Cognitive-behavioral and response-prevention treatments for bulimia nervosa

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.

Efficacy of psychotherapies and pharmacotherapies for Bulimia nervosa

BACKGROUND

Bulimia nervosa (BN), a mental disorder that causes significant impairment, can be treated with psychological, pharmacological, nutrition-based and self-help interventions. We conducted a pre-registered meta-analysis of randomized-controlled trials (RCTs) to assess the efficacy of these interventions in up to 19 different interventions.

METHODS

Database search terms were combined for BN and RCTs from database inception to March 2017. Abstinence from binge eating episodes, compensatory behaviors, the absence of a BN diagnosis and reduction of symptom severity were considered as primary outcome variables, reduction of self-reported eating pathology and depression served as secondary outcome variables. Retrieved RCTs were meta-analyzed using fixed and random effects models.

RESULTS

RCT (79 trials; 5775 participants) effects post-treatment revealed moderate to large intervention effects for psychotherapy [mostly cognitive-behavioral therapy (CBT)] for primary outcome variables. Slightly reduced effects were obtained for self-help and moderate effects for pharmacotherapy. Similarly, psychotherapy yielded large to very large effects in regard to secondary outcome variables, while moderate to large effects were observed for self-help, Pharmacotherapy and combined therapies. Meta-analyses for the pre to post changes within group confirmed these findings. Additionally, follow-up analyses revealed the sustainability of psychotherapies in terms of large effects in primary outcome criteria, while these effects were moderate for self-help, pharmacotherapy, and combined therapies.

CONCLUSIONS

Most psychological and pharmacological interventions revealed to be effective in BN treatment. Taking effect size, sustainability of the intervention, as well as the consistency of findings and available evidence into consideration, CBT can be recommended as the best intervention for the initial treatment of BN.

Patient Experiences Using a Self-Monitoring App in Eating Disorder Treatment: Qualitative Study

Background

The Recovery Record smartphone app is a self-monitoring tool for individuals recovering from an eating disorder. Unlike traditional pen-and-paper meal diaries, which are often used in eating disorder treatment, the app holds novel features, such as meal reminders, affirmations, and patient-clinician in-app linkage, the latter allowing for clinicians to continuously monitor patients' app data.

Objective

To explore patients' experiences with using Recovery Record as part of outpatient eating disorder treatment.

Methods

A total of 41 patients from a Danish eating disorder treatment facility were included in the study. All 41 patients participated in participant observations of individual or group treatment sessions, and 26 were interviewed about their experiences with using the app in treatment. The data material was generated and analyzed concurrently, applying the inductive methodology of Interpretive Description.

Results

The patients' experiences with Recovery Record depended on its app features, the impact of these features on patients, and their specific app usage. This patient-app interaction affected and was affected by changeable contexts making patients' experiences dynamic. The patient-app interaction affected patients' placement of specific Recovery Record app features along a continuum from supportive to obstructive of individual everyday life activities including the eating disorder treatment. As an example, some patients found it supportive being notified by their clinician when their logs had been monitored as it gave them a sense of relatedness. Contrarily, other patients felt under surveillance, which was obstructive, as it made them feel uneasy or even dismissing the app.

Conclusions

Some patients experienced the app and its features as mostly supportive of their everyday life and the eating disorder treatment, while others experienced it primarily as obstructive. When applying apps in eating disorder treatment, we therefore recommend that patients and clinicians collaborate to determine how the app in question best fits the capacities, preferences, and treatment needs of the individual patient. Thus, we encourage patients and clinicians to discuss how specific features of the applied app affect the individual patient to increase the use of supportive features, while limiting the use of obstructive ones.

Dropout from cognitive-behavioral therapy for eating disorders: A meta-analysis of randomized, controlled trials

OBJECTIVE

Cognitive-behavioral therapy (CBT) is efficacious for a range of eating disorder presentations, yet premature dropout is one factor that might limit CBTs effectiveness. Improved understanding of dropout from CBT for eating disorders is important. This meta-analysis aimed to study dropout from CBT for eating disorders in randomized controlled trials (RCTs), by (a) identifying the types of dropout definitions applied, (b) providing estimates of dropout, (c) comparing dropout rates from CBT to non-CBT interventions for eating disorders, and (d) testing moderators of dropout.

METHOD

RCTs of CBT for eating disorders that reported rates of dropout were searched. Ninety-nine RCTs (131 CBT conditions) were included.

