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The Treatment of Bulimia Nervosa Christopher G. Fairburn & Phillipa J. Hay To cite this article: Christopher G. Fairburn & Phillipa J. Hay (1992) The Treatment of Bulimia Nervosa, Annals of Medicine, 24:4, 297-302, DOI: 10.3109/07853899209149958 To link to this article: http://dx.doi.org/10.3109/07853899209149958
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SDecial Section: Eatinq Disorders
The Treatment of Bulimia Nervosa
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Christopher G. Fairburn' and Phillipa J. Hay2
Bulimia nervosa is a significant source of morbidity amongst young women. There has been a considerable body of work on Its treatment since it was first described In 1979. Three treatments have shown particular promise: antidepressant drug treatment, cognitive behavlour therapy and exposure with response prevention. The research findings indicate that the approach of choice is cognitive behaviour therapy, with most patlents benefiting significantly and the changes being well maintained. However, Cognitive behaviour therapy is neither necessary nor sufflcient for all patlents with bulimia nervosa: some benefit from simpler interventions whilst others fail to respond. At present, too little is known about the factors that predict response to particular forms of treatment to allow the matchlng of patients with treatments. Key words: bulimia nervosa; treatment; cognitive behaviour therapy; antidepressant drugs. (Annals of Medicine 2 4 297-302,1992)
Introduction Much has been learned about the treatment of bulimia nervosa since the disorder was first described in 1979 (1). Over 25 controlled treatment trials have been conducted and more are in progress (2). Three approaches have shown particular promise: treatment with antidepressant drugs (3, 4); a specific form of cognitive behaviour therapy (5); and exposure with response prevention (6). This paper reviews the research on these three forms of treatment.
across the studies only about a quarter of patients are reported to have stopped overeating and purging by the end of treatment. Even this modest figure should be interpreted with caution since, in most studies, abstinence rates are based on a short time frame of just 1-2 weeks. There is evidence that whilst antidepressant drugs produce a reduction in the frequency of overeating, they have little effect on the extreme dieting that is characteristic of these patients (20, 21). It might be predicted that treatments which simply reduce the frequency of overeating, without lessening the degree of dietary restraint, would lead to weight loss and possibly anorexia
Treatment with Antidepressant Drugs The main controlled studies of antidepressant drugs are listed in Table 1. It is clear from these studies that antidepressant drugs are superior to placebo at reducing many of the features of bulimia nervosa There is generally a marked reduction in the frequency of overeating and self-induced vomiting (in the region of 60%) which is accompanied by an enhanced sense of control over eating, and substantial improvement in general psychiatric disturbance. However, most patients remain symptomatic. 'Abstinence' rates are often quoted and 'Wellcome Trust Senior Lecturer and "uff ield Research Fellow. Address and reprint requests: Christopher G. Fairburn, M.D., University Department of Psychiatry, Warneford Hospital, Oxford OX3 7JX, U.K.
Table 1. The main controlled studies on the use of antidepressant drugs to treat bulimia nervosa.
lmiprarnine Mianserin Amitriptyline Desipramine
lsocarboxazid Phenelzine Bupropion
Pope 81 al. 1983 (7) Mitchell et al. 1990 (8)" Agras et al. 1987 (9) Sabine et al. 1983 (10) Mitchell & Groat 1984 ( 7 1) Hughes et al. 1986 (12) Barlow et al. 1988 (13) McCann & Agras 1990 (14) Walsh et al. 1991 (15) Agras et al. 1992 (16)* Kennedy et al. 1988 (17) Walsh et al. 1988 (18) Horne et al. 1988 (19)
'Studies involving a comparison with cognitive behaviour therapy.
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nervosa (assuming that the drug effect is maintained). Alternatively, it might be predicted that the maintenance of the drug effect would be poor given the continuing presence of extreme dietary restraint, especially since there is evidence that the latter promotes overeating (22, 23). The few studies that have investigated maintenance of change following treatment with antidepressant drugs have found the topic difficult to study, since few patients respond sufficiently well to enter a maintenance phase; for example, Pyle and colleagues (24) could only study nine patients because only 17%had responded (9/54) in the acute phase of their study. In the largest and most rigorous study to date, Walsh and colleagues (15) found that fewer than half their subjects (29/71, 41%) had improved sufficiently to enter a 4-month maintenance phase, and of those who could be entered, only half maintained their improvement. With regard to the time course of the drug effect, it seems that the onset of treatment response resembles that in depression with the effect being gradual rather than immediate. Systematic dose-response studies have yet to be conducted, except for fluoxetine where it has been found that a 60 mg dose is more effective than the dose of 20 mg conventionally used to treat depression (see review by Walsh (25)).Interestingly, no consistent predictors of treatment response have been identified. It is of note that patients without significant depressive symptoms appear to respond as well as those who are, depressed (12, 14, 17, 18). .Two recent studies have compared antidepressant drugs with psychological treatments, both alone and in combination. Mitchetl and colleagues (8) found that group cognitive behaviour therapy was more effective than imipramine and that no advantage came from combining the two treatments, other than on anxiety and depressive symptoms. Agras and colleagues (t6) obtained similar findings when comparing desipramine, cognitive behaviour therapy (of a less intensive and more conventional type), and their combination, although there was some evidence favouring the combination. There was no follow-up.
