A comparison of two psychological treatments for bulimia nervosa

Two standardized psychological treatments for bulimia nervosa were studied. A cognitive behavioural approach was compared with a form of short-term focal psychotherapy. Twenty-four patients who met strict diagnostic criteria for bulimia nervosa were randomly allocated to the two treatments. All the interviews were tape-recorded so that checks on their content could be made. Assessments took place at the beginning and end of treatment, and at 4-, 8- and 12-month follow-up. None of the patients dropped out of treatment or follow-up, but 1 patient from each treatment group had to be withdrawn on clinical grounds. Patients in both groups made substantial improvements which were well maintained over the 12-month treatment-free follow-up period. The cognitive behavioural approach was superior to short-term focal psychotherapy in terms of its effect on the patients' overall clinical state, their general psychopathology and social adjustment, and their assessment of their outcome.     

Cognitive behaviour therapy to treating bulimia nervosa: A case study

The general cognitive behaviour therapy postulates that bulimic symptoms are maintained by a characteristic set of overvalued thoughts about the personal implications of body shape and weight. Research shows that there is both a close relationship and specific interaction between thoughts and behaviours that help to maintain the overvalued thoughts. This theoretical proposition concerning the role of behaviours in the maintenance of psychological problems is commonly accepted and empirically validated. To ensure a sustainable therapeutic change in the treatment of bulimia nervosa, therapists may need to initially target these overvalued thoughts about the personal implications of body shape and weight; and then to work on the behaviours that help to maintain the bulimic symptoms. The purpose of the present paper is to discuss the conceptual and practical issues underpinning a therapeutic focus that reflects an integrated clinical approach in the treatment of bulimia nervosa. This integrated approach includes the assessment and disputation of the overvalued thoughts that are causal to bulimia nervosa, and various strategies that facilitate the change in those behaviours that help to maintain the bulimic conditions. Using a case example, this paper also discusses the cognitive behaviour conceptualization in the maintenance of bulimia nervosa.     

An experimental study of the relationship between thoughts and eating behaviour in bulimia nervosa

This study tested the hypothesis that cognitive disturbance has a causal role in the maintenance of disturbed eating in bulimia nervosa. Thoughts about eating, weight and shape were activated in one group of patients with bulimia nervosa (the experimental group) but not in another (the control group). There was an increase in negative self-statements in the experimental group following the experimental manipulation. Food consumption was then measured in a taste test. As predicted, the experimental group ate less in the short term than the control group. Contrary to expectations, they did not subsequently report more objective bulimic episodes as a consequence of this decreased food intake. They did, however, report significantly fewer subjective bulimic episodes.     

Selective processing of eating-, shape-, and weight-related words in persons with bulimia nervosa.

The Stroop color-naming task was used to investigate selective information processing in people with bulimia nervosa. Three cards were used: a target card consisting of words related to eating, weight, and shape; a control word card; and the standard conflicting-color card. Thirty-six patients with bulimia nervosa were compared with a group of age-matched female controls. It was found that the amount of disruption caused to color naming by the target card was significantly greater in the bulimia nervosa group than in the female control group, whereas that caused by the color card was similar in the two groups. The Stroop color-naming task may be a useful objective measure of one aspect of the cognitive disturbance of patients with bulimia nervosa.     

Body-image disturbances and bulimia nervosa: An empirical analysis of recent revisions of the DSM-III

In the recent revision of the DSM-III, the diagnosis of bulimia nervosa includes the criterion of persistent overconcern with body shape and weight, which may be conceptualized as a form of body-image disturbance. The new diagnostic criteria for bulimia nervosa include only those who exhibit a binge-purge eating patern, excluding binge-eaters who, in the older DSM-III, receive a diagnosis of bulimia. This study was conducted to investigate body-image disturbances in bulimia nervosa and simple bulimia (i.e., binge-eating without purging). The experimental design included two control groups, obese and normal subjects, in order to determine whether the binge-eater had body-image disturbances different form those of normal and overweight samples. The study evaluated 596 subjects (417 normals, 109 bulimia nervosa subjects, 50 binge-eaters, and 30 obese subjects) in terms of perception of current body size and selection of ideal body size. Results indicated that the bulimia nervosa group selected a current body size larger than that selected by normals and an ideal body size smaller than that chosen by normals. However, bingeeaters did not differ from the obese control group on either current or ideal body size. These results are discussed in terms of the recent debate regarding the diagnosis of bulimia nervosa and sociocultural influences upon body-image disturbances.     

Family therapy for bulimia nervosa in adolescents: an exploratory study

Family therapy has only rarely been reported as a treatment for bulimia nervosa and not specifically’for adolescents. This account describes family therapy with eight adolescents who suffered from bulimia nervosa. Change was measured by assessing symptomatic behaviours and global measures of family and social function prior to treatment and again one year later. At reassessment there was a significant reduction in bulimic behaviours although many had some continuing symptoms. Some aspects of the therapy are described and implications for further study of treatment for adolescent bulimia are discussed.     

