Treatment of bulimia nervosa: when CBT fails

Comparing a Tailored Self-Help Mobile App With a Standard Self-Monitoring App for the Treatment of Eating Disorder Symptoms: Randomized Controlled Trial

BACKGROUND

Eating disorders severely impact psychological, physical, and social functioning, and yet, the majority of individuals with eating disorders do not receive treatment. Mobile health apps have the potential to decrease access barriers to care and reach individuals who have been underserved by traditional treatment modalities.

OBJECTIVE

The objective of this study was to evaluate the effectiveness of a tailored, fully automated self-help version of Recovery Record, an app developed for eating disorders management. We examined differences in eating disorder symptom change in app users that were randomized to receive either a standard, cognitive behavioral therapy-based version of the app or a tailored version that included algorithmically determined clinical content aligned with baseline and evolving user eating disorder symptom profiles.

METHODS

Participants were people with eating disorder symptoms who did not have access to traditional treatment options and were recruited via the open-access Recovery Record app to participate in this randomized controlled trial. We examined both continuous and categorical clinical improvement outcomes (measured with the self-report Eating Disorder Examination Questionnaire [EDE-Q]) in both intervention groups.

RESULTS

Between December 2016 and August 2018, 3294 Recovery Record app users were recruited into the study, out of which 959 were considered engaged, completed follow-up assessments, and were included in the analyses. Both study groups achieved significant overall outcome improvement, with 61.6% (180/292) of the tailored group and 55.4% (158/285) of the standard group achieving a clinically meaningful change in the EDE-Q, on average. There were no statistically significant differences between randomized groups for continuous outcomes, but a pattern of improvement being greater in the tailored group was evident. The rate of remission on the EDE-Q at 8 weeks was significantly greater in the group receiving the tailored version (d=0.22; P≤.001).

CONCLUSIONS

This is the first report to compare the relative efficacy of two versions of a mobile app for eating disorders. The data suggest that underserved individuals with eating disorder symptoms may benefit clinically from a self-help app and that personalizing app content to specific clinical presentations may be more effective in promoting symptomatic remission on the EDE-Q than content that offers a generic approach.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02503098; https://clinicaltrials.gov/ct2/show/NCT02503098.

Patient baseline interpersonal problems as moderators of outcome in two psychotherapies for bulimia nervosa

Objective: We tested an aptitude by treatment interaction; namely, whether patients' baseline interpersonal problems moderated the comparative efficacy of cognitive-behavioral therapy (CBT) vs. interpersonal psychotherapy (IPT) for bulimia nervosa (BN). Method: Data derived from a randomized-controlled trial. Patients reported on their interpersonal problems at baseline; purge frequency at baseline, midtreatment, and posttreatment; and global eating disorder severity at baseline and posttreatment. We estimated the rate of change in purge frequency across therapy, and the likelihood of attaining clinically meaningful improvement (recovery) in global eating disorder severity by posttreatment. We then tested the interpersonal problem by treatment interactions as predictors of both outcomes. Results: Patients with more baseline overly communal/friendly problems showed steeper reduction in likelihood of purging when treated with CBT vs. IPT. Patients with more problems of being under communal/cold had similar reductions in likelihood of purging across both treatments. Patients with more baseline problems of being overly agentic were more likely to recover when treated with IPT vs. CBT, whereas patients with more problems of being under agentic were more likely to recover when treated with CBT vs. IPT. Conclusions: Interpersonal problems related to communion and agency may inform treatment fit among two empirically supported therapies for BN.

Cognitive–behavioural therapies for children and adolescents

The merging of behaviour and cognitive therapy into cognitive–behavioural therapy (CBT) occurred in the 1980s in both Europe and North America, particularly on the basis of the successful treatment of panic disorder by Clark (1986) in the UK and Barlow (1988) in the USA. The behavioural emphasis on empiricism with good-quality research design was combined with the cognitive focus on content and meaning.

The management of bulimia nervosa and other binge eating problems

This article is about the management of eating disorders in which binge eating is a prominent feature. These disorders include bulimia nervosa, the most common eating disorder, and ‘binge eating disorder’, a provisional new diagnosis included in DSM–IV. In addition, binge eating is seen in anorexia nervosa and in many atypical eating disorders.