RESULTS

Dropout definitions varied widely across studies. The overall dropout estimate was 24% (95% CI = 22-27%). Diagnostic type, type of dropout definition, baseline symptom severity, study quality, and sample age did not moderate this estimate. Dropout was highest among studies that delivered internet-based CBT and was lowest in studies that delivered transdiagnostic enhanced CBT. There was some evidence that longer treatment protocols were associated with lower dropout. No significant differences in dropout rates were observed between CBT and non-CBT interventions for all eating disorder subtypes.

CONCLUSION

Present study dropout estimates are hampered by the use of disparate dropout definitions applied. This meta-analysis highlights the urgency for RCTs to utilize a standardized dropout definition and to report as much information on patient dropout as possible, so that strategies designed to minimize dropout can be developed, and factors predictive of CBT dropout can be more easily identified.

The cost-effectiveness of cognitive behavioral therapy for bulimia nervosa in the Australian context

OBJECTIVE

This study was to model the cost-effectiveness of specialist-delivered cognitive behavioral therapy for bulimia nervosa (CBT-BN) compared to no intervention within the Australian context.

METHOD

An illness-death model was developed to estimate the cost per disability-adjusted life-year (DALY) averted of CBT-BN over 2 years from the healthcare perspective. Target population was adults aged 18-65 years with BN. Results are reported as incremental cost-effectiveness ratios (ICER) in 2013 Australian dollars per DALY averted. Uncertainty and sensitivity analyses were conducted to test the robustness of results.

RESULTS

Primary analysis indicated that CBT-BN was associated with greater DALY averted (0.10 DALY per person) and higher costs ($1,435 per person) than no intervention, resulting the mean ICER of $14,451 per DALY averted (95% uncertainty interval [UI]: $8,762 to $35,650). Uncertainty analysis indicated CBT-BN is 99% likely to be cost-effective at a threshold of $50,000 per DALY averted. Including the patients' time and travel costs resulted in the mean ICER of $18,858 per DALY averted (95% UI: $11,235 to $46,026). Sensitivity analysis indicated the intervention was not cost-effective if over 80% people discontinued treatment. Other analyses including a reduced time horizon, increased remission rates, and 4-month effect size of CBT-BN increases the ICERs but these ICERs remained well below under a threshold of $50,000 per DALY averted.

CONCLUSION

This study has demonstrated that CBT-BN for adults with BN is a cost-effective treatment intervention. Further research is required to investigate the practicability of CBT-ED and the cost-effectiveness of other formats of CBT-BN delivery.

Psychotherapy for bulimia nervosa on symptoms of depression: A meta-analysis of randomized controlled trials

OBJECTIVE

Depressive symptoms are an important risk factor and consequence of binge eating and purging behavior in bulimia nervosa (BN). Although psychotherapy is effective in reducing symptoms of BN in the short- and long-term, it is unclear whether psychotherapy for BN is also effective in reducing depressive symptoms. This meta-analysis examined the efficacy of psychotherapy for BN on depressive symptoms in the short- and long-term.

METHOD

Randomized controlled trials (RCTs) on BN that assessed depressive symptoms as an outcome were identified. Twenty-six RCTs were included.

RESULTS

Psychotherapy was more efficacious at reducing symptoms of depression at post-treatment (g = 0.47) than wait-lists. This effect was strongest when studies delivered therapist-led, rather than guided self-help, treatment. No significant differences were observed between psychotherapy and antidepressants. There was no significant post-treatment difference between CBT and other active psychological comparisons at reducing symptoms of depression. However, when only therapist-led CBT was analyzed, therapist-led CBT was significantly more efficacious (g = 0.25) than active comparisons at reducing depressive symptoms. The magnitude of the improvement in depressive symptoms was predicted by the magnitude of the improvement in BN symptoms.

DISCUSSION

These findings suggest that psychotherapy is effective for reducing depressive symptoms in BN in the short-term. Whether these effects are sustained in the long-term is yet to be determined, as too few studies conducted follow-up assessments. Moreover, findings demonstrate that, in addition to being the front-running treatment for BN symptoms, CBT might also be the most effective psychotherapy for improving the symptoms of depression that commonly co-occur in BN.

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.

