Bulimia nervosa and a stepped care approach to management

Guided self-help as the first step for bulimic symptoms: implementation of a stepped-care model within specialized psychiatry

OBJECTIVE

This study describes the implementation and effectiveness of the first step, guided self-help (GSH), in a clinical setting, of a stepped-care model of cognitive behavior therapy for patients with bulimic symptoms.

METHOD

Eighty-nine patients participated.

RESULTS

In the intent to-treat analyses, the effect sizes were small to moderate (0.25-0.66). However, the effect sizes were substantially larger (0.44-1.66) for the patients who completed all the GSH sessions (45%). The majority of noncompleters stayed within psychiatric services. Supplementary treatments were mostly directed towards comorbid conditions, especially depression. Those discontinuing treatment in advance where characterized by more lifetime diagnoses and higher ratings on the restraint subscale of the EDE-Q.

DISCUSSION

GSH within specialized psychiatry might be effective for about 30% of the patients. There is no indication of patients losing their confidence in psychiatric services by being offered GSH as the first treatment.

Self-help for bulimic disorders: a randomised controlled trial comparing minimal guidance with face-to-face or telephone guidance

BACKGROUND

There is great potential demand for treatment of bulimia nervosa and binge eating disorder. Skilled therapists are in short supply. Self-help and guided self-help based upon books have shown some promise as an economical alternative to full therapy in some cases.

AIMS

To investigate the efficacy and effectiveness of self-help with and without guidance in a specialist secondary service.

METHOD

A randomised controlled trial comparing three forms of self-help over 4 months with a waiting-list comparison group and measurement of service consumption over the subsequent 8 months.

RESULTS

Self-help delivered with four sessions of face-to-face guidance led to improved outcome over 4 months. There is also some evidence to support the use of telephone guidance. A minority of participants achieved lasting remission of their disorder in relation to self-help, but there was no significant difference in final outcome between the groups after they had progressed through the stepped care programme. Patients initially offered guided self-help had a lower long-term drop-out rate.

CONCLUSIONS

Guided self-help is a worthwhile initial response to bulimia nervosa and binge eating disorder. It is a treatment that could be delivered in primary care and in other non-specialist settings.

Guided and unguided self-help for binge eating

This study compared the relative short- and longer-term efficacy of therapist-guided and unguided use of a cognitive behavioral self-help manual for binge eating [Fairburn, C. G. (1995). Overcome binge eating. New York: The Guilford Press.] Forty women (82.5% with binge eating disorder) were randomized to one of the two treatment levels. Results indicate that both conditions represent viable means of treating binge eating. Overall, patients improved their eating behavior, eliminated any inappropriate compensatory behaviors, reduced their shape concern, weight concern, and other symptoms of eating-related psychopathology, and improved their general psychological functioning. The guided self-help condition was notably superior in reducing the occurrence of binge eating and its associated symptomatology, as well as lowering interpersonal sensitivity. A high degree of general psychopathology was a negative prognostic indicator. The implications for a stepped-care approach to treating binge eating are discussed.

Guided and unguided self-help for binge eating

This study compared the relative short- and longer-term efficacy of therapist-guided and unguided use of a cognitive behavioral self-help manual for binge eating [Fairburn, C. G. (1995). Overcome binge eating. New York: The Guilford Press.] Forty women (82.5% with binge eating disorder) were randomized to one of the two treatment levels. Results indicate that both conditions represent viable means of treating binge eating. Overall, patients improved their eating behavior, eliminated any inappropriate compensatory behaviors, reduced their shape concern, weight concern, and other symptoms of eating-related psychopathology, and improved their general psychological functioning. The guided self-help condition was notably superior in reducing the occurrence of binge eating and its associated symptomatology, as well as lowering interpersonal sensitivity. A high degree of general psychopathology was a negative prognostic indicator. The implications for a stepped-care approach to treating binge eating are discussed.

Medications in the treatment of eating disorders

Effective planning for medication treatment in patients with bulimia nervosa and anorexia nervosa is based on a comprehensive clinical assessment, including a careful review of comorbid psychiatric disorders and response to treatments for previous episodes of the disorder. Although most patients with bulimia nervosa are offered a trial of psychotherapy, significant results of controlled trials have contributed to an increased role for medications in the treatment of patients with this disorder. Pharmacologic treatment of anorexia nervosa has similarities to that of treatment-resistant depression, with the clinician turning to open trials and clinical reports for clues to rational management. As described in this article, considerations of potential side effects and medical complications are likely to play an important role in guiding the choice of medication used for treatment of patients with eating disorders.

First step in managing bulimia nervosa: controlled trial of therapeutic manual

OBJECTIVE

To test the short term efficacy of a self directed treatment manual for bulimia nervosa.

DESIGN

Randomised controlled trial of the manual against cognitive behavioural therapy and a waiting list.

SETTING

Tertiary referral centre.

SUBJECTS

81 consecutive referrals presenting with bulimia nervosa or atypical bulimia nervosa.

MAIN OUTCOME MEASURES

Frequency of binge eating, vomiting, and other behaviours to control weight as well as abstinence from these behaviours.

RESULTS

Cognitive behavioural treatment produced a significant reduction in the frequency of binge eating, vomiting, and other behaviours to control weight. The manual significantly reduced frequency of binge eating and weight control behaviours other than vomiting, and there was no change in the group on the waiting list. Full remission was achieved in five (24%) of the group assigned to cognitive behavioural treatment, nine (22%) of the group who used the manual, and two (11%) of the group on the waiting list.

CONCLUSIONS

A self directed treatment manual may be a useful first intervention in the treatment of bulimia nervosa.