Cognitive restructuring and response prevention in the treatment of bulimia nervosa

Bulimia: A Review of the Medical, Behavioural and Psychodynamic Models of Treatment

Current treatment approaches for bulimia are reviewed. The use of hospitalisation and drug therapy is examined. The behavioural and psychodynamic models of treatment, including cognitive-behavioural therapy, behaviour therapy, group therapy and family therapy, and counselling and educational approaches are discussed.

Cognitive-Behavioural Treatment of Bulimia Nervosa

This paper reviews the literature on cognitive-behavioural treatment of bulimia nervosa, including the rationale and procedure for including an exposure plus response-prevention component. Comparisons of the full cognitive-behavioural therapy package to no treatment, other forms of psychotherapy, and pharmacotherapy are evaluated. The evidence suggests that cognitive-behavioural therapy is a relatively effective treatment for bulimia nervosa, although long-term outcome is still far from optimal.

Cue Reactivity and Bulimia Nervosa: Refining and Standardising Methodology

Cue reactivity has been assessed in women with bulimia nervosa both in conjunction with treatment studies and in independent laboratory investigations. Methodology for investigating cue reactivity varies widely, providing little guideline for the optimal assessment parameters. The present pilot study describes the evolution of a methodology for assessing cue reactivity in response to in vivo cues in women with bulimia nervosa. Patients' responses are compared with those of health controls. Recommendations for the standardisation of the procedure are given. The guidelines proposed have equal applicability to research on cue reactivity in the fields of substance abuse and anxiety disorders.

Cue exposure in the treatment of resistant bulimia nervosa

OBJECTIVE

It was hypothesized that binge eating (bulimia nervosa [BN]) may be caused by the anticipatory and immediate anxiety associated with certain types of food. Consequently, an extinction schedule should reduce binge eating.

METHODS

Cue exposure was carried out with 6 bulimic women who had responded poorly or not at all to the usual pharmacologic or cognitive-behavioral treatments.

RESULTS

Binge eating and vomiting were almost totally suppressed in the 6 patients. Symptom suppression was maintained at two follow-ups, one at 4-20 months and another at 2.5-3 years.

DISCUSSION

Cue exposure may be effective with BN that is resistant to conventional treatments. The anxiety associated with food plays an important role in provoking and/or maintaining binge eating. Motivation to change is likely to be an important mediator.

Nutritional interventions for individuals with bulimia nervosa

Many physical and psychological effects of bulimia nervosa are caused by the patient's partial starvation and chaotic nutritional cycle. Attention should thus be initially directed to correcting nutritional deficiencies and abnormal eating patterns, and providing dietary counselling. Nevertheless, very little has been written about the nutritional management of this eating disorder. Nutritional counselling for bulimia patients is reviewed in this paper. Current knowledge about nutritional therapy and its efficacy, goals and objectives is presented, along with recommendations used in treatment programmes. Lastly, the key steps of nutritional management are summarised.

Changes in cue reactivity following treatment for bulimia nervosa

OBJECTIVE

To examine changes in cue reactivity following cognitive-behavior therapy (CBT) for bulimia nervosa and to evaluate whether changes are associated with treatment modality or treatment outcome.

METHOD

Subjects were 135 women (17-45 years old) with a current, primary diagnosis of bulimia nervosa. They were participants in a randomized clinical trial examining the additive efficacy of exposure and nonexposure-based behavior therapy to a core of CBT. Physiological, self-report, and behavioral measures of cue reactivity to individualized high-risk binge foods were obtained at pretreatment and posttreatment. Primary, secondary, and tertiary outcome measures are reported for posttreatment.

RESULTS

Bulimic patients experienced significant changes in cue reactivity following treatment. With the exception of salivary reactivity, patients experienced less reactivity at posttreatment. Changes in cue reactivity were not related to treatment modality, but were related to positive treatment outcome for self-report measures of cue reactivity.

DISCUSSION

Favorable treatment outcome among bulimic women is associated with low cue reactivity on self-report measures at posttreatment.