Cognitive-behavioral treatment of adult rumination behavior in the setting of disordered eating: A single case experimental design

The integration of feeding and eating disorders into a single DSM-5 chapter introduces an opportunity to explore common mechanisms and transdiagnostic treatment approaches. In contrast to a robust literature on the evidence-based treatment of eating disorders, very few data guide the treatment of rumination disorder (RD). In a single case experimental design, we describe the treatment of a 27-year-old woman who presented to an eating-disorder clinic with a 15-year history of untreated rumination and intermittent binge eating. According to time series analysis, she reduced rumination frequency at trend-level during the initial baseline phase (self-monitoring only), and exhibited significant reductions during the active intervention phase (self-monitoring + cognitive-behavioral techniques including diaphragmatic breathing and behavioral experimentation). She maintained these gains at 23 weeks post-intervention. Although more rigorous systematic investigation is needed, these data suggest that selected cognitive and behavioral techniques already familiar to eating-disorder clinicians may have heuristic value for RD treatment. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:967-972).

Toward Science-Practice Integration in Brief Counseling and Therapy

Increased interest in the practice of brief counseling and therapy has been accompanied by an expansion of research activity. Nevertheless, signs abound of a schism between science- and practice-based understandings. This article outlines major approaches to brief counseling practice, including psychodynamic, cognitive-behavioral, and strategic; summarizes recent research on brief therapeutic outcomes and processes; and identifies overlapping themes in the science and practice literatures. An integrative model of brief intervention, capable of being flexibly modified for a variety of client populations, is offered as a framework for future practice, research, and training activities.

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.

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?

Psychopharmacologic treatment of obesity and eating disorders in children and adolescents

This review discusses the evidence base for medications that are currently used for obesity and eating disorders, including their Food and Drug Administration approval status by disorder and age group, contraindications, and major adverse effects. Investigational agents currently being considered, issues related to psychiatric and medical comorbidity, limitations of pharmacologic strategies, and recommendations for treatment are also addressed.

From disordered eating to addiction: the "food drug" in bulimia nervosa

The high prevalence of substance abuse in individuals with bulimia nervosa (BN) and the pervasive symptom substitution in many types of drug addiction suggest that a number of substances--including food--can impair an individual's self-control, even in the presence of negative consequences. Nonetheless, the neurobiological similarities between BN and drug addiction are not clearly established. This review explores how the specific eating patterns seen in BN (binge eating and purging, with intermittent dietary restriction) are particularly addictive and differentiate BN from other eating disorders and obesity. A number of peripheral and central biological aberrations seen in BN may result in altered reward sensitivity in these individuals, particularly through effects on the dopaminergic system. Neurobiological findings support the notion that BN is an addictive disorder, which has treatment implications for therapy and pharmacological manipulations.

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.

Social cognition in eating disorders: encoding and representational processes in binging and purging patients

OBJECTIVE

The present study investigates social cognition impairments in 29 women with bingeing/purging spectrum eating disorders (ED) compared to 27 healthy controls.

METHOD

Measures were used to examine encoding and representational processes in relation to affect perception and affect attribution, as well as the ability to recognize mental causality in social relationships.

RESULTS

ED patients failed to correctly encode causality in interpersonal relations, exhibited deficits in their ability to ascribe behaviour to mental states, and showed a greater tendency to attribute negative affects in interpersonal relationships. Stepwise regression analyses suggested that ED symptoms could account for deficits in the recognition of causality in interpersonal relations.

CONCLUSIONS

In addition to addressing ED symptoms, social cognition deficits should be addressed in the psychological treatment of EDs.

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.

Management of anorexia and bulimia nervosa: An evidence-based review

Anorexia nervosa and bulimia nervosa are primarily psychiatric disorders characterized by severe disturbances of eating behavior. Eating disorders are most prevalent in the Western culture where food is in abundance and female attractiveness is equated with thinness. Eating disorders are rare in countries like India. Despite a plethora of management options available to the mental health professionals, no major breakthrough has been achieved in recent years. Nutritional rehabilitation along with some form of re educative psychotherapy remains the mainstay of management of anorexia nervosa. In bulimia nervosa, both fluoxetine and cognitive behavior therapy have been found to be effective. Although the above-mentioned management options have been in use for decades, the active ingredient is still to be ascertained.

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.

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.

Cognitive Theory in Anorexia Nervosa and Bulimia Nervosa: A Review

This paper reviews cognitive theories of eating disorders as they are usually applied in treatment. More recent theoretical contributions and theory that is not widely applied are also reviewed. A set of hypotheses is derived from these theories and evidence for the validity of each hypothesis is discussed: this includes evidence from treatment studies, questionnaire studies and from experimental psychology. Following review of existing evidence, the paper summarizes the current status of cognitive theory in eating disorders. It then considers ways in which theory and research could be developed in order to improve and extend our understanding of cognitive content and processes in eating disorders. Limitations of existing models are highlighted and gaps in our knowledge, including knowledge of variables that typically have a central role in cognitive theory, are identified. Further strategies to test the validity of hypotheses derived from cognitive theory are suggested, together with strategies that might extend existing theory. It is concluded that much further research is needed, both to test the validity of existing theoretical contributions and to extend theory so that it will be more useful in clinical practice.