The Sequential Binge, a New Therapeutic Approach for Binge Eating: A Pilot Study

Background and Objectives

A sizeable proportion of patients experiencing binge eating do not respond to cognitive behavioral therapy (CBT). We present the sequential binge (SB), a new behavioral intervention that complements CBT, and preliminary results of its effects. SB breaks up the binge into repeated identical sequences of eating separated by incremental pauses. This pattern of ingestion aims at facilitating boredom toward the ingested foods and at turning cognitive control away from binge food restriction. SB is hypothesized to reduce food intake during the binge and the number of daily binges.

Methods

Prospective pilot study. Fifteen binging patients with previous unsuccessful intensive CBT were given SB as an adjunct to their treatment and were followed up for 16 weeks from admission. All patients were reassessed 47 weeks on average after discharge.

Results

SB was associated with a 44% relative reduction in the planned food intake (p<0.001), a longer consecutive binge refractory period compared to regular binges (median: 48 hours versus 4 hours, p = 0.002) and an average relative reduction by 26% of binge number the day after each SB (p = 0.004). 47% of patients reached binge abstinence for four consecutive weeks 16 weeks after the first SB.

Conclusion

This case series shows promising evidence for the use of SB in patients with refractory binge eating. Further evaluation in a prospective randomized controlled trial would be justified.

Patients' Perspective of Treatment in Eating Disorders: A Preliminary Study

The patient's perspective of treatment is seldom considered when psychological interventions are evaluated. Our aim was to undertake a qualitative study to assess the patients' viewpoint of what was helpful as well as harmful about the treatment they have completed. Twenty-one female referrals to an outpatient university-based eating disorders service (10 anorexia nervosa and 11 bulimia nervosa, mean age = 24.7 years, SD = 9.8) were interviewed on average one year after completion of either family counselling or cognitive-behavioural treatment. Most patients reported improvements as a result of treatment, although our formal assessment was more cautious. Patients identified psychoeducation, a supportive environment, challenging of dysfunctional beliefs, and behavioural strategies as helpful components of treatment. A significant minority felt that causes of the illness were dealt with inadequately, and that behavioural strategies were insufficient when symptoms were too overpowering. This study shows that gaining the patient's perspective of therapy could provide clinicians with helpful feedback to improve treatment for this challenging patient population.

Dieting and Cognitive Style

This study aimed to investigate the relationship between dieting and global cognitive style in a non-clinical sample. Questionnaires were administered to 218 Australian undergraduate students. Dieting was operationalized in two ways: self-reported current dieting behaviour; and scores on dietary restraint. It was found that current, but not past, dieters had more dysfunctional cognitive attitudes, confirming the necessity of distinguishing between current and past dieting behaviour. The Concern for Dieting subscale of dietary restraint was also related to a dysfunctional cognitive style, even after level of depressed mood was statistically controlled. In particular, the dysfunctional attitude of Dichotomous Thinking was implicated. Taken together, the findings imply that dieters do not have an enduring maladaptive cognitive style, but rather that current dieting concerns and behaviour are associated with poorer cognitive functioning.

Eating Disorders

More than 2 million female Americans have a clinically relevant eating disorder. Although the prevalence and seriousness of this problem has gained increasing attention in recent years, relatively little is known about eating disorder prevention. This article addresses a number of issues related to prevention efforts applied to eating disorders. An overview of putative risk factors that have been identified is presented. In particular, the article emphasizes the importance of understanding the psychological and physical developmental processes during adolescence and the sociocultural context in which eating disorders develop. A summary of empirical investigations of the efficacy of eating disorder prevention programs follows, including an illustration of one of the more promising strategies that has been reported to date. The role of counseling psychologists in further refining eating disorder prevention efforts is discussed.

Treatment of Eating Disorders in Women

This article reviews the most recent treatment literature for anorexia nervosa, bulimia nervosa, and binge eating disorder and serves as a guide for recommended readings and therapist resources. The primary focus is on empirically tested treatment modalities; for each of these approaches reviewed, the theoretical background, nature of the intervention, and existing empirical support are summarized. The article also presents less researched, albeit promising, approaches to eating disorder treatment, describing the rationale and available research. A focus on multicultural issues, including the paucity of eating disorder treatment research among participants of color, and suggestions for building research and enhancing treatment effectiveness with ethnic minority clients, is incorporated throughout. Recommendations concerning pressing research needs are made, and a summary of clinical recommendations for each disorder is formulated.

