Cognitive-behavioral treatment of bulimia nervosa: a controlled evaluation

A systematic review of sociodemographic reporting and representation in eating disorder psychotherapy treatment trials in the United States

OBJECTIVE

Eating disorders (EDs) were once conceptualized as primarily affecting affluent, White women, a misconception that informed research and practice for many years. Abundant evidence now discredits this stereotype, but it is unclear if prevailing "evidence-based" treatments have been evaluated in samples representative of the diversity of individuals affected by EDs. Our goal was to evaluate the reporting, inclusion, and analysis of sociodemographic variables in ED psychotherapeutic treatment randomized controlled trials (RCTs) in the US through 2020.

METHODS

We conducted a systematic review of ED psychotherapeutic treatment RCTs in the US and examined the reporting and inclusion of gender identity, age, race/ethnicity, sexual orientation, and socioeconomic status (SES) of enrolled participants, as well as recruitment methods, power analyses, and discussion of limitations and generalizability.

RESULTS

Our search yielded 58 studies meeting inclusion criteria dating back to 1985. Reporting was at times incomplete, absent, or centered on the racial/gender majority group. No studies reported gender diverse participants, and men and people of color were underrepresented generally, with differences noted across diagnoses. A minority of papers considered sociodemographic variables in analyses or acknowledged limitations related to sample characteristics. Some progress was made across the decades, with studies increasingly providing full racial and ethnic data, and more men included over time. Although racial and ethnic diversity improved somewhat, progress appeared to stall in the last decade.

DISCUSSION

We summarize findings, consider context and challenges for RCT researchers, and offer suggestions for researchers, journal editors, and reviewers on improving representation, reporting, and analytic practices.

PUBLIC SIGNIFICANCE

Randomized controlled trials of eating disorder psychotherapeutic treatment in the US are increasingly reporting full race/ethnicity data, but information on SES is inconsistent and sexual orientation absent. White women still comprise the overwhelming majority of participants, with few men and people of color, and no gender-diverse individuals. Findings underscore the need to improve reporting and increase representation to ensure evidence-based treatments are effective across and within diverse groups.

Mediators of change in cognitive behavior therapy and interpersonal psychotherapy for eating disorders: A secondary analysis of a transdiagnostic randomized controlled trial

OBJECTIVE

Understanding the mechanisms of action of psychological treatments is a key first step in refining and developing more effective treatments. The present study examined hypothesized mediators of change of enhanced cognitive behavior therapy (CBT-E) and interpersonal psychotherapy for eating disorders (IPT-ED).

METHOD

A series of mediation studies were embedded in a randomized controlled trial (RCT) comparing 20 weeks of CBT-E and IPT-ED in a transdiagnostic, non-underweight sample of patients with eating disorders (N = 130) consecutively referred to the service. Three hypothesized mediators of change in CBT-E (regular eating, weighing frequency, and shape checking) and the key hypothesized mediator of IPT-ED (interpersonal problem severity) were studied.

RESULTS

The data supported regular eating as being a mediator of the effect of CBT-E on binge-eating frequency. The findings were inconclusive regarding the role of the other putative mediators of the effects of CBT-E; and were similarly inconclusive for interpersonal problem severity as a mediator of the effect of IPT-ED.

DISCUSSION

This research highlights the potential benefits of embedding mediation studies within RCTs to better understand how treatments work. The findings supported the role of regular eating in reducing patients' binge-eating frequency. Other key hypothesized mediators of CBT-E and IPT-ED were not supported, although the data were not inconsistent with them. Key methodological issues to address in future work include the need to capture both behavioral and cognitive processes of change in CBT-E, and identifying key time points for change in IPT-ED.

Conceptualizing eating disorder psychopathology using an anxiety disorders framework: Evidence and implications for exposure-based clinical research

Eating disorders (EDs) and anxiety disorders (ADs) evidence shared risk and significant comorbidity. Recent advances in understanding of anxiety-based disorders may have direct application to research and treatment efforts for EDs. The current review presents an up-to-date, behavioral conceptualization of the overlap between anxiety-based disorders and EDs. We identify ways in which anxiety presents in EDs, consider differences between EDs and ADs relevant to treatment adaptions, discuss how exposure-based strategies may be adapted for use in ED treatment, and outline directions for future mechanistic, translational, and clinical ED research from this perspective. Important research directions include: simultaneous examination of the extent to which EDs are characterized by aberrant avoidance-, reward-, and/or habit-based neurobiological and behavioral processes; improvement in understanding of how nutritional status interacts with neurobiological characteristics of EDs; incorporation of a growing knowledge of biobehavioral signatures in ED treatment planning; development of more comprehensive exposure-based treatment approaches for EDs; testing whether certain exposure interventions for AD are appropriate for EDs; and improvement in clinician self-efficacy and ability to use exposure therapy for EDs.