Evidence-based psychosocial treatments for eating problems and eating disorders

Eating disorders represent a significant source of psychological impairment among adolescents. However, most controlled treatment studies have focused on adult populations. This review provides a synthesis of existing data concerning the efficacy of various psychosocial interventions for eating disorders in adolescent samples. Modes of therapy examined in adolescent samples include family therapy, cognitive therapy, behavioral therapy, and cognitive behavioral therapy mostly in patients with anorexia nervosa. At this time, the evidence base is strongest for the Maudsley model of family therapy for anorexia nervosa. Evidence of efficacy for other treatments and other conditions is limited by several methodological factors including the small number of studies, failure to use appropriate control conditions or randomization procedures, and small sample sizes (i.e., fewer than 10 participants per treatment arm). Potential moderators and mediators of treatment effect are reviewed. Finally, results from adolescent studies are contrasted with those from adult studies of eating disorders treatment. Many studies of adult populations comprise late adolescent/young adult participants, suggesting that findings regarding the efficacy of cognitive behavioral therapy for bulimia nervosa in adults likely extend to older adolescent populations.

A critical evaluation of the efficacy of self-help interventions for the treatment of bulimia nervosa and binge-eating disorder

OBJECTIVE

Cognitive behavioral therapy (CBT) is efficacious for the treatment of bulimia nervosa (BN) and binge-eating disorder (BED). As a number of factors limit the availability of CBT, self-help manuals have been developed to make the treatment more widely available.

METHOD

Published studies evaluating the efficacy of self-help programs in the treatment of BN and BED were reviewed.

RESULTS

Controlled studies of self-help programs for BN and BED have often employed a waiting list control group, and indicate that self-help provides more benefit than remaining on a waiting list. However, fewer studies have utilized a more active control group, and these studies have not been as positive.

CONCLUSION

In general, open and wait-list trials indicate that self-help is helpful in treating BN and BED, but there is little evidence for the specific efficacy of self-help in comparison to other treatments. Additional studies of self-help are needed to determine the specific utility of self-help interventions for BN and BED.

Bulimia nervosa treatment: a systematic review of randomized controlled trials

OBJECTIVE

The RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center systematically reviewed evidence on efficacy of treatment for bulimia nervosa (BN), harms associated with treatments, factors associated with treatment efficacy, and differential outcome by sociodemographic characteristics.

METHOD

We searched six major databases published from 1980 to September 2005 in all languages against a priori inclusion/exclusion criteria; we focused on eating, psychiatric or psychological, and biomarker outcomes.

RESULTS

Forty-seven studies of medication only, behavioral interventions only, and medication plus behavioral interventions for adults or adolescents met our inclusion criteria. Fluoxetine (60 mg/day) decreases the core symptoms of binge eating and purging and associated psychological features in the short term. Cognitive behavioral therapy reduces core behavioral and psychological features in the short and long term.

CONCLUSION

Evidence for medication or behavioral treatment for BN is strong, for self-help is weak; for harms related to medication is strong but either weak or nonexistent for other interventions; and evidence for differential outcome by sociodemographic factors is nonexistent. Attention to sample size, standardization of outcome measures, attrition, and reporting of abstinence from target behaviors are required. Longer follow-up intervals, innovative treatments, and attention to sociodemographic factors would enhance the literature.

Conceptualizing changes in behavior in intervention research: the range of possible changes model

An international movement has focused on identifying evidence-based interventions that were developed to change psychological constructs and that are supported by controlled studies. However, inconsistent findings within individual intervention studies and among multiple studies raise critical problems in interpreting the evidence, and deciding when and whether an intervention is evidence-based. A theoretical and methodological framework (Range of Possible Changes [RPC] Model) is proposed to guide the study of change in intervention research. The authors recommend that future quantitative reviews of the research literature use the RPC Model to conceptualize, examine, and classify the available evidence for interventions. Future research should adopt the RPC Model to both develop theory-driven hypotheses and conduct examinations of the instances in which interventions may or may not change psychological constructs.

