Cognitive Behavioral Therapy for Bulimia Nervosa – A Success Story
When I was researching to write this article, I found a piece entitled Fifteen years of bulimia, then came the miracle of CBT. The article told the story of a woman who had “seen the light” through cognitive behavioral therapy (CBT), and linked to the clinic where she had been treated in Spain. While CBT may be the most effective treatment for bulimia nervosa (BN), this type of — most certainly paid — advertising only does the treatment a poor service.
Whoever thinks CBT is going to solve all their problems, with little effort, ignores the most fundamental thing about CBT, namely, it is really hard work, and patients need to apply themselves, in order to see the “fast CBT results” everyone has been raving about over the last couple of decades.
All that said, the evidence supporting the positive outcome of CBT treatments for patients diagnosed with BN is overwhelming. After carefully reviewing the literature, I am presenting here a review of a variety of studies (based on both qualitative and quantitative elements) analyzing the short and long term results of CBT for bulimia and binge eating disorder (BED).
Study Details and Results
1. Group cognitive-behavior therapy for bulimia nervosa: Statistical versus clinical significance of changes in symptoms across treatment
Method: 29 patients diagnosed with bulimia were assessed using the Stirling Eating Disorder Scales, the Beck Depression Inventory, and the Beck Anxiety Inventory at four different points: assessment, pre CBT, end of CBT, and at 6 months follow-up. Symptom change was measured.
The treatment: 12 weekly group sessions lasting 90 minutes each. Treatment lead by a cognitive behavioral therapist assisted by a dietitian. Individual meetings with both professionals were held before the beginning of the group sessions, and one follow-up group session plus one final individual meeting with the therapist. Total number of sessions was 16.
Treatment included the following elements:
- sessions on body image and interpersonal/relational issues
- cognitive-behavioral challenges
- asking patients to keep ‘‘food and feelings’’ diaries to track disordered behaviors and psychological factors, which were shared during part of the sessions
- dealing with the diet/binge cycle
- stress management
- managing myths & reality
- challenging negative thinking workshop
- maintenance and relapse prevention
Results/conclusions: An overall improvement maintained after 6 months was observed in dimensional measures of bulimic and restrictive attitudes and behaviors, and there were clinically significant changes in bulimic behaviors. Depression was targeted much more effectively than anxiety, and there was a significant reduction of self-directed hostility. Deterioration in terms of all bulimic symptoms was minimal.
After 6 months, 20.7% of participants believed that they had recovered and 44.8% believed that they were much improved. These self-evaluation figures closely matched the analysis of clinically significant change.
2. Cognitive-Behavioral Therapy for Bulimia Nervosa: An Empirical Analysis of Clinical Significance
Method: Fifteen different treatment outcome studies of CBT for BN were assessed, using the reliable change index and normative comparison analyses, in order to reach a conclusion about the clinical significance of the treatment.
Results/conclusions: Clinically significant change was observed for several treatment outcome measures.
3. Investigating the use of CD-Rom CBT for bulimia nervosa and binge eating disorder in an NHS adult outpatient eating disorders service
Method: Considering the high dropout rates for outpatient treatments for BN and BED, a program offering CD-Rom CBT, self-help treatment for these disorders was devised.
40 patients assessed by the National Health Service as having either of the disorders followed the 8 sessions, CD-Rom program, later attending an evaluation meeting.
Results/conclusions: Both the BN and the BED groups showed significant improvements in well-being and functioning and significant reductions in problems and risk. A significant reduction was also observed on the “Bulimic Subscale” of the EDI. The use of self-help multimedia programs for binge-related eating disorders was evaluated as “very promising.”
4. A multicenter comparison of cognitive-behavioral therapy and interpersonal psychotherapy for bulimia nervosa.
Method: Two hundred twenty patients recruited at two treatment sites (Stanford and Columbia Universities) meeting DSM-III-R criteria for BN were allocated 19 sessions of either CBT or interpersonal psychotherapy (IPT) over a 20-week period, followed by a 12-month post-treatment evaluation.
Results/conclusions: CBT was found to be significantly superior to IPT at the end of treatment point in terms of:
- Percentage of patients recovered 29% for CBT vs 6% for IPT
- Remittance 48% vs 28%
- Meeting community norms for eating attitudes and behaviors 41% vs 27%
- No significant differences were observed in terms of recovery at the follow-up evaluation point.
The researchers recommended CBT for treating BN, due to the rapid improvements observed in patients, when compared to IPT. Data showed that IPT doesn´t ensure more long-lasting results than CBT.
5. Cognitive-behavioral therapy for bulimia nervosa: Time course and mechanisms of change.
Method: Analysis of results of a randomized control trial comparing CBT with IPT in BN treatments, focussing on mediators of change and time course of action.
Results/conclusions: Reduction in dietary restraint as early as week 4 was observed to mediate posttreatment improvement in binge eating and vomiting. At midtreatment, measures of self-efficacy regarding maladaptive eating behaviors, negative affect as well as body image and weight were also seen to mediate posttreatment improvement. The effect of CBT was observed to be much significantly more rapid than IPT. There was no evidence that the therapeutic alliance mediated treatment outcomes, which, interestingly enough, clearly indicates that the benefits were directly connected with the type of treatment.