Using early change to predict outcome in cognitive behaviour therapy: exploring timeframe, calculation method, and differences of disorder-specific versus general measures

Early change can predict outcome of psychological treatment, especially in cognitive behavior therapy. However, the optimal operationalization of “early change” for maximizing its predictive ability, and differences in predictive ability of disorder-specific versus general mental health measures has yet to be clarified. This study aimed to investigate how well early change predicted outcome depending on the week it was measured, the calculation method (regression slope or simple subtraction), the type of measures used, and the target disorder. During 10–15 weeks of internet-based cognitive behavior therapy for depression, social anxiety disorder, or panic disorder, weekly ratings were collected through both disorder-specific measures and general measures (Outcome Questionnaire-45 (OQ-45) and Clinical Outcomes in Routine Evaluation-10 (CORE-10)). With outcome defined as the disorder-specific measure, change at week four was the optimal predictor. Slope and subtraction methods performed equally well. The OQ-45 explained 18% of outcome for depression, 14% for social anxiety disorder, and 0% for panic disorder. Corresponding values for CORE-10 were 23%, 29%, and 25%. Specific measures explained 41%, 43%, and 34% respectively: this exceeded the ability of general measures also when they predicted themselves. We conclude that a simple calculation method with a disorder-specific measure at week four seems to provide a good choice for predicting outcome in time-limited cognitive behavior therapy.

Emerging psychological treatments in the field of eating disorders

Few treatments for eating disorders have established a base of empirical support, and those that have are still limited by high dropout rates and low abstinence rates. Thus, there is a critical need for innovative eating disorder treatments to fill this gap. The past decade has seen a surge in the development of novel treatments that address eating pathology. This review provides an overview of the emerging psychological treatments for eating disorders, including descriptions of the therapeutic rationales, treatment techniques, and research support. The review will cover face-to-face interventions that are provided in the context of individual or group psychotherapy. Treatments included in this review were organized into the following six categories based on their underlying therapeutic rationales: (1) cognition-focused approaches, (2) emotion regulation approaches, (3) exposure-based approaches, (4) motivational enhancement, (5) integrative approaches, and (6) family- and couple-based interventions.

Weight suppression in bulimia nervosa: relationship with cognitive behavioral therapy outcome

OBJECTIVE

In light of prior inconsistent findings, this study revisits the relationship between weight suppression and treatment outcome in bulimia nervosa. Aside from differences in methodology, we propose that moderator effects may assist the field in interpreting previous inconsistency. In this study, we considered moderators that might place individuals at risk of broad cognitive and biobehavioral mechanisms implicated in weight (dys)regulation and binge eating, and that within the context of a history of weight suppression, might be associated with especially poor outcomes.

METHOD

Participants were 117 female outpatients aged 16-54 years (M = 25.5) with bulimic disorders treated with enhanced cognitive behavioral therapy.

RESULTS

Logistic regression indicated that higher pretreatment weight suppression did not predict drop-out or poor treatment outcome (nonabstinence from binging and purging). Moderators of parental history of overweight, childhood body shape, pretreatment body mass index, and the difference between highest and lowest ever adult body weight were analyzed, but no moderator effects were apparent.

DISCUSSION

This study, along with other negative studies, calls into question the association between weight suppression and treatment outcome. We maintain that moderators may account for inconsistencies, but no candidates were identified in this study. Moderator models could assist us to refine conceptualizations of why some patients high in weight suppression may be vulnerable to poor treatment adherence and outcome and to establish clinical interventions that enhance prognosis.

Internet-delivered cognitive-behavioural therapy v. conventional guided self-help for bulimia nervosa: long-term evaluation of a randomised controlled trial

BACKGROUND

Cognitive-behavioural therapy (CBT)-based guided self-help is recommended as a first step in the treatment of bulimia nervosa.