Evolution of cognitive-behavioral therapy for eating disorders

The evolution of cognitive-behavioral therapy (CBT) for the treatment of bulimic disorders is described in this review. The impacts of successive attempts to enhance CBT such as the addition of exposure and response prevention; the development of enhanced CBT; and broadening the treatment from bulimia nervosa to binge eating disorder are considered. In addition to developing advanced forms of CBT, shortening treatment to guided self-help was the first step in broadening access to treatment. The use of technology such as computer-based therapy and more recently the Internet, promises further broadening of access to self-help and to therapist guided treatment. Controlled studies in this area are reviewed, and the balance of risks and benefits that accompany the use of technology and lessened therapist input are considered. Looking into the future, more sophisticated forms of treatment delivered as mobile applications ("apps") may lead to more personalized and efficacious treatments for bulimic disorders, thus enhancing the delivery of treatments for eating disorders.

Bulimia Nervosa: A Comprehensive Analysis of Treatment, Policy, and Social Work Ethics

Bulimia nervosa is an often debilitating eating disorder with a biopsychosocial set of risk factors. Those presenting are at an increased mortality rate and often have physical health complications as well as harmful cognitions related to self-esteem and overall self-concept. This article examines treatment, policy, and social work ethics as they relate to bulimia nervosa. A comprehensive cognitive-behavioral approach including psychoeducation, self-monitoring, exposure therapy, interpersonal therapy, body image therapy, energy balance training, and relapse prevention is recommended as evidence-based practice for treating bulimia nervosa. Authors identify health care policy and analyze it as a common barrier to treatment access. They also review ethical principles of competency and social justice as they relate to social work practitioners working with those diagnosed with bulimia nervosa.

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.

The therapeutic process in psychological treatments for eating disorders: a systematic review

OBJECTIVE

For eating disorders, a vast number of investigations have demonstrated the efficacy of psychological treatments. However, evidence supporting the impact of therapeutic process aspects on outcome (i.e., process-outcome research) has not been disentangled.

METHOD

Using the Generic Model of Psychotherapy (GMP) to organize various process aspects, a systematic literature search was conducted on psychological treatment studies for anorexia nervosa, bulimia nervosa, binge-eating disorder, and eating disorders not otherwise specified.

RESULTS

Improved outcomes resulted for family-based treatment compared to individual treatment, for individual compared to group treatment, booster sessions, and positive patient expectations (GMP contract aspect); for nutritional counseling and exercising but not exposure with response prevention as adjunct interventions (therapeutic operations); for highly motivated patients and, to a lesser extent, for therapeutic alliance (therapeutic bond); as well as for rapid response and longer overall treatment duration (temporal patterns). Regarding other GMP aspects, studies on self-relatedness were completely lacking and in-session impacts were rarely investigated.

DISCUSSION

As most studies assessed only a limited number of process aspects, the ability to draw conclusions about their overall impact regarding outcome is rather limited. Therefore, future process-outcome research is needed beyond investigations of treatment efficacy for eating disorders.

The changing "weightscape" of bulimia nervosa

Ms. Z, a 35-year-old African-American single woman with a body mass index (BMI) of 37.8 kg/m² (height 5 feet, 5.5 inches, weight 238 lb.), presents for an evaluation for bulimia nervosa. She was referred to the eating disorders program by her primary care physician who knew about her eating disorder, but was primarily concerned about her weight and blood pressure. Ms. Z has an advanced degree and is employed full time. She has struggled with her eating, weight, and body image since childhood and began binge eating regularly (1–2× week) at age 15. Fasting and self-induced vomiting began in her early twenties, when she achieved her lowest adult BMI of 21.6 kg (weight 130 lb. at age 23). She gained 100 pounds in the past 7 years and currently binges and purges 1–2 times a day. A typical binge consists of a box of cookies, a pint of ice cream, 7 oz. of cheese, two bowls of cereal with 2 cups of milk, and 4 pickles. Ms. Z has seen five therapists to address her eating behaviors and weight concerns and participated in numerous commercial weight loss programs. She states binge eating has always served a self-soothing purpose for her. Ms. Z has a demanding university-related job that absorbs most of her time. She has few friends and has not been in a romantic relationship for the past five years believing that no one would be interested in a woman of her size. She also claimed that food is more reliable than any man because “it’s always there when you need it and you don’t have to take care of it or stoke its ego.” She spends evenings at home working until she is completely exhausted, heads to the kitchen for an all-out binge, vomits everything up, and then cries herself to sleep. She has never smoked and does not drink alcohol. Current medications prescribed by her primary care physician include Fluoxetine (20 mg), Norvasc (5 mg), and Clonazepam (prn). What are Ms. Z’s treatment goals? What are her primary care physician’s? Is her medication for bulimia nervosa adequate? How well would cognitive-behavioral therapy for bulimia nervosa address her personal treatment goals? Her physician’s? What challenges might a therapist face having Ms. Z in group therapy for bulimia?

