. Archives of General Psychiatry, 1974, 30, 279-286.
CASE REPORTS AND STUDIES
263
Blinder, B. J., Freeman, D. M. A., & Stunkard, A. J. Behavior therapy of anorexia nervosa: Effectiveness of activity as a reinforcer of weight gain. American Journal o f Psychiatry, 1970, 126, 1093-1098. Bruch, H. Perils of behavior modification in treatment of anorexia nervosa. Journal o f the American Medical Association, 1974, 230, 1419-1422. Feinstein, S. C. Anorexia Nervosa. Letter to the editor. Journal o f the American Medical Association, 1974, 228, 1230. Leitenberg, H., Agras, W. S., & Thomson, L. E. A sequential analysis of the effect of selective positive reinforcement in modifying anorexia nervosa. Behaviour Research and Therapy, 1968, 6~ 211-218. Russell, G. F. M. Anorexia nervosa: Its identity as an illness and its treatment. In J. H. Price (Ed.), Modern trends in psychological medicine. London: Butterworth, 1971. Spector, S. Behavior therapy in anorexia nervosa. Letter to the editor. Journal o f the American Medical Association, 1975, 233, 317. RECEIVED: May 25, 1976 FINAL ACCEPTANCE" September 13, 1976
Effect of Positive Reinforcement, Informational Feedback, and Contingency Contracting on a Bulimic Anorexic Female PETER M . M O N T I , BARBARA S. M C C R A D Y , AND DAVID H . BARLOW
Brown University and Butler Hospital Effects of reinforcement and feedback on the weight and caloric intake of a bulimic anorexic female were studied in a modified reversal design. Also studied was the effect of instructions on vomiting and effects of desensitization and conU'acting on weight and intake. The following phases were run: baseline, reinforcement, reinforcement plus feedback, reinforcement, reinforcement plus feedback plus desensitization, and desensitization plus contingency contracting. Results showed that feedback had a powerful influence. Also, instructions were effective in eliminating vomiting. When desensitization to thoughts which the patient had (which led her to feel as though she was a "bad person") was initiated, there was an increase in intake and weight. Interpretation of weight data was complicated because the patient developed edema which required treatment. This complication emphasized the importance of making reinforcement contingent on both weight gain and intake. A 6-month outpatient follow-up treatment period, during which desensitization and contracting were employed, suggested that treatment results were maintained. The discussion emphasizes this study's uniqueness in that it reports treatment of a bulimic anorxic. The fact that data for a 6-month follow-up period are reported is particularly important in light of recent criticisms of behavioral treatment of anorexia nervosa.
Behavior modification procedures incorporating selective positive reinforcement have proven effective in treating anorexia nervosa (Blinder, Freeman, & Stunkard, 1970; Leitenberg, Agras, & Thomson, 1968). Although most studies suggest that reinforcement leads to weight gain, only two studies have attempted to isolate the role of reinforcement. In the first study, Leitenberg et al. (1968) demonstrated that although positive reinforcement increased caloric intake and weight gain, weight gain continued after withdrawal of reinforcement. In the second, Agras, Barlow, Chapin, Abel, and Leitenberg (1974) demonstrated, in a series of single-case experiments, that reinforcement, informational feedback, and meal size all contribute to increased eating. Although the above studies have demonstrated the effectiveness of behavioral treatment for anorexia nervosa, none of the patients in the studies cited were bulimic anorexics. This is unfortunate since bulimia Reprint requests should be sent to Peter M. Monti, Brown University Medical School/ V.A. Hospital, Providence, RI 02908. 258 Copyright(~ 1977by the Associationfor Advancementof BehaviorTherapy. All rightsof reproductionin any formreserved.