AIMS

To evaluate in a randomised controlled trial (Clinicaltrials.gov registration number: NCT00461071) the long-term effectiveness of internet-based guided self-help (INT-GSH) compared with conventional guided bibliotherapy (BIB-GSH) in females with bulimia nervosa.

METHOD

A total of 155 participants were randomly assigned to INT-GSH or BIB-GSH for 7 months. Outcomes were assessed at baseline, month 4, month 7 and month 18.

RESULTS

The greatest improvement was reported after 4 months with a continued reduction in eating disorder symptomatology reported at month 7 and 18. After 18 months, 14.6% (n = 7/48) of the participants in the INT-GSH group and 25% (n = 7/28) in the BIB-GSH group were abstinent from binge eating and compensatory measures, 43.8% (n = 21/48) and 39.2% (n = 11/28) respectively were in remission. No differences regarding outcome between the two groups were found.

CONCLUSIONS

Internet-based guided self-help for bulimia nervosa was not superior compared with bibliotherapy, the gold standard of self-help. Improvements remain stable in the long term.

An evaluation of the impact of introducing compassion focused therapy to a standard treatment programme for people with eating disorders

OBJECTIVE

This study explored the outcome of introducing Compassion Focused Therapy (CFT) into a standard treatment programme for people with eating disorders. In particular, the aim was to evaluate the principle that CFT can be used with people with eating disorders and improve eating disorder symptomatology.

METHOD

Routinely collected questionnaire data were used to assess cognitive and behavioural aspects of eating disorders and social functioning/well being (n = 99).

RESULTS

There were significant improvements on all questionnaire measures during the programme. An analysis by diagnosis found that people with bulimia nervosa improved significantly more than people with anorexia nervosa on most of the subscales. Also, in terms of clinical significance, 73% of those with bulimia nervosa were considered to have made clinically reliable and significant improvements at the end of treatment (compared with 21% of people with anorexia nervosa and 30% of people with atypical eating disorders).

CONCLUSION

This study demonstrates the potential benefits of using CFT with people with eating disorders and highlights the need for further research on this new approach.

KEY PRACTITIONER MESSAGE

CFT offers new ways to conceptualize and formulate some of the self-critical and shame-based difficulties associated with eating disorders. CFT offers a framework that can enable people with eating disorders to conceptualize their difficulties in different ways. CFT can be combined with standard therapies especially cognitive behavioural therapy. CFT can be especially useful in a group context where the relationships between members can become increasingly compassionate, validating, supportive and encouraging.

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.

Discerning thoughts from feelings: the cognitive-affective division in eating disorders

This article delineates the phenomenon of "cognitive-affective division" in eating disorders, used to refer to the difficulty some patients face in translating what they "think" cognitively to what they "feel" emotionally. A clinical description of cognitive-affective division is first presented, drawing on existing research, before moving on to discuss psychological theories that might shed some light on this often-seen but seldom understood phenomenon. These include the role of emotion awareness and alexithymia, cognitive and emotional development, and neuropsychological theories. We discuss implications for treatment and further research of the cognitive-affective division in eating disorders.

Enhanced cognitive behavioural therapy for an adolescent with purging disorder: a case report

OBJECTIVE

To present a case report detailing the use of an enhanced form of cognitive behaviour therapy (CBT). The treatment was provided to an adolescent with an eating disorder not otherwise specified (EDNOS) diagnosis, and included a focus on the additional maintaining mechanisms of mood intolerance and interpersonal problems.

CASE

This case began as an unsuccessful attempt at family therapy, where the underlying dysfunction exacerbated symptoms and demoralized the family. The therapist subsequently chose to utilize an enhanced version of CBT to simultaneously address the patient's symptoms and try to effect change across multiple domains. A description of the patient's eating disorder pathology, the 29-session treatment, and outcome, are provided.

CONCLUSION

This case study illustrates that it is possible to successfully use enhanced CBT with developmentally appropriate adaptations in the treatment of a young patient with an EDNOS diagnosis, as suggested by Cooper and Stewart (2008).