CBT4BN versus CBTF2F: comparison of online versus face-to-face treatment for bulimia nervosa

Cognitive-behavioral therapy (CBT) is currently the "gold standard" for treatment of bulimia nervosa (BN), and is effective for approximately 40-60% of individuals receiving treatment; however, the majority of individuals in need of care do not have access to CBT. New strategies for service delivery of CBT and for maximizing maintenance of treatment benefits are critical for improving our ability to treat BN. This clinical trial is comparing an Internet-based version of CBT (CBT4BN) in which group intervention is conducted via therapeutic chat group with traditional group CBT (CBTF2F) for BN conducted via face-to-face therapy group. The purpose of the trial is to determine whether manualized CBT delivered via the Internet is not inferior to the gold standard of manualized group CBT. In this two-site randomized controlled trial, powered for non-inferiority analyses, 180 individuals with BN are being randomized to either CBT4BN or CBTF2F. We hypothesize that CBT4BN will not be inferior to CBTF2F and that participants will value the convenience of an online intervention. If not inferior, CBT4BN may be a cost-effective approach to service delivery for individuals requiring treatment for BN.

Fear of food as a treatment target: exposure and response prevention for anorexia nervosa in an open series

OBJECTIVE

Anorexia nervosa (AN) is a severe mental illness with high rates of relapse and rehospitalization. New treatment approaches are needed. We aimed to evaluate the potential utility of addressing eating-related fear in the treatment of AN using psychotherapy techniques known to be effective in the treatment of anxiety disorders and obsessive compulsive disorder, namely exposure therapy and response prevention.

METHOD

We developed a brief treatment intervention for AN (AN-EXRP) and evaluated its effects in an open series of nine individuals with AN towards the end of acute weight restoration. We focused on eating behavior as the primary outcome, as it is related both to anxiety and to longer term course.

RESULTS

Change in anxiety with AN-EXRP was associated with greater caloric intake.

DISCUSSION

These findings support the anxiety-centered model of AN and suggest the potential utility of further developing this treatment approach.

Five-year outcome of cognitive behavioral therapy and exposure with response prevention for bulimia nervosa

BACKGROUND

Few data exist examining the longer-term outcome of bulimia nervosa (BN) following treatment with cognitive behavioral therapy (CBT) and exposure with response prevention (ERP).

METHOD

One hundred and thirty-five women with purging BN received eight sessions of individual CBT and were then randomly assigned to either relaxation training (RELAX) or one of two ERP treatments, pre-binge (B-ERP) or pre-purge cues (P-ERP). Participants were assessed yearly following treatment and follow-up data were recorded.

RESULTS

Eighty-one per cent of the total sample attended long-term follow-up. At 5 years, abstinence rates from binging were significantly higher for the two exposure treatments (43% and 54%) than for relaxation (27%), with no difference between the two forms of exposure. Over 5 years, the frequency of purging was lower for the exposure treatments than for relaxation training. Rates of recovery varied according to definition of recovery. Recovery continued to increase to 5 years. At 5 years, 83% no longer met DSM-III-R criteria for BN, 65% received no eating disorder diagnosis, but only 36% had been abstinent from bulimic behaviors for the past year.

CONCLUSIONS

This study provides possible evidence of a conditioned inoculation from exposure treatment compared with relaxation training in long-term abstinence from binge eating at 5 years, and the frequency of purging over 5 years, but not for other features of BN. Differences among the groups were not found prior to 5 years. CBT is effective for BN, yet a substantial group remains unwell in the long term. Definition of recovery impacts markedly on recovery rates.