ISSN 0005-7894
CASE REPORTS
AND
STUDIES
259
( m o r b i d l y i n c r e a s e d a p p e t i t e ) is o f t e n a p r o b l e m w h i c h a l t e r n a t e s w i t h anorexia. Also absent from the literature are reports of posthospitalization follow-up on anorexic cases treated with behavior m o d i f i c a t i o n ( F e i n s t e i n , 1974). L a c k o f f o l l o w - u p d a t a h a s m a d e e v a l u a tion o f t h e l o n g - t e r m e f f e c t i v e n e s s o f b e h a v i o r a l t r e a t m e n t f o r a n o r e x i a n e r v o s a i m p o s s i b l e . S u c h d a t a a r e p a r t i c u l a r l y c r u c i a l in v i e w o f r e c e n t c r i t i c i s m s o f t h e b e h a v i o r m o d i f i c a t i o n o f a n o r e x i a n e r v o s a ( B r u c h , 1974; S p e c t o r , 1975). T h e p r e s e n t c a s e differs f r o m p r e v i o u s r e p o r t s in s e v e r a l i m p o r t a n t dimensions. First, the patient was a bulimic anorexic. The patient would overeat and then induce vomiting and take laxatives and/or diuretics. Overeating/vomiting alternated with periods of decreased eating. Second, a b e h a v i o r a l a n a l y s i s r e v e a l e d t h a t t h o u g h t s w h i c h l e d t h e p a t i e n t to feeling as t h o u g h she w a s a " b a d p e r s o n " u s u a l l y p r e c e d e d h e r m a l a d a p tire behavior. The consequences of these bad feelings were either that the p a t i e n t w o u l d n o t eat, o r w o u l d o v e r e a t , feel " d i s g u s t i n g , " a n d t h e n t a k e o v e r d o s e s o f l a x a t i v e s a n d / o r d i u r e t i c s a n d i n d u c e v o m i t i n g . T h e s e intrusive t h o u g h t s w h i c h f o r m e d an e a r l y c o m p o n e n t in the b e h a v i o r a l a n d c o g n i t i v e c h a i n l e a d i n g to t h e m a l a d a p t i v e t a r g e t b e h a v i o r s d e s c r i b e d above also required treatment. Finally, data for a 6-month, outpatient, follow-up period are also reported.
METHOD Subject The patient was a 28-year-old female registered nurse, referred for admission because she had been losing weight and abusing medications such as diuretics and laxatives for the past 6 months. She had been taking an average of 30 Ex-Lax daily for the 2 months prior to admission. Six months prior to admission the patient had been overweight (79.38 kg and 1.75 m tall), had begun to diet, and ceased menstruating. Gradually she took more medications to lose weight, ate less, and when she overate, she induced vomiting. Vomiting occurred daily for several weeks prior to hospitalization. Upon admission she was severely emaciated, weighing 49.90 kg. Criteria used in making the diagnosis for anorexia nervosa in the present case were those generally accepted (Russell, 1971), namely, (1) behaviors leading to at least 20% loss of body weight; (2) cessation of menstruation in the patient above the age of puberty occurring before weight loss was extreme; (3) a fear of becoming obese, with marked resistance to the idea of gaining weight; and (4) no evidence of psychosis, but with other psychopathology usually similar to that described as hysterical personality. Measures Two measures of eating behavior were employed, caloric intake and weight. Caloric intake. Immediately after meals, caloric intake was calculated and charted by one of several nurses who had been trained to use a calorie counting booklet to calculate caloric intake. Weight. Each morning, at 10:00 AM, the patient was weighed by a nurse and her weight was recorded.