Dialectical behaviour therapy and an added cognitive behavioural treatment module for eating disorders in women with borderline personality disorder and anorexia nervosa or bulimia nervosa who failed to respond to previous treatments. An open trial with a 15-month follow-up

There is evidence from case studies suggesting that adapted dialectical behavior therapy (DBT) for borderline personality disorder (BPD) and eating disorders (ED) might improve disorder related complaints. Twenty-four women with BPD (9 with comorbid anorexia nervosa [AN] and 15 with bulimia nervosa [BN]), who already had failed to respond to previous eating-disorder related inpatient treatments were consecutively admitted to an adapted inpatient DBT program. Assessment points were at pre-treatment, post-treatment, and 15-month follow-up. At follow-up, the remission rate was 54% for BN, and 33% for AN. Yet 44% of women with AN crossed over to BN and one woman additionally met the criteria of AN. For women with AN, the mean weight was not significantly increased at post-treatment, but had improved at follow-up. For women with BN, the frequency of binge-eating episodes was reduced at post-treatment as well as at follow-up. Self-rated eating-related complaints and general psychopathology, as well as ratings on global psychosocial functioning, were significantly improved at post-treatment and at follow-up. Although these findings support the assumption that the adapted DBT inpatient program is a potentially efficacious treatment for those who failed to respond to previous eating-disorder related inpatient treatments, remission rates and maintained eating-related psychopathology also suggest that this treatment needs further improvement.

Evaluation of a guided internet self-treatment programme for bulimia nervosa in several European countries

OBJECTIVE

The purposes of this study were to evaluate the use of an online guided self-treatment programme for bulimia nervosa (BN) and to determine predictors of outcome. Data were collected in four European countries where the programme was simultaneously used.

METHOD

One hundred and twenty-seven BN or subthreshold BN female patients (mean age of 24.7 years) participated in a 4-month intervention using a CBT based online-guided self-help programme. Contact during the treatment period included weekly e-mails with a coach.

ASSESSMENT

Measures included the Eating Disorders Inventory-2 (EDI-2) and the Symptom Check List-Revised (SCL-90R).

RESULTS

Severity of eating disorders symptoms and general psychopathology improved significantly. Twenty-three per cent of patients were symptom free at the end of treatment. The dropout rate was 25.2%. A better score of general psychological health was a predictor of a better outcome.

CONCLUSIONS

This study encourages further developments and research on innovative therapy approaches, particularly for those disorders such as BN, with difficult therapy and unclear prognosis.

Cognitive-behavioural therapy for individuals with bulimia nervosa and a co-occurring substance use disorder

A significant percentage of individuals with bulimia nervosa (BN) also can be diagnosed with a co-occurring substance use disorder (SUD). Although studies have addressed the frequency of overlap between the disorders, etiology and shared personality traits, limited research is available about the treatment of these comorbid patients. Adapting cognitive-behaviour therapy (CBT) to serve as an integrated treatment for patients with both BN and a SUD is a viable option, as studies of CBT suggest that this form of treatment is efficacious for both disorders independently. The shared strategies in CBT for BN and SUDs facilitate the development of a combined treatment for individuals with both disorders with the addition of modules designed to address some common features of these disorders, such as motivation, difficulty with interpersonal relationships, reward sensitivity and impulsivity. Future research should begin to evaluate the efficacy of an integrated CBT in treating individuals with BN and a SUD.

Management of bulimia nervosa

Bulimia nervosa is a disorder of complex etiology that tends to occur in young women. These individuals binge eat and purge by vomiting or other means, and often have depression, anxiety, substance abuse and extremes of impulse control. It is thought that binge eating and purging behaviors are, at least in part, a means of coping with dysphoric mood states and interpersonal stress. Bulimic symptoms are not likely to abate without development of new coping skills and behaviors. In the past 25 years, considerable progress has been made in developing specific psychotherapies and medication for the treatment of bulimia nervosa. Despite this progress, many individuals have partial responses to therapy and may remain chronically ill. This complex illness often requires a multidisciplinary team of professionals for effective management and, despite significant advances in treatment, bulimia nervosa continues to present major challenges for providers of care.

A retrospective comparison of purging type disorders: eating disorder not otherwise specified and bulimia nervosa

OBJECTIVE

In light of recent research indicating the clinical significance of eating disorder not otherwise specified-purging only (EDNOS-P), differences between women with lifetime bulimia nervosa purging subtype (BN-P) and EDNOS-P were examined.