Psychological treatments for bulimia nervosa and binging

BACKGROUND

A specific manual-based form of cognitive behavioural therapy (CBT) has been developed for the treatment of bulimia nervosa (CBT-BN) and other common related syndromes such as binge eating disorder. Other psychotherapies and modifications of CBT are also used.

OBJECTIVES

To evaluate the efficacy of CBT, CBT-BN and other psychotherapies in the treatment of adults with bulimia nervosa or related syndromes of recurrent binge eating.

SEARCH STRATEGY

Handsearch of The International Journal of Eating Disorders since first issue; database searches of MEDLINE, EXTRAMED, EMBASE, PsycInfo, CURRENT CONTENTS, LILACS, SCISEARCH, CENTRAL and the The Cochrane Collaboration Depression, Anxiety & Neurosis Controlled Trials Register; citation list searching and personal approaches to authors were used. Search date June 2007.

SELECTION CRITERIA

Randomised controlled trials of psychotherapy for adults with bulimia nervosa, binge eating disorder and/or eating disorder not otherwise specified (EDNOS) of a bulimic type which applied a standardised outcome methodology and had less than 50% drop-out rate.

DATA COLLECTION AND ANALYSIS

Data were analysed using the Review Manager software program. Relative risks were calculated for binary outcome data. Standardised mean differences were calculated for continuous variable outcome data. A random effects model was applied.

MAIN RESULTS

48 studies (n = 3054 participants) were included. The review supported the efficacy of CBT and particularly CBT-BN in the treatment of people with bulimia nervosa and also (but less strongly due to the small number of trials) related eating disorder syndromes.Other psychotherapies were also efficacious, particularly interpersonal psychotherapy in the longer-term. Self-help approaches that used highly structured CBT treatment manuals were promising. Exposure and Response Prevention did not enhance the efficacy of CBT.Psychotherapy alone is unlikely to reduce or change body weight in people with bulimia nervosa or similar eating disorders.

AUTHORS' CONCLUSIONS

There is a small body of evidence for the efficacy of CBT in bulimia nervosa and similar syndromes, but the quality of trials is very variable and sample sizes are often small. More and larger trials are needed, particularly for binge eating disorder and other EDNOS syndromes. There is a need to develop more efficacious therapies for those with both a weight and an eating disorder.

Psychotherapy approaches for adolescents with eating disorders

PURPOSE OF REVIEW

Adolescence is the most common period for the onset of eating disorders, and early intervention is critical. Primary care providers should feel equipped to discuss psychotherapy approaches for eating disorders with adolescents and their families and to provide appropriate referrals. The present review focuses on six prominent treatment modalities and the evidence supporting each approach.

RECENT FINDINGS

Although the majority of studies about psychotherapy approaches for eating disorders focus on adult women, there is a growing body of research on effective treatments for an adolescent population. Family-based treatment (the 'Maudsley method') and supportive psychotherapy appear to be promising approaches for anorexia in teens. Treatments for bulimia yield extremely high relapse rates, but cognitive-behavioral therapy and family-based treatment are favored modalities. Dialectical behavior therapy and interpersonal psychotherapy may also be applicable to adolescent bulimia and binge eating. Most psychotherapists draw upon a variety of these treatment approaches, depending upon the patient's unique presentation. Regardless of the modality used, some degree of family involvement is important in limiting dropout and improving outcomes.

SUMMARY

Adolescent health providers need to be aware of the psychotherapy approaches recommended for teens with eating disorders in order to effectively refer patients to and collaborate with mental health providers.

Substance Misuse

Social learning theory has provided the field of substance misuse with a solid base from which to generate hyotheses and develop treatments. The emphasis during the last decade has been upon outcome and efficacy expectancies, relapse prevention and stages of change. Helping people to move through these stages of change (motivational interviewing) has been a particularly strong focus. The literature on alcohol dependence provides reasonable evidence to support the effectiveness of the following treatment approaches: antidepressant medication, behavioural contracting, brief interventions, behavioural marital therapy, behavioural self-control training, community reinforcement approach, covert sensitization, Disulfiram (Antabuse), social skills training and stress management training. It is also suggested that interest in cue exposure will develop in the future. During the next decade self-regulation theory will turn out to be a rich source of ideas as well as a useful conceptual framework that integrates a range of treatment approaches.