260
CASE REPORTS AND STUDIES
Vomiting. The patient was asked to report each time she vomited. Also, staff and other patients observed and reported vomiting, which was recorded by a staff member. Procedure Procedures involving positive reinforcement and informational feedback which were employed in this study were chosen in light of the data reported by Agras et al. (1974). However, these procedures were modified because of medical complications and the specific psychological complexities of the patient. The patient was treated on an inpatient unit for 44 days. Three daily meals were served to the patient who ate on the unit except when she earned the privilege of eating in the cafeteria. Eating in the cafeteria occurred only after baseline. Meals consisted of choices which the patient selected. No food was available other than that served at meals. Meal size was gradually increased by the therapist. The study consisted of six phases which were completed sequentially: baseline, reinforcement, reinforcement plus feedback, reinforcement, reinforcement plus feedback plus systematic desensitization and systematic desensitization plus contingency contracting. 1. Baseline. Therapeutic instructions communicated that we were interested in the patient, that she should eat as much as possible, that weight gain was expected, that she should vomit only in a specific toilet, and that she should report each time she vomited. The patient was given a minimum of nursing attention and was restricted to the unit. 2. Reinforcement. In this phase the patient was told that each 0.5-1b (0.2-kg) increase in her weight beyond the previous day's weight would earn her one of the following privileges which she had selected: dining in the cafeteria for a given day's meals; a 0.5-hr individual therapy session; attending a movie; or an accompanied walk outside. In addition, the patient was asked not to induce vomiting. Other procedures remained as in baseline. 3. Reinforcement plus feedback. In this phase the patient was asked by her therapist to calculate her caloric intake after meals and to plot these data as well as her daily weight on a wall graph in her room. These data were checked by a nurse daily. Reinforcement was as in Phase 2. 4. Reinforcement. This consisted of a return to reinforcement as in the second phase. In addition, since weight gain was occurring due to edema rather than increased caloric intake, reinforcers were made contingent on consumption of a minimum of 2000 calories per day. The patient was told that in order to earn her rewards she would have to consume a minimum of 2000 calories per day in addition to gaining 0.5 lb beyond her previous day's weight. 5. Reinforcement plus feedback plus systematic desensitization. Reinforcement conditions of Phase 4 plus feedback conditions of Phase 3 were reintroduced and daily sessions of deep muscle relaxation and systematic desensitization were initiated. Desensitization focussed on thoughts which led the patient to feel as though she was a "bad person." The rationale for desensitizing the patient to the content of these thoughts was that if the patient could learn to relax in the presence of these thoughts, they would eventually extinguish since their source of reinforcement (anxiety and its subsequent reduction by suppressing the thoughts) would be absent. 6. Post-hospital systematic desensitization plus contingency contracting. Sessions of muscle relaxation and desensitization were continued on a weekly outpatient basis. In addition, the patient consented to and signed (on a weekly basis) a behavioral contingency contract stipulating that she would consume between 1800 and 2300 calories per day, that she would not induce vomiting, and that she would not take nonprescribed drugs. The contract was considered broken if the patient consumed any less than 1800 or any more than 2300 calories in any given day, if she induced vomiting one or more times during a given day, or if she took any nonprescribed drugs during the course of any given day. Thus, the
261
CASE REPORTS A N D S T U D I E S
contract could be broken as m a n y as three times daily. The c o n s e q u e n c e for each time the contract was broken was a $5.00 check to an organization disfavored by the patient (the President Ford Re-election Committee),
RESULTS Weight decreased over the first 5 days of hospitalization (Fig. 1). Mean baseline caloric intake was 292 calories. Vomiting occurred once daily during baseline and occurred only twice more during treatment. Following reinforcement, weight increased (0.17 kg/day). However, there was no parallel increase in intake. This discrepancy was clarified after discovering the patient had developed edema and was retaining an excess of fluid for which Diuril, 500 mg, qid, was prescribed on Day 17. Reinforcement plus feedback began on Day 19. Increased caloric intake occurred immediately. Edema had not substantially improved until Day 22 when Diuril was reduced to 250 mg, qid. Unfortunately, until Day 22 the patient was very concerned that she was gaining weight too fast. Edema was eliminated by Day 23 and Diuril was discontinued until Day 27 when some edema reappeared and Hydrodiuril, 50 mg, qid, was prescribed for the duration of hospitalization. Following the return to reinforcement, caloric intake gradually increased while weight stabilized. When desensitization was added to reinforcement plus feedback, there was a continued gain in caloric intake and weight (0.35 kg/day) followed by a stabilization. During the first week of outpatient treatment, there was a slight increase in both caloric intake and weight. This was followed by a decrease in both these measures and then a stabilization. -
kNII~
I~TI|NT
QUTPATIENT TltiATMEN T
TIIATMEklT
In~rce~f
~nfor~nt
~ &
OmNmlitlzatton F4US¢ c m t i n g ~ y C o n t ~ t i n l l
26OO weight eeJorI¢ intakl
2500
22OO 2OOO
~S "~
IS00
~,
S4
i" so
"
t¢ ~,, ,,,,
I %5, ',,=4 . .72. . S~. . .100. . .114. . .12S. . ~.:. .1st. . .1.7 0.: 5. . .Wt. . .~.1 : 2 2 0 : 5 0
5oo
2S5
DAYS
FIG. 1. M e a n weight and caloric intake as a function of t r e a t m e n t p h a s e s for inpatient treatment ( m e a n of two days) and outpatient t r e a t m e n t ( m e a n of 7 days).