METHOD

Three groups of women were examined, a control group (n = 684) and two groups with lifetime eating disorders: BN-P (n = 22), and EDNOS-P (n = 53).

RESULTS

Women with lifetime BN-P were significantly more likely to use vomiting than women with EDNOS-P but the latter group relied more on laxative abuse. Compared with controls, women with both eating disorders had higher weight and shape concern, dietary restraint, lifetime major depression, and suicidality. The BN-P group had significantly higher eating concern, dietary restraint, and suicidality than the EDNOS-P group.

CONCLUSION

In accordance with previous research examining women with current eating disorders, EDNOS-P is indicated to be clinically significant. On the whole, the pattern of results indicated that EDNOS-P lies somewhere between BN-P and healthy controls in its clinical significance.

Attrition and outcome in self-help treatment for bulimia nervosa and binge eating disorder: a constructive replication

The aim of the study was to assess the efficacy of a 12-week CBT-based pure and guided self-help among 29 patients with full and subthreshold bulimia nervosa, and binge eating disorder. In the intention-to-treat analyses, self-help had a moderately positive and sustained effect on the patients' eating problems. The patients reduced their mean number of objective bulimic episodes and purging behavior by 26% and 22% over the course of treatment. The corresponding reduction levels for the treatment completers (n=21) were 41% and 34%, respectively. As in the previous study, there were no significant differences between the pure and guided self-help mode in terms of outcome, and the results were sustained 6 months after the end of the treatment. The findings are discussed in relation to the shorter duration of the self-help, the lower rate of attrition, and the characteristics of the sample compared to the earlier trial.

Does individualization matter? A randomized trial of standardized (focused) versus individualized (broad) cognitive behavior therapy for bulimia nervosa

Does higher level of individualization increase treatment efficacy? Fifty patients with bulimia nervosa were randomized into either manual-based (focused) or more individualized (broader) cognitive behavioral therapy guided by logical functional analysis. Eating disorders Examination and a series of self-report questionnaires were used for assessment at pre-, and post-treatment as well as at follow-up. Both conditions improved significantly at post-treatment, and the results were maintained at the 6 months follow-up. There were no statistically and clinically significant differences between the two conditions at post-treatment with the exception of abstinence from objective bulimic episodes, eating concerns, and body shape dissatisfaction, all favoring the individualized, broader condition. Both groups improved concerning self-esteem, perceived social support from friends, and depression. The improvements were maintained at follow-up. Ten patients (20%) did not respond to the treatment. Notably, a majority of non-responders (80%) were in the manual-based condition. Non-responders showed extreme dominance of rule-governed behavior, and lack of contact with actual contingencies compared to responders. The study provided preliminary support for the superiority of higher level of individualization (i.e. broader CBT) in terms of the response to treatment, and relapses. However, the magnitude of effects was moderate, and independent replications, with blind assessment procedures, and a larger sample sized are needed before more clear cut conclusions can be drawn.

A comparison of sequenced individual and group psychotherapy for patients with bulimia nervosa

OBJECTIVE

The current study examined the effectiveness of individual (IND) versus group (GRP) therapy for patients with bulimia nervosa (BN), using a manual of sequenced treatment with cognitive-behavioral therapy (CBT) followed by interpersonal psychotherapy (IPT).

METHOD

Eighty-six participants with BN were matched and randomized to 23 sessions of IND or GRP. Participants were measured pretreatment and posttreatment and at 1-year and 2.5-year follow-ups using both intent-to-treat and completer samples.

RESULTS

The intent-to-treat analysis revealed that the percentage of participants recovered and remitted was equivalent between IND and GRP. Significant group differences were found between completers on binge eating and compensatory behavior with greater improvement for IND. On most measures, effect sizes were larger for IND at 1-year follow-up.

CONCLUSION

Sequencing CBT and IPT worked well in both IND and GRP formats. We found few outcome differences between IND as opposed to GRP.