Treatment of Compulsive Over-exercising in Anorexia Nervosa: A Case Study

Despite being a long recognized feature of Anorexia Nervosa, exercising has been largely neglected as a topic for research and treatment. An increasing cultural emphasis on fitness has highlighted the dangers of becoming addicted to exercise and its role in the development and maintenance of Anorexia Nervosa. Most estimates of the incidence of exercise addiction in the anorexic population are high, and the behaviour would appear to pre- and post-date the eating disorder.

In view of this, the development of an effective treatment method for this particular problem is needed. One such approach that employs cognitive behavioural techniques, including exposure and response prevention is described and illustrated by case example.

Treatment Acceptability for Anorexia Nervosa: Effects of Treatment Type, Problem Severity and Treatment Outcome

One hundred and ninety two students from schools and university rated the acceptability of treatments for anorexia nervosa as presented in written vignettes. Psychologically-based treatments, such as counselling and behaviour therapy, were rated more acceptable than drugs; flooding occupied an intermediate position. Context variables such as problem severity and outcome did not significantly effect treatment acceptability.

Clinical validation of the trait and state versions of the Food Craving Questionnaire

This is the first study to evaluate the psychometric properties of the Food Craving Questionnaire-Trait (FCQ-T), and Food Craving Questionnaire-State (FCQ-S) measures using a clinically heterogeneous sample of eating disorder patients (N = 177) recruited from seven different outpatient eating disorder treatment centers in Spain. Confirmatory factor analyses (CFAs) corroborated the factor structures of the FCQ-T and FCQ-S. The measures' scores and their factor-derived scale-scores yielded internal consistency reliability indexes that ranged from adequate to excellent. The measures were predictive of eating disorder symptoms. As expected, the FCQ-T was more strongly associated with eating disorder psychopathology than the FCQ-S. The results replicated the psychometric properties of the FCQ-T and FCQ-S in eating disorder populations and could become useful tools in clinical and research settings.

Cue exposure in the treatment of resistant adolescent bulimia nervosa

OBJECTIVE

A percentage of bulimic patients do not greatly improve with the usual treatment. Therefore, the objective was to further evaluate cue exposure (CE), in order to attain better results in clinical settings.

METHOD

Twenty-two adolescent patients who fulfilled DSM-IV diagnostic criteria for bulimia nervosa (mean age 16.7, SD 1.5) and who were resistant to the usual treatment followed a program of 12 CE sessions. Clinical characteristics were evaluated and different psychopathological scales were administered at the beginning and the end of the CE program and at 6 month follow-up. Subjective anxiety and physiological parameters were recorded during the sessions.

RESULTS

A significant decrease was observed in subjective anxiety (p = .023), heart rate (p < .001), and blood pressure (p = .001) during the first session. A decrease in these parameters was also recorded between the first and the last session. The number of binges per week (p = .005) and the mean score for the psychopathological scales decreased significantly from the beginning of the treatment, and were significantly lower at the end of the CE program and at follow-up. Purging behaviors per week only decreased significantly after the end of the CE session during the follow-up (p = .04).

CONCLUSION

Anxiety, binging, purging, and psychopathological scales improve with a CE program in resistant bulimia nervosa.

Cue reactivity in bulimia nervosa: A useful self-report approach

OBJECTIVE

To examine the usefulness of a self-report questionnaire in the assessment of cue reactivity among women treated for bulimia nervosa.

METHOD

Subjects were women participating in a randomized clinical trial evaluating the additive efficacy of exposure- and non-exposure-based behavioral treatment to a core of cognitive behavior therapy, with follow-up at 6 months post treatment. Complete data were available for 82 women. Cue reactivity was assessed using an adaptation of the Situational Appetite Measure (SAM).

RESULTS

Improvements in cue reactivity occurred over time for the sample as a whole, with greater improvements being associated with favorable treatment outcome and treatment modality (exposure based treatments associated with greater improvements). The best single predictor of abstinence at 6 months was abstinence at posttreatment.

CONCLUSION

A self-report questionnaire (adapted SAM) provided useful information regarding cue reactivity among women treated for bulimia nervosa, without the difficulties associated with in vivo assessment.