Self-help treatments for disorders of recurrent binge eating: a systematic review

OBJECTIVE

To evaluate self-help interventions for patients with binge eating disorder (BED) and bulimia nervosa (BN), tested in randomized controlled trials, and compared with waiting list or any other type of control group.

METHODS

A systematic review including quality appraisal was conducted of randomized controlled trials, using self-help techniques in patients with BED and/or BN. Six databases were searched during the period between January 1994 and June 2004.

RESULTS

A total of 2686 articles were identified, 1701 abstracts were evaluated in detail and, nine studies fulfilled the inclusion criteria for this review. All studies indicated that patients treated with active interventions had a reduced number of binge eating episodes at end of treatment.

CONCLUSION

The results support self-help interventions but shall be interpreted with caution. Because of the small number of studies using self-help techniques for BED and BN, further larger randomized, multi-center controlled studies that apply standardized inclusion criteria, evaluation instruments and self-help materials, are needed.

Expositionsverfahren in der Behandlung der Bulimia nervosa

Zusammenfassung. Theoretischer Hintergrund: In der Behandlung von Bulimia nervosa erwiesen sich kognitiv-verhaltenstherapeutische Verfahren als besonders wirksam. Expositions- bzw. Konfrontationsverfahren gewannen dabei in den letzten Jahren zunehmend an Bedeutung. Fragestellung: Untersuchung der Wirksamkeit eines spezifischen kognitiv-verhaltenstherapeutischen Intensivansatzes in der stationären Behandlung von Bulimia nervosa. Methode: Schwerpunkte dieses Ansatzes waren cue-exposure, Ernährungs- und Figur- bzw. Videokonfrontationen. Einer stationären Intensivphase (3-4 Wochen) schloss sich eine ambulante 6-wöchige Selbstmanagementphase an (40 Therapieeinheiten pro Person für beide Phasen zusammen). Eine Vorstudie an 13 Patientinnen gab Hinweise auf die Wirksamkeit des Verfahrens (Vergleich: Vor Aufnahme und ein Jahr nach Abschuss der Behandlung). Die Hauptstudie (73 Patientinnen) wurde ohne wesentliche Änderung der Behandlungsmethode in einem 3-Messzeitpunkte-Design (Aufnahme, 6 Wochen nach Behandlungsende und 1-Jahres-Follow-Up) durchgeführt. Messvariablen waren Anzahl der Essanfälle, Body Mass Index sowie Essstörungssymptomatik (Eating Disorder Inventory - EDI, Fragebogen zum Essverhalten - FEV) und allgemeine Psychopathologie (Symptom-Check-List-90-R; Beck Depression Inventory). Ergebnisse: Bedeutsame Verbesserungen ergaben sich sowohl 6 Wochen nach Ende der Therapie als auch zum 1-Jahres-Follow-Up. Patientinnen der Hauptstudie reduzierten ihre wöchentlichen Essanfälle von 12.27 auf 2.45 (post) und 4.27 (1-Jahres-Follow-Up). Auch in sämtlichen Merkmalen der Essstörungssymptomatik (EDI, FEV) sowie in den SCL-90-Skalen und dem BDI fanden sich signifikante Verbesserungen. 48% hatten nach einem Jahr weniger als zwei Essanfälle pro Woche, was mit den Patientenratings einer “(sehr) guten Besserung“ (49.3%) korrespondierte. Schlussfolgerung: Der untersuchte Therapieansatz an stationären Patientinnen erwies sich einem zuvor erfolgreich getesteten Ansatz an weniger stark beeinträchtigten ambulanten Patientinnen als gut vergleichbar. Auf Grund der sehr guten Erfolge bei einem hohen Anteil der Patientinnen wird diskutiert, ob Ansätze wie der hier untersuchte eine Alternative zu langdauernden ambulanten Therapien und stationären Breitbandprogrammen darstellen.

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.

Can the Randomized Controlled Trial Literature Generalize to Nonrandomized Patients?

To determine the extent to which published randomized controlled trials (RCTs) of psychotherapy can be generalized to a sample of outpatients, the authors matched information obtained from charts of patients who had been screened out of RCTs to inclusion and exclusion criteria from published RCT studies. Most of the patients in the sample who had primary diagnoses represented in the RCT literature were judged eligible for at least 1 RCT. However, many patients in the sample with substance use disorders or social anxiety disorder were not eligible for at least 2 RCTs. Common reasons that patients did not match with at least 2 published RCTs for psychotherapy included (a) patients were in partial remission, (b) patients failed to meet minimum severity or duration criteria, (c) patients were being treated with antidepressant medication, and (d) the disorder being studied was not primary (mostly for social anxiety patients). The implications of these findings for future research and clinical practice are discussed.