Enhanced Cognitive Behavior Therapy: A Single Treatment for All Eating Disorders

Eating disorders are serious mental illnesses affecting a significant proportion of women and a smaller number of men. Approximately half of those with an eating disorder (ED) will not meet the criteria for anorexia or bulimia nervosa, and will be diagnosed with an eating disorder not otherwise specified (EDNOS). Until recently, there were no recommended treatments for EDNOS. This article provides an overview of enhanced cognitive behavior therapy, a validated treatment for all forms of EDs.     

Engagement and outcome in the treatment of bulimia nervosa: first phase of a sequential design comparing motivation enhancement therapy and cognitive behavioural therapy

Despite the major advances in the development of treatments for bulimia nervosa, drop-outs and a lack of engagement in treatment, continue to be problems. Recent studies suggest that the transtheoretical model of change may be applicable to bulimia nervosa. The aim of this study was to examine the roles of readiness to change and therapeutic alliance in determining engagement and outcome in the first phase of treatment. One hundred and twenty five consecutive female patients meeting DSM-IV criteria for bulimia nervosa took part in a randomised controlled treatment trial. The first phase of the sequential treatment compared four sessions of either cognitive behavioural therapy (CBT) or motivational enhancement therapy (MET) in engaging patients in treatment and reducing symptoms. Patients in the action stage showed greater improvement in symptoms of binge eating than did patients in the contemplation stage. Higher pretreatment scores on action were also related to the development of a better therapeutic alliance (as perceived by patients) after four weeks. However, pretreatment stage of change did not predict who dropped out of treatment. There were no differences between MET and CBT in terms of reducing bulimic symptoms or in terms of developing a therapeutic alliance or increasing readiness to change. The results suggest that the transtheoretical model of change may have some validity in the treatment of bulimia nervosa although current measures of readiness to change may require modification. Overall, readiness to change is more strongly related to improvement and the development of a therapeutic alliance than the specific type of treatment.     

Dietary restraint of bulimic subjects following cognitive-behavioral or pharmacological treatment

The pre and posttreatment self-monitored caloric intake of bulimic subjects treated with either cognitive-behavioral therapy or imipramine was compared. Results indicated that both groups equally and successfully reduced purged calories but that only cognitive-behaviorally treated subjects increased non-purged caloric intake. These results show that cognitive-behavioral treatment lessens dietary restraint whereas imipramine treatment of bulimia nervosa does not. These findings are discussed and it is suggested that they may account for the superior therapeutic maintenance following cognitive-behavioral treatment when compared with pharmacological treatment of bulimia nervosa.     

The cost effectiveness of cognitive behavioral therapy for bulimia nervosa delivered via telemedicine versus face-to-face

Objective

A number of effective treatments for bulimia nervosa have been developed, but they are infrequently used, in part due to problems with dissemination. The goal of this study was to examine the cost effectiveness of telemedicine delivery of cognitive behavioral therapy for bulimia nervosa.

Method

A randomized controlled trial of face-to-face versus telemedicine cognitive behavioral therapy for bulimia nervosa. One hundred twenty eight women with DSM-IV bulimia nervosa or eating disorder, not otherwise specified subsyndromal variants of bulimia nervosa were randomized to 20 sessions of treatment over 16 weeks. A cost effectiveness analysis from a societal perspective was conducted.

Results

The total cost per recovered (abstinent) subject was $9324.68 for face-to-face CBT, and $7300.40 for telemedicine CBT. The cost differential was accounted for largely by therapist travel costs. Sensitivity analyses examining therapy session costs, gasoline costs and telemedicine connection costs yielded fundamentally similar results.

Discussion

In this study, CBT delivered face-to-face and via telemedicine were similarly effective, and telemedicine delivery cost substantially less. These findings underscore the potential applicability of telemedicine approaches to eating disorder treatment and psychiatric treatment in general.     

Emotion Dysregulation and Affective Intensity Mediate the Relationship Between Childhood Abuse and Suicide‐Related Behaviors Among Women with Bulimia Nervosa

Self‐harm and suicide attempts occur at elevated rates among individuals with bulimia nervosa, particularly among those who have experienced childhood abuse. This study investigated the potential mediating roles of emotion dysregulation and affective intensity in the relationship between these variables in 125 women with bulimia nervosa. Analyses revealed that emotion dysregulation mediated the relationship between sexual and emotional abuse with both self‐harm and suicide attempts. Negative affective intensity mediated the relationship between abuse and suicide attempts. The findings may advance the understanding of mechanisms underlying suicide‐related behaviors in women with bulimia nervosa who experienced abuse and suggest potential clinical targets.     