Towards the pharmacotherapy of eating disorders

The purpose of this review is to discuss pharmacological options for the treatment of patients with eating disorders. Sequentially described are pharmacotherapy studies of anorexia nervosa (AN), bulimia nervosa (BN) and binge-eating disorder (BED). The quantity of drug trials performed with AN patients has been very limited. While the majority of studies have failed to show medication efficacy for the acute treatment of AN, there is data which suggests that fluoxetine hydrochloride may play a role in preventing relapse during maintenance therapy. Atypical antipsychotics, most often olanzapine, have shown promise in a number of uncontrolled studies. BN has been most extensively studied, with the majority of pharmacological trials focusing on antidepressants. Fluoxetine, at a dose of 60 mg/day, is FDA-approved for the treatment of BN. Psychotherapy, particularly cognitive behavioural therapy (CBT) is of well-established utility in BN and data suggests that the combination of an antidepressant plus CBT is superior to either treatment alone. Recently, there has been interest in the 5-HT3 antagonist, ondansetron, and the anticonvulsant, topiramate. BED investigators have focused largely on antidepressants, which may reduce symptoms of depression and augment psychotherapy. While sibutramine and topiramate have both been associated with weight loss in controlled trials, the former appears to be fairly well-tolerated and the latter appears to be responsible for the emergence of significant cognitive and peripheral nervous system side effects in some patients. Further pharmacological research with eating disorder patients is needed, particularly in the areas of AN and BED. Also, pharmacological augmentation strategies for those not responding to primary therapies should be explored.

Psychotherapy for bulimia nervosa and binging

BACKGROUND

Bulimia nervosa and related syndromes such as binge eating disorder are common in young Western women. A specific manual-based form of cognitive behaviour therapy (CBT) has been developed for the treatment of bulimia nervosa (CBT-BN). Other psychotherapies, some from a different theoretical framework, and some modifications of CBT are also used.

OBJECTIVES

To evaluate the efficacy of CBT and CBT-BN and compare them with other psychotherapies in the treatment of adults with bulimia nervosa or related syndromes of recurrent binge eating.

SEARCH STRATEGY

A handsearch of The International Journal of Eating Disorders since its first issue; database searches of MEDLINE, EXTRAMED, EMBASE, PsycInfo, CURRENT CONTENTS, LILACS, SCISEARCH, CENTRAL and the The Cochrane Collaboration Depression, Anxiety & Neurosis Controlled Trials Register; citation list searching and personal approaches to authors were used.

SELECTION CRITERIA

All studies that have tested any form of psychotherapy for adults with non-purging bulimia nervosa, binge eating disorder and/or other types of eating disorders of a bulimic type (eating disorder, not otherwise specified, or EDNOS), and which applied a randomised controlled and standardised outcome methodology.

DATA COLLECTION AND ANALYSIS

Data were analysed using the Review Manager software program. Relative risks were calculated for binary outcome data. Standardized mean differences were calculated for continuous variable outcome data. A fixed effects model was used to analyse the data. Sensitivity analyses of a number of measures of trial quality were conducted. Data were not reported in such a way to permit subgroup analyses, but the effects of treatment on depressive symptoms, psychosocial and/or interpersonal functioning, general psychiatric symptoms and weight were examined where possible. Funnel plots were drawn to investigate the presence of publication bias.

MAIN RESULTS

The review supported the efficacy of cognitive-behavioural psychotherapy (CBT) and particularly CBT-BN in the treatment of people with bulimia nervosa and also (but less strongly due to the small number of trials) related eating disorder syndromes. CBT was also shown to be effective in group settings. Other psychotherapies were also efficacious, particularly interpersonal psychotherapy in the longer-term. Self-help approaches that used highly structured CBT treatment manuals, were promising albeit with more modest results generally, and their evaluation in bulimia nervosa merits further research. Exposure and Response Prevention did not appear to enhance the efficacy of CBT.Psychotherapy alone is unlikely to reduce or change body weight in people with bulimia nervosa or similar eating disorders.

REVIEWERS' CONCLUSIONS

There is a small body of evidence for the efficacy of cognitive-behaviour therapy in bulimia nervosa and similar syndromes, but the quality of trials is very variable and sample sizes are often small. More trials of CBT are needed, particularly for binge eating disorder and other EDNOS syndromes. Trials evaluating other psychotherapies and less intensive psychotherapies should also be conducted.

Psychiatric comorbidity and inpatient treatment history in bulimic subjects

Bulimia nervosa (BN) is often associated with other forms of psychopathology. There is a need to clarify which specific factors of psychopathology are linked with the referral to psychiatric or psychotherapeutic inpatient treatment. This study examined which factors of psychopathology are linked with the referral of BN patients to inpatient treatment while controlling for history of suicide attempts and history of underweight. 126 females with a current diagnosis of BN purging type were assessed with the Structured Clinical Interview for DSM-IV and interviewed about their history of treatment for the BN, history of weight, and history of suicide attempts. Logistic regressions were conducted to examine whether psychiatric comorbidity, suicide attempts, and underweight were associated with inpatient treatment history. Axis I comorbidity in general, but no specific axis I disorder, was associated with inpatient history. Axes II comorbidity, especially Cluster B disorders and to a lesser degree depressive/negativistic personality disorders, was associated with a history of inpatient treatment. History of suicide attempts was also linked with inpatient experience, but history of underweight was not. The results showed that BN patients with specific types of comorbidity are more likely to be hospitalized than others.