Patterns of weight change after treatment for bulimia nervosa

OBJECTIVE

The current study examined changes in weight and body mass index (BMI) at 5-year follow-up among women treated for bulimia nervosa.

METHOD

The study comprised 80 women who had participated in a randomized clinical trial evaluating cognitive-behavior therapy for bulimia nervosa. The women had attended assessments at posttreatment and at 5-year follow-up while not pregnant.

RESULTS

Changes in mean weight and BMI between posttreatment and 5-year follow-up were small in absolute terms and were not statistically significant. However, by the 5-year follow-up, approximately one half of the participants had either lost (31%) or gained (18%) 5 or more kilograms or were underweight (31%) or overweight (24%) as defined by BMI. Univariate analyses suggest that it is the patients who gain weight over the follow-up that are distinctive. Patients who gained weight over the follow-up were more likely to have commenced menstruation at a younger age, to have a lifetime history of being heavier, and to have been heavier and more dissatisfied with their body at pretreatment, posttreatment, and at 5-year follow-up.

CONCLUSION

Five years after treatment for bulimia nervosa, approximately one half of the participants had changed substantially in weight. For those who had changed, weight loss was more common than weight gain.

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.

Are samples in randomized controlled trials of psychotherapy representative of community outpatients? A new methodology and initial findings

To determine the extent to which published randomized controlled trials (RCTs) of psychotherapy can be generalized to a sample of community outpatients, the authors used a method of matching information obtained from outpatient charts to inclusion and exclusion criteria from published RCT studies. They found that 80% of the patients in their sample who had diagnoses represented in the RCT literature were judged eligible for at least 1 published RCT; however, 58% of the patients had primary diagnoses such as adjustment disorder or dysthymia, which were not represented in the existing psychotherapy outcome literature. The most common reasons that patients in their sample did not match with published RCTs for psychotherapy are listed, and the implications of these findings for research and practice are discussed.

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.

Management of child and adolescent eating disorders: the current evidence base and future directions

Although eating disorders in children and adolescents remain a serious cause of morbidity and mortality, the evidence base for effective interventions is surprisingly weak. The adult literature is growing steadily, but this is mainly with regard to psychological therapies for bulimia nervosa and to some extent in the field of pharmacotherapy. This review summarises the recent research literature covering management in three areas, namely physical management, psychological therapies, and service issues, and identifies prognostic variables. Findings from the adult literature are presented where there is good reason to believe that these might be applied to younger patients. Evidence-based good practice recommendations from published clinical guidelines are also discussed. Suggestions for future research are made, focusing on 1) the need for trials of psychological therapies in anorexia nervosa, 2) applications of evidence-based treatments for adult bulimia nervosa to the treatment of adolescents, and 3) clarification of the benefits and costs of different service models.

Cue exposure in the treatment of resistant bulimia nervosa

OBJECTIVE

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

METHODS

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

RESULTS

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

DISCUSSION

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

Role of exposure with response prevention in cognitive-behavioral therapy for bulimia nervosa: three-year follow-up results

BACKGROUND

Previous studies have not reported the longer-term outcome of exposure-based treatments for bulimia nervosa. The current study evaluated the 3-year outcome of a randomized clinical trial that compared the additive efficacy of exposure-based versus nonexposure-based behavioral treatments (BT) with a core of cognitive-behavior therapy (CBT).

METHODS

One hundred thirteen women participated in the original treatment trial and attended a 3-year follow-up assessment. Eating disorder diagnoses and primary, secondary, and tertiary outcome measures were assessed. The impact of treatment completion on symptomatology and the stability of treatment effects over time were evaluated.

RESULTS

At the 3-year follow-up, 85% of the sample had no current diagnosis of bulimia nervosa and 69% had no current eating disorder diagnoses of any sort. Failure to complete CBT was associated with inferior outcome. No clear advantages were evident for participants who completed BT in addition to CBT. For subjects who did complete both CBT and BT, outcome was mostly stable from posttreatment to follow-up. No differential effects were found for exposure versus nonexposure-based treatments at 3-year follow-up.

DISCUSSION

The results of the current study compare favorably with other treatment outcome studies for bulimia nervosa and suggest that treatment gains are maintained after 3 years.