6. Bulimia nervosa treatment: A systematic review of randomized controlled trials
Method: Forty-seven studies (published between 1980 and 2005) of bulimia treatment outcomes were selected according to a set of inclusion criteria, which put the focus on medication only treatments, behavioral interventions only, and combined medication with behavioral interventions for both adults or adolescents.
Results/conclusions: Analysis of the included studies revealed that, in the short term, fluoxetine (60 mg/day) reduces core symptoms and associated psychological, while Cognitive behavioral therapy has a similar effect in both the short and the long term. The authors concluded that there was sufficient evidence for the treatment of BN with medication and/or behavioral therapies.
7. Relapse Predictors of Patients With Bulimia Nervosa Who Achieved Abstinence Through Cognitive Behavioral Therapy
Metod: The sample comprised 48 patients with BN who had been assessed as having achieved abstinence (no binges or purges) after CBT and were available for assessment 17 weeks later. This was a multisite study conducted at: Weill Medical College of Cornell University, the University of Minnesota and Rutgers University.
Results/conclusions: 17 weeks after treatment, 44% of the patients in the sample had relapsed. Identified relapse predictors included a higher level of preoccupation and ritualization of eating and a lesser motivation for change, as well as a shorter period of abstinence maintained during treatment.
Although the sample was small to draw universal conclusions, the authors suggest that the identified predictors can help single out patients who might need additional treatment for relapse prevention.
8. Meta-analysis of CBT for bulimia nervosa: investigating the effects using DSM-III-R and DSM-IV criteria.
Year: 1986-1998. Published in 1999.
Method: The meta analysis included 7 empirical, randomised, and controlled studies published between 1986 and 1998, investigating the use of CBT for BN, diagnosed according to DSM-III-R or DSM-IV, where the frequency of binge eating and purging had been assessed. The studies selected included comparisons between CBT and other treatments.
The authors used statistical analysis to calculate the effect size of CBT for binging and purging behaviors based on both between-group (treatment vs control) and within-group (pre- vs post-treatment) comparisons
Results/conclusions: In view of the superior results (in terms of measured effect sizes) of CBT for treating BN, the authors recommended it as the treatment of choice for this disorder.
Given the consistency of rapid, positive short and long term results observed when treating bulimia nervosa with CBT, throughout the world, I believe that the best path to recommend for anyone suffering from this disorder is to find an accredited cognitive behavioral therapist with experience in the field, a group CBT program, or even a self-help CBT program.
As for therapists, whatever their therapeutic convictions may be, in view of the overwhelming evidence, they should all be aware and try to keep informed about the methods and tools developed by CBT for the treatment of Bulimia Nervosa, as they may be of use within a variety of therapeutic contexts
Openshaw C, Waller G, & Sperlinger D (2004). Group cognitive-behavior therapy for bulimia nervosa: statistical versus clinical significance of changes in symptoms across treatment. The International journal of eating disorders, 36 (4), 363-75 PMID: 15558655
Lundgren JD, Danoff-Burg S, & Anderson DA (2004). Cognitive-behavioral therapy for bulimia nervosa: an empirical analysis of clinical significance. The International journal of eating disorders, 35 (3), 262-74 PMID: 15048942
Graham L, & Walton M (2011). Investigating the use of CD-Rom CBT for bulimia nervosa and binge eating disorder in an NHS adult outpatient eating disorders service. Behavioural and cognitive psychotherapy, 39 (4), 443-56 PMID: 21208485
Agras WS, Walsh T, Fairburn CG, Wilson GT, & Kraemer HC (2000). A multicenter comparison of cognitive-behavioral therapy and interpersonal psychotherapy for bulimia nervosa. Archives of general psychiatry, 57 (5), 459-66 PMID: 10807486
Wilson GT, Fairburn CC, Agras WS, Walsh BT, & Kraemer H (2002). Cognitive-behavioral therapy for bulimia nervosa: time course and mechanisms of change. Journal of consulting and clinical psychology, 70 (2), 267-74 PMID: 11952185
Shapiro JR, Berkman ND, Brownley KA, Sedway JA, Lohr KN, & Bulik CM (2007). Bulimia nervosa treatment: a systematic review of randomized controlled trials. The International journal of eating disorders, 40 (4), 321-36 PMID: 17370288
Halmi KA, Agras WS, Mitchell J, Wilson GT, Crow S, Bryson SW, & Kraemer H (2002). Relapse predictors of patients with bulimia nervosa who achieved abstinence through cognitive behavioral therapy. Archives of general psychiatry, 59 (12), 1105-9 PMID: 12470126
Ghaderi A, Andersson G. Meta-analysis of CBT for bulimia nervosa: investigating the effects using DSM-III-R and DSM-IV criteria. Scandinavian Journal of Behaviour Therapy 1999; 28(2): 79-87.
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