A randomized secondary treatment study of women with bulimia nervosa who fail to respond to CBT

OBJECTIVE

Since the description of bulimia nervosa as a distinct diagnostic entity in 1979, several psychological and pharmacological interventions have been developed and empirically tested. The existence of several effective treatments, none of which is completely effective, is common to most psychiatric conditions. The research question that flows from such findings is whether second-level treatments would be effective for those who fail initial treatment.

METHOD

In the case of bulimia nervosa, the research findings suggest that cognitive behavioral therapy (CBT) is the first level of treatment and that both antidepressant medication and interpersonal psychotherapy (IPT) may potentially be effective second-level treatments. This was a multicenter study in which 194 patients were initially treated with CBT. Those treated unsuccessfully (n = 62) were then randomized to treatment with IPT or medication management.

RESULTS

Of those assigned to secondary treatment, 37 completed such treatment and 25 dropped out or were withdrawn. The abstinence rate for subjects assigned to treatment with IPT was 16% and for those assigned to medication management was 10%. No significant differences were found between medication and IPT in either the intent-to-treat or completer analysis.

DISCUSSION

Dropout rates were high, and response rates were low among BN patients assigned to secondary treatments who failed to achieve remission with CBT. Offering lengthy sequential treatments appears to have little value, and alternative models for therapy need to be tested.

Does concurrent psychopathology at presentation influence response to treatment for bulimia nervosa?

Pub Med and Psych Lit were searched using the key terms 'outcome' and 'bulimia nervosa' for papers on outcome and bulimia nervosa (BN). The studies which examined any aspect of psychopathology are included and the findings reviewed. No robust findings emerged. This paper reviews the methodological problems that beset this area, and then examines in detail the relationship between other psychological dysfunctions and psychiatric co-morbidity and treatment outcome for BN. The psychological variables that most probably predict poorer outcome are low self-esteem, and low satisfaction with or perceived quality of friendships. With regard to psychiatric co-morbidity, there is no consistent relationship with any Axis I disorder. Most of the studies assessing Axis II dysfunction show that borderline symptom severity or cluster B personality disorder can impair outcome. The implications for clinical practice are discussed and directions for future research suggested.

Evidence-based treatment of eating disorders

Anorexia nervosa and bulimia nervosa are common problems facing adolescents and young adults. Treatment of these disorders poses a challenge to health care providers given the general paucity of clinical trials to guide management. There is evidence to support the use of CBT as well as psychopharmacotherapy to decrease binge and purge behaviors in bulimia nervosa. Significantly fewer trials have examined the efficacy of such therapies for anorexia nervosa. Short-term trials appear promising regarding potential treatments for bone loss in anorexia nervosa. The role of exercise in the management of anorexia nervosa remains controversial and begs future investigative efforts.

Cue reactivity as a predictor of outcome with bulimia nervosa

The present study sought to evaluate specific hypotheses concerning the relation between cue reactivity and outcome among women with bulimia nervosa. Participants were 135 women aged between 17 and 45 years with a current, primary diagnosis of bulimia nervosa who participated in a randomized clinical trial evaluating the additive efficacy of exposure and nonexposure-based behavior therapy, to a core of cognitive behavior therapy (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 and six-month follow-up. Self-report measures of cue reactivity at posttreatment were significantly positively associated with symptomatology at posttreatment. Cue reactivity at posttreatment was significantly positively associated with symptomatology at 6-month follow-up. However, cue reactivity at posttreatment did not contribute to the prediction of outcome at follow-up over and above posttreatment outcome. The notion that pretreatment cue reactivity may predict which treatment modality will be most beneficial (exposure or nonexposure-based treatment), as measured by reductions in symptomatology at posttreatment could not be supported. Implications for future research are discussed.

Long-term impact of treatment in women diagnosed with bulimia nervosa

OBJECTIVE

Both cognitive-behavioral therapy (CBT) and antidepressant medication have demonstrated efficacy in the treatment of bulimia nervosa. However, data concerning the long-term impact of such treatments have been limited. This study sought to determine if treatment with CBT and antidepressant medication was associated with better long-term outcome among women diagnosed with bulimia nervosa.