A comparison of two psychological treatments for bulimia nervosa: implications for models of maintenance

In an effort to elucidate the role of cognitive factors in the maintenance of bulimia nervosa, the efficacy of two psychological treatments was examined in a randomised control trial: cognitive behaviour therapy in the absence of explicit exposure instructions was compared with exposure and response prevention treatment in the absence of cognitive restructuring procedures. In the short term both treatments were successful at effecting substantial improvement in both the specific and the non-specific psychopathology of the disorder. However, at a one year follow up, whilst improvements were well maintained for those who had received the cognitive-behavioural treatment, virtually all of those who had responded to the purely behavioural treatment had relapsed. This provides some support for the cognitive model of the maintenance of bulimia nervosa. Nevertheless, the two treatment groups could not be distinguished on post-treatment measures of cognitive disturbance and neither was it the case that residual levels of cognitive disturbance, as assessed, predicted relapse. This may suggest that the level at which the necessary cognitive change takes place may not be accessible by conventional assessment procedures.

Advances in diagnosis and treatment of anorexia nervosa and bulimia nervosa

This paper reviews four areas of research into anorexia nervosa (AN) and bulimia nervosa (BN). First, in terms of diagnosis, the psychological concerns about weight and shape are now addressed in BN, bringing it more in line with the related disorder, anorexia nervosa. Second, studies of psychiatric comorbidity confirm the overlap between eating disorders and depression, obsessive compulsive disorder, substance abuse, and personality disorder. Nevertheless, there are reasons to accept the distinct qualities of each syndrome, and eating disorders are not merely a variant of these other conditions. Third, treatment advances in BN involve mainly cognitive-behavioural or interpersonal psychotherapies and pharmacotherapies primarily with antidepressants. The effect of combining more than one approach is beginning to be addressed. Finally, outcome studies involving people with both AN and BN have shown that the disorders "cross over" and that both conditions have a high rate of relapse. A renewed interest in the treatment of AN is needed.

Retention of massed vs distributed response-prevention treatments in rats and a revised training procedure

Two experiments were conducted to estimate the retention of response-prevention effects using massed vs distributed treatments in a model of animal avoidance-learning. In Exp. I, 120 rats were trained to avoid shock in a one-way platform avoidance apparatus. Groups received response-prevention treatment or nontreatment in a 36-min. massed session or in several sessions distributed over a four-day period. In Exp. II, 160 rats were given two trials of escape training in a one-way shuttle box. Groups received response-prevention treatment or nontreatment in a 24-min. session of massed or distributed treatments delivered in one day. Subjects in both studies were tested using a passive-avoidance paradigm immediately following treatment, 24 hours later, and 30 days later. Analysis showed that response-prevention treatments were effective in reducing avoidance behavior and there were no significant differences in retention of avoidance associated with massed vs distributed response-prevention treatments. Implications for animals and humans are discussed, and researchers are encouraged to change from a criterion training procedure to an escape procedure since the latter is a closer analogue to the human condition.

Cognitive-behavioral treatment with and without response prevention for bulimia

We compared cognitive-behavior therapy (CBT) with and without exposure and response prevention (ERP) in the treatment of eating disorder patients who both binged and purged, and reported abnormal attitudes concerning body weight and shape. Both treatments produced significant and comparable reductions in binge-eating and purging, eating patterns, and attitudes about weight and shape at posttreatment. Treatment effects were generalized to improvements in different measures of general psychopathology, and were maintained over follow-ups of 3 and 12 months. The findings are consistent with prior research showing that CBT is an effective treatment for patients with the core features of bulimia nervosa. Furthermore, the data suggest that the addition of in-session exposure and response prevention does not enhance the effectiveness of the basic CBT program.

Toward a new nosology of obsessive compulsive disorder

Obsessive compulsive disorder (OCD) is receiving increasing attention in the clinical research literature. This review briefly summarizes data concerning diagnosis, phenomenology, and epidemiology of OCD and examines other disorders that closely resemble OCD. In addition, the nosological and treatment implications of these data are discussed. We find that OCD is characterized by a focal anxiety point(s) reflected in obsessions and by behavioral or cognitive compulsions. The appearance of these characteristics in other disorders suggests some relation between them and, consequently, the treatment of these disorders may be enhanced by conceptualizing them as OCD "variants".