An open trial of outpatient group therapy for bulimic disorders: combination program of cognitive behavioral therapy with assertive training and self-esteem enhancement

The purposes of this study were to examine the therapeutic efficacy of combined group cognitive behavioral therapy (CGCBT) and to explore the characteristics of the patients who failed to complete it. Our group cognitive behavioral therapy combined with assertiveness training for alexithymia and self-esteem enhancement therapy were attended over a 10-week period. Twenty-five participants were enrolled in the study. The clinical symptoms were assessed before and after treatment, using rating scales including the Eating Disorder Inventory-2, the Bulimic Investigatory Test, Edinburgh, the Toronto Alexithymia Scale, the Rosenberg Self-Esteem Scale, and Global Assessment of Functioning. Sixteen participants (64%) completed the CGCBT program. Completion of the CGCBT resulted in significant improvements in reducing binge-eating behavior and improving social functioning. Eight patients (32%) significantly improved using the Clinical Global Impression Change (CGI-C). Stepwise logistic regression analysis of the results indicated that a lower age (P=0.04) and psychiatric comorbidity (P=0.06) were predictors of dropout from the CGCBT program. Our CGCBT program is a promising first-line treatment for bulimic outpatients. Lower age and the presence of comorbidity had effects on dropout rates.

The dearth of psychological treatment studies for anorexia nervosa

OBJECTIVE

Anorexia nervosa (AN) was first described more than 130 years ago, yet few psychological treatments have been formally studied. Our objective was to review the available studies to understand whether these may highlight directions for future investigation.

METHOD

Medline and PsycINFO were consulted to identify relevant treatment studies. Twenty psychotherapy treatment studies were identified for review. These were divided in terms of patient age (adolescent vs. adult) and type of study (uncontrolled vs. controlled).

RESULTS

Without exception, adolescent studies (uncontrolled or controlled) involved the parents or family in the treatment. The adult studies were much more varied in terms of treatments that were compared. Most studies were statistically underpowered and only one utilized manualized treatments. More recent investigations have attempted to remedy these methodologic shortcomings.

DISCUSSION

The review highlights the effectiveness of one particular treatment modality for adolescents, but emphasizes the compelling need for further and larger systematic investigation into treatments for both adolescent and adult AN.

Baseline personality characteristics of responders to 6-month psychotherapy in eating disorders: preliminary data

OBJECTIVE

The Karolinska Psychodynamic Profile (KAPP) was used for the assessment of the six-month outcome of Brief Adlerian Psychodynamic Psychotherapy (B-APP).

METHOD

Fifty-seven eating disordered women (28 with anorexia nervosa, 29 with bulimia nervosa), were included in the study. The sample was evaluated at baseline (time 0) and after six months (T6) with a clinical assessment and with Temperament and Character Inventory (TCI), Eating Disorder Inventory (EDI-2), State-Trait Anger Expression Inventory (STAXI), and KAPP.

RESULTS

Based on symptomatologic improvement, two sub-groups were obtained: responders (66.6%) and non-responders (33.3%). Significantly higher baseline scores emerged in the responders group on Ineffectiveness and Impulsivity (EDI-2) and on Harm Avoidance (TCI). Several KAPP items and areas improved in both groups at T6.

CONCLUSION

Multimodal treatment centered on B-APP lead to both a global clinical improvement and an improvement in several psychological and psychopathological features as assessed by EDI-2, STAXI and KAPP. The results suggest interesting clinical implications, though outcome predictors are quite weak.

Empirically Supported Psychotherapies: Comment on Westen, Novotny, and Thompson-Brenner (2004)

D. Westen, C. M. Novotny, and H. Thompson-Brenner (2004; see record 2004-15935-005) suggested that efforts to identify empirically supported treatments are misguided because they are based on assumptions that are not appropriate for some types of treatment and patients. The authors of this comment argue that Westen and colleagues are simply incorrect when they assert that empirically supported treatments require that psychopathology must be highly malleable, that treatments must be brief, or that the samples studied are unrepresentative of the kinds of patients typically encountered in clinical practice--comorbidity is common in many clinical trials. Randomized controlled trials remain the most powerful way to test notions of causal agency.

A case series evaluation of guided self-help for bulimia nervosa using a cognitive manual

OBJECTIVE

The current study examined the usefulness of a new, cognitive-based self-help manual for bulimia nervosa.