METHOD

Women (N = 101) who completed a controlled treatment study of bulimia nervosa participated in follow-up assessments approximately 10 years later.

RESULTS

Women who received treatment with CBT or antidepressant medication or both reported improved social adjustment at long-term follow-up compared with women randomized to the placebo condition.

DISCUSSION

Treatments with demonstrated efficacy for short-term outcome appear to improve psychosocial function at long-term follow-up among women initially diagnosed with bulimia nervosa.

The efficacy of cognitive-behavioral therapy on the core symptoms of bulimia nervosa

Cognitive behavioral therapy (CBT) is widely regarded as the treatment of choice for bulimia nervosa (BN), with previous reviews of the CBT outcome literature claiming an approximate 40%-50% recovery rate. Most of these reviews have focused on reductions of binge eating and purging; however, the cognitive model of BN that underlies the CBT approach identifies three additional symptoms as central to the disorder: restrictive eating, concerns with shape and weight, and self-esteem. The purpose of this review was to determine the effect of CBT on the five core symptoms of BN, particularly those neglected in previous reviews. This review found that while most studies provided outcome data on binge eating, purgative behavior, and concern with shape and weight, fewer studies provided data on restraint and self-esteem. While generally favorable, evidence for the efficacy of CBT on the core symptoms of BN was mixed, depending on the outcome measures used. Shortcomings in the literature are identified and suggestions to correct these shortcomings are provided.

The relative efficacy of fluoxetine and manual-based self-help in the treatment of outpatients with bulimia nervosa

A randomized, placebo-controlled study was conducted examining the singular and combined effects of fluoxetine and a self-help manual on suppressing bulimic behaviors in women with bulimia nervosa. A total of 91 adult women with bulimia nervosa were randomly assigned to one of four conditions: placebo only, fluoxetine only, placebo and a self-help manual, or fluoxetine and a self-help manual. Subjects were treated for 16 weeks. Primary outcome measures included self-reports of bulimic behaviors. Fluoxetine and a self-help manual were found to be effective in reducing the frequency of vomiting episodes and in improving the response rates for vomiting and binge-eating episodes. Furthermore, both factors were shown to be acting additively on the primary and secondary efficacy measures in this study. Results are discussed in relation to previous research and the implications for treatment of bulimia nervosa.

Combining pharmacotherapy and psychotherapy in the treatment of patients with eating disorders

The available treatment literature supports a role for medication management in the treatment of both AN and BN. The data on BN are clearer and suggest that antidepressant therapy--fluoxetine being the drug most widely studied--is superior to treatment with placebo but less effective than CBT alone, with one such study suggesting that the combination may provide optimal treatment. Specific recommendations as to when to add or not add antidepressants to CBT have been made, although the rules suggested here have yet to be empirically tested. Although the data on AN are much more limited, information available suggests a lack of efficacy for SSRIs in patients with AN at low weight and considerable use for SSRIs when used in combination with psychotherapy for patients with AN following weight recovery. Where do we go from here? Several pressing issues require careful study. First, in the case of patients with AN, can other agents, in particular the new atypical antipsychotics, be useful in treating patients when they are at low weight? In terms of relapse prevention, can the available findings indicating a role for antidepressants in relapse prevention be replicated, and, if so, can predictor variables that are associated with antidepressant response be identified? In the case of BN, clinicians need to know more about the best possible way to sequence interventions. It has been proposed to add medication to CBT early in treatment if the response to CBT alone is thought to be inadequate. However, other models should be considered, such as stepped-care models in which self-help manuals are used in conjunction with medications. The advantage of these interventions is they could be made more widely available than CBT, which requires a specialist's care. Also, several other new agents, such as sibutramine, which is a drug with serotonin and norepinephrine reuptake inhibition effects, should be tested empirically in subjects with BN, given their pharmacologic profiles.

Matching patient variables to treatment intensity. The continuum of care

This article has reviewed what is currently known regarding the relationship between specific patient variables and treatment response in AN, BN, and BED. Matching patient variables to treatment intensity remains an important and fruitful area for future research. There is a need for established guidelines for clinicians regarding the choice of the appropriateness of treatment settings and type of interventions delivered in those settings. These guidelines should be evidence based, with clear clinical indicators for each of the recognized eating disorders and their subclinical variants.