262
CASE REPORTS AND STUDIES
DISCUSSION Results support those of Agras et al. (1974) which suggest feedback plays a most important role in treatment. In the present case, as in two cases reported by Agras et al. (1974), the initial reinforcement phase produced little weight gain or caloric intake. The addition of feedback led to gains in caloric intake but not weight. This discrepancy can be explained by noting that the patient's edema and its treatment complicated data on weight. Initially, the patient's weight gain, due to water retention rather than increased caloric intake, was reinforced. When the edema was treated by diuretics the patient lost this excess water. When her caloric intake did increase, the increase did not immediately result in weight gain. It is possible that the patient was drinking more fluids so as to increase her weight (thus fulfilling reinforcement contingencies). Although when questioned the patient denied this, the importance of reinforcing caloric intake in addition to weight gain is apparent. The method of reinforcing caloric intake and weight gain has not been reported in previous studies of anorexia nervosa. The change from reinforcing weight gain to reinforcing both weight gain and caloric intake was made in Phase 4 when reinforcement was contingent on both a 0.2-kg weight increase and consumption of a minimum of 2000 calories per day. This combination had a powerful effect on caloric intake. It is not possible, due to the design of the present study, to assess the effect of adding desensitization to reinforcement plus feedback. However, there was a continued gain in caloric intake and weight when desensitization was added to the treatment. Although no data supporting the effectiveness of desensitization to thoughts are reported, some preliminary data (SUDS ratings) and the first author's clinical impressions suggest that this may be a promising approach to a complicated clinical problem. Follow-up outpatient treatment involved a continuation of systematic desensitization in conjunction with the behavioral contract regarding eating, vomiting, and pill-taking behaviors. After 3 weeks of outpatient treatment there was a leveling off of both weight and caloric intake. The contract was broken only six times during a 6-month treatment period, suggesting that the contract was effective in maintaining treatment successes. It is important to point out that follow-up treatment and effective maintenance are essential in treating anorexia nervosa since many anorexics reportedly redevelop severe symptoms after relatively shortterm successes (Bruch, 1974). REFERENCES Agras, W. S., Barlow, D. H., Chapin, H. N., Abel, G. G., & Leitenberg, H. Behavior modification of anorexia nervosa. Archives of General Psychiatry, 1974, 30, 279-286.
CASE REPORTS AND STUDIES
263
Blinder, B. J., Freeman, D. M. A., & Stunkard, A. J. Behavior therapy of anorexia nervosa: Effectiveness of activity as a reinforcer of weight gain. American Journal o f Psychiatry, 1970, 126, 1093-1098. Bruch, H. Perils of behavior modification in treatment of anorexia nervosa. Journal o f the American Medical Association, 1974, 230, 1419-1422. Feinstein, S. C. Anorexia Nervosa. Letter to the editor. Journal o f the American Medical Association, 1974, 228, 1230. Leitenberg, H., Agras, W. S., & Thomson, L. E. A sequential analysis of the effect of selective positive reinforcement in modifying anorexia nervosa. Behaviour Research and Therapy, 1968, 6~ 211-218. Russell, G. F. M. Anorexia nervosa: Its identity as an illness and its treatment. In J. H. Price (Ed.), Modern trends in psychological medicine. London: Butterworth, 1971. Spector, S. Behavior therapy in anorexia nervosa. Letter to the editor. Journal o f the American Medical Association, 1975, 233, 317. RECEIVED: May 25, 1976 FINAL ACCEPTANCE" September 13, 1976