METHOD

Twenty people were provided with assessment and six sessions of guided self-help using the manual. Participants were assessed for eating-related behaviors and attitudes and psychopathology at pretreatment, posttreatment, and at the 3-month follow-up. Assessment instruments included the Eating Disorder Examination, Symptom Checklist-90-Revised, Rosenberg Self-Esteem Scale, Screening Test for Co-morbid Personality Disorders, and The University of Rhode Island Change Assessment. Data from 15 people were available at posttreatment and from 13 people at follow-up.

RESULTS

Using intention-to-treat analyses, binge eating, vomiting, four of the five eating attitudes and self-esteem significantly improved between pretreatment and posttreatment. At follow-up, there was continued improvement on all measures, with the exception of binge eating.

DISCUSSION

Guided self-help using cognitive techniques is a promising first-line treatment for bulimia nervosa, with further evaluation required in a randomized, controlled trial with long-term follow-up.

Cognitive-behavioral therapy for bulimia nervosa: an empirical analysis of clinical significance

OBJECTIVE

The purpose of this review was to assess the clinical significance of cognitive-behavioral therapy for bulimia nervosa using the reliable change index and normative comparison analyses.

METHOD

Fifteen treatment outcome studies using either individual or group cognitive-behavioral therapy for bulimia nervosa were selected for inclusion.

RESULTS

Results suggest that cognitive-behavioral therapy for bulimia nervosa produces clinically significant change for many treatment outcome measures when using the reliable change index. However, posttreatment symptomatology is rarely within a normative range when examined with normative comparison analyses.

DISCUSSION

This review provides a first step in examining the clinical significance of treatment for bulimia nervosa. Future studies should further this work by comparing the clinical significance of different types of treatment for bulimia nervosa using additional assessment measures.

Cognitive behaviour therapy for eating disorders: a "transdiagnostic" theory and treatment

This paper is concerned with the psychopathological processes that account for the persistence of severe eating disorders. Two separate but interrelated lines of argument are developed. One is that the leading evidence-based theory of the maintenance of eating disorders, the cognitive behavioural theory of bulimia nervosa, should be extended in its focus to embrace four additional maintaining mechanisms. Specifically, we propose that in certain patients one or more of four additional maintaining processes interact with the core eating disorder maintaining mechanisms and that when this occurs it is an obstacle to change. The additional maintaining processes concern the influence of clinical perfectionism, core low self-esteem, mood intolerance and interpersonal difficulties. The second line of argument is that in the case of eating disorders shared, but distinctive, clinical features tend to be maintained by similar psychopathological processes. Accordingly, we suggest that common mechanisms are involved in the persistence of bulimia nervosa, anorexia nervosa and the atypical eating disorders. Together, these two lines of argument lead us to propose a new transdiagnostic theory of the maintenance of the full range of eating disorders, a theory which embraces a broader range of maintaining mechanisms than the current theory concerning bulimia nervosa. In the final sections of the paper we describe a transdiagnostic treatment derived from the new theory, and we consider in principle the broader relevance of transdiagnostic theories of maintenance.

The effects of movement, relaxation, and education on the stress levels of women with subclinical levels of bulimia

The purpose of this study was to assess the impact of a multidisciplinary intervention program on the attitudes and symptoms associated with bulimia nervosa (BN). The Bulimia Test (BULIT) and subscales from the Eating Disorder Inventory-2 (EDI-2) associated with BN were administered to 373 females to determine eligibility for participation in the study. In order to qualify for the study, participants had to be female, not be anorexic, and meet one of four criteria indicating that they had some of the symptoms of BN. Following the screening, 12 females were randomly assigned to a control group (C, n=6) or an intervention group (I, n=6). The I group then participated in an 8-week multidisciplinary intervention program consisting of small group discussions, movement improvisation, and relaxation techniques. Dependent variables consisted of scores from standardized instruments for anxiety, self-esteem, and BN. A multivariate analysis of variance (MANOVA) on the difference score from post- to pretest was calculated for state and trait anxiety. That analysis indicated that compared to the C group, which showed no reduction in anxiety, the I group had a significant reduction in anxiety following the intervention program. No significant differences were found between groups for self-esteem or symptoms of BN. Conclusions were that anxiety levels were lowered in the I group; however, attitudes or behaviors associated with BN were not affected by the intervention.

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.