Cognitive-behavioral treatment with and without response prevention for Bulimia

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

Tailoring Cognitive Behavioral Therapy for Individuals Diagnosed with Bulimia Nervosa

There is a wealth of data indicating the effectiveness of cognitive behavioral therapy in the treatment of bulimia nervosa. However, the best evidence indicates a treatment success rate of 50%. The purpose of this paper is to briefly describe cognitive behavioral treatment of bulimia nervosa and to offer suggestions on how this therapy approach may be tailored to best serve the needs of individual clients. Such tailoring should ultimately lead to even greater treatment success.     

Obsessive-compulsive symptoms in eating disorders

Obsessive-compulsive symptoms were measured in a consecutive series of new referrals with anorexia nervosa (n = 29) and bulimia nervosa (n = 77). In contrast with previous reports, there was no significant difference on MOCI scores between eating disorder groups and normal controls. A consecutive series of 38 patients with bulimia nervosa then entered a structured treatment programme. Poor outcome cases had a higher score on the MOCI-doubting sub-scale. However, there was no significant difference in obsessive-compulsive scores between those who were binge-free and those who were bingeing daily at the end of treatment and there was no significant in outcome between high and low-scorers on the MOCI. This study fails to support the view that the eating disorders are a subtype of OCD. Previous conflicting results are attributed to selection bias and the effects of low body weight.     

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.     

Thoughts about eating, weight and shape in anorexia nervosa and bulimia nervosa.

Concurrent verbalisation and a self-report questionnaire were used to investigate self-statements in patients with anorexia nervosa, patients with bulimia nervosa, two groups of dieters and non-dieting controls. Thoughts were collected while subjects performed three behavioural tasks, looking at themselves in a full-length mirror, weighing themselves and eating a chocolate covered mint. Both groups of patients had more negative thoughts related to eating, weight and shape than those in the three control groups. In addition, patients with anorexia nervosa showed a greater concern with eating while patients with bulimia nervosa showed a greater concern with weight and appearance. Differences were found between the patients and non-dieting controls using both methods but the self-report questionnaire was less sensitive than concurrent verbalisation to differences between the patients and dieters. Implications of the findings for cognitive-behavioural treatments of the two disorders are discussed.     

Evaluation of manual-based cognitive-behavioral therapy for bulimia nervosa in a service setting

In the present study manual-based cognitive-behavioral therapy for bulimia nervosa was evaluated on an unselected sample of an out-patient service facility. A total of 73 female patients who asked for treatment received the primary diagnosis of bulimia nervosa. Of these, 67 took up treatment. Treatment was completed by 66 patients. Outcome variables were the number of binge episodes along with questionnaire scores for restraint eating, emotional eating, body dissatisfaction and depressiveness. At the end of treatment and 1 year after the end of treatment significant improvements were found in all outcome variables. Effect sizes for outcome variables were within the range of those of controlled research. Therefore, the present study delivered empirical evidence that manual-based cognitive-behavioral therapy is an effective treatment for bulimia nervosa not only within the restricted area of research.     

Predictors of short-term treatment outcome in bulimia nervosa inpatients.

Recent studies, mostly performed on bulimic outpatients, did not find consistent predictors of treatment outcome in bulimia nervosa. This is the first study to investigate anamnestic and clinical factors predictive of the short-term outcome of hospital treatment in 31 female bulimia nervosa patients with a mean age of 22.9 yr. Treatment outcome was assessed by several self-rating instruments measuring different features of the specific and unspecific psychopathology of bulimia nervosa. The most relevant predictors of the outcome of the 8-week hospital treatment were duration of previous inpatient treatments for bulimia, the intensity of anorexic tendency and the pretreatment level of depression. The majority of predictors tested did not show a strong relationship to treatment outcome. The findings are discussed in relation to results of other studies as well as to possible implications for treatment and research.     

Evaluation of a healthy-weight treatment program for bulimia nervosa: a preliminary randomized trial

Objective: Conduct a randomized treatment trial to test whether healthy dieting maintains bulimic symptoms or effectively reduces this eating disturbance.

Methods: Female participants (n=85) with full- and sub-threshold bulimia nervosa were randomly assigned to a 6-session healthy dieting intervention or waitlist condition and assessed through 3-month follow-up.

Results: Relative to control participants, intervention participants showed modest weight loss during treatment and demonstrated significant improvements in bulimic symptoms that persisted through follow-up.

Discussion: These preliminary results suggest that this intervention shows potential for the treatment of bulimia nervosa and may be worthy of future refinement and evaluation. Results also provide experimental evidence that dieting behaviors do not maintain bulimia nervosa, suggesting the need to reconsider maintenance models for this eating disorder.