Bulimia nervosa: group behavior therapy with exposure plus response prevention

Exposure plus response prevention has been demonstrated to be effective in the treatment of bulimia nervosa. However, when done individually, it is labor intensive and cost-ineffective. In the present study exposure plus response prevention was used in the context of a 6-wk., 12-session behavioral group. In addition to the exposure plus response-prevention component, other techniques included self-monitoring, cognitive restructuring, eating-habit stabilization and problem-solving. Eight bulimic women, vomiting a minimum of five times per week for at least a year, participated in the group. At the end of treatment significant reductions in bingeing and vomiting behaviors were reported by all but one subject, substantiated by significantly lower depression scores (Beck Depression Inventory) and binge-eating scores (Binge Eating Scale). At 6 mo. and 1 yr. posttreatment, 6 of 8 subjects reported averaging less than one binge-purge episode per week, one subject continued unchanged, and one subject had relapsed. A group of wait-list control subjects reported essentially no change in binge-purge frequency over the treatment period. Exposure plus response prevention conducted in a behavioral group context appears to be a cost-effective alternative to individual treatment.

Successful self-management of severe bulimia: a case study

A young woman with a nine-year history of bingeing and purging was given instruction in behavioral principles. She then designed and carried out a program that included paced eating of pre-planned meals, following by differential reinforcement of non-purging behaviors, which featured high frequency of reinforcement early in training. Inter-meal "binge-feelings" were treated by reinforcing abstentions. A graded system of contingent exercise also was employed for purging behaviors. Episodes decreased to a low level after one month and were completely absent nine months later. The amelioration of this problem resulted in progress being made for the first time with her emotional problems that were being treated elsewhere by psychodynamic psychotherapy.

A review of behavioral treatments for bulimia nervosa

Despite early pessimism regarding its prognosis, behavior therapy has proven to be an effective treatment for bulimia nervosa. The average reduction in vomiting achieved at the end of behavioral treatment is 70%, with about 44% of patients completely abstinent. Even greater improvements are found in studies that use cognitive and behavioral procedures over a longer period and emphasize relapse prevention. Patients treated with behavior therapy also exhibit improvement on measures of psychological symptoms, self-esteem, and social relationships, though the focus of treatment may be on binge eating and vomiting. Nevertheless, a significant minority of individuals drop out of treatment prematurely or remain unimproved. Still in its early stage, behavior therapy for bulimia nervosa needs much more empirical development and evaluation.

Innovative treatment approaches to bulimia nervosa

The available evidence indicates that behavioral interventions for bulimia nervosa are effective in many cases; yet a significant proportion of patients are not symptom-free and others relapse following termination of treatment. Explanations for the nonresponsiveness to behavioral treatment and relapse are offered, including characteristics of certain patients and the scope and implementation of behavioral interventions. The conceptual basis and therapeutic implementation of two alternate behavioral interventions, namely, temptation with exposure and response prevention (TERP) and implosive therapy (IT), are presented and reviewed for their potential utility in nonresponsive and relapsing cases.

Bulimia: a case illustration of the superiority of behavioral over cognitive treatment

The present study compared the relative efficacy of two major clinical procedures previously used in multicomponent cognitive-behavioral programs for treating bulimia. A single-subject experimental design was used and the results showed that the behavioral procedure of exposure plus response prevention was more effective than the cognitive procedure in reducing binge and vomit episodes as well as the urges to binge-vomit. These results suggest that the exposure plus response prevention component is more relevant for cognitive as well as behavioral changes in treating bulimia.

The treatment of bulimia nervosa

We review treatment approaches to bulimia nervosa, with particular emphasis on methodology and research design. The following treatments are considered: behaviour therapy, cognitive behaviour therapy, pharmacological treatment, group therapy, psychoanalytic psychotherapy, self-help and support groups, hypnosis and miscellaneous (family therapy and nutritional approaches). Several directions for future research and methodological recommendations are suggested.