Cognitive Behaviour Therapy The studies of psychological treatments for bulimia nervosa have been mostly of a higher quality than the drug studies, particularly with respect to their use of more sophisticated and comprehensive assessment measures and their evaluation of maintenance of change. The focus has been on cognitive behavioural treatments for this disorder and the main studies are listed in Table 2. Cognitive behavioural treatments for bulimia nervosa have three properties in common. First, they are based upon the cognitive view of the maintenance of bulimia nervosa (40, 41). According to this view, these patients' extreme concerns about shape and weight are a central feature of the disorder. On a priori grounds it is argued that mast of the other features are secondary to these concerns and that these concerns are therefore of pri-
Hay main controlled studies of cognltive behavloural treatments for bullrnla newosa (including studies of exposure with response prevention). Table 2. The
Yates & Sornbrailo 1984 (26) Ordman & Kirschenbaum1985 (27) Kirkley et al. 1985 (28) Fairburne t al. 1986 (29) Wjlson et al. 1986 (30)' Lee & Flush 1986 (31) Wolchik et al. 1986 (32) Laessls et al. 1987 (33) Freeman et a!. 1988 (34) Leitenberg et al. 1988 (35)' Agras et al. 1989 (36)' Mitchell et al. 1990 (8)t Fairburn et al. 1991 (37) Wilson & Eldredge 1991 (38)' Wolf & Crowther 1992 (39) Agras et al. 1992 (I6)t 'Studies of exposure with response prevention tStudies involving a comparison with antidepressant drugs.
mary importance in its maintenance.This view has clear implications for treatment in particular, it suggests that, if there is to be complete and lasting recovery, there must be change not just in these patients' behaviour but also in their attitudes towards their shape and weight. This is the goal of cognitive behavioural treatments for bulimia nervosa This view on the maintenance of the disorder is presented explicitly to patients and provides the rationale for most of the treatment procedures. The second property shared by cognitive behavioural treatments is the aim to change both these patients' behaviour and their attitudes to shape and weight. Their third common characteristic is the use of a combination of cognitive and behavioural procedures. Cognitive behavioural treatments tor bulimia nervosa are usually 3-6 months in duration and involve 10-20 treatment sessions. The following techniques are commonly used: cognitive restructuring using techniques simifar to those developed by Beck and colleagues for the treatment of depression (42); self-monitoring of relevant thoughts and behaviour; education; the use of self-control measures to establish a pattern of regular eating; and the introduction of avoided foods into the patient's diet. Some programmes include additional elements such as relapse prevention techniques, training in problem-solving, anxiety management training, and formal exposure with response prevention (see below). Detailed descriptions of the treatment are available (43, 44). Across the studies of cognitive behaviour therapy, it has been found that the average reduction in the frequency of overeating and purging is at least as great as that obtained with antidepressant drugs. Accompanying this reduction is a decrease in the level of general psychopathology and an improvement in social functioning. Dietary restraint, a key psychopathological feature, lessens (37) and there is evidence that there is an increase in the amount of food eaten outside bulimic episodes (20). Attitudes to shape and weight, another key feature, also improve (37,45). Most of the studies of
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Treatment of Bulimia Nervosa cognitive behaviour therapy have included at least a 6-month period of follow-up and in two studies follow-up has been for one year and has been closed (i.e. free from additional treatment) (29, 45). The findings in general suggest that, in contrast with treatment with antidepressant drugs, maintenance of change is good with there being little tendency to relapse. The cognitive behavioural approach has been shown to be superior to being allocated to a waiting-list control group (31, 35, 36, 46) and to treatment with antidepressant drugs (8, 16). In addition, it has been compared with a variety of non-behavioural psychological treatments. The Stanford group found group cognitive behaviour therapy to be superior to a form of supportive group therapy (with self-monitoring), although this difference was no longer present at 4-month follow-up (28). In a second study, individual cognitive behaviour therapy was found to be more effective than supportive psychotherapy (again with self-monitoring), both at the end of treatment and at 6-month follow-up (36). The Oxford group has compared cognitive behaviour therapy with two established alternative psychological treatments. In the first study cognitive behaviour therapy was compared with a form of brief focal psychotherapy (47) to which education and self-monitoring had been added. Whilst the results tended to favour cognitive behaviour therapy, the main finding was that both treatment groups improved substantially and that the changes were maintained (29). More recently, cognitive behaviour therapy was compared with an adaptation of interpersonal psychotherapy (48), the focal psychotherapy for depression (49). In this adaptation no attention was paid to eating habits or attitudes to shape and weight. As in the previous study, it was found that both treatment groups improved significantly. At the end of treatment, cognitive behaviour therapy was found to be more effective than interpersonal psychotherapy at reducing the patients’ level of dietary restraint and their degree of shape and weight concern, but this difference disappeared during follow-up (45). In view of the tempofal differences in the pattern of response to the two treatments, it is likely that they achieved equivalent outcomes through the operation of different mediating mechanisms. There have been three attempts to examine the value of the cognitive component of cognitive behaviour therapy by comparing the full treatment with a purely behavioural version. The results of the first study suggested that the immediate effects of behaviour therapy are as great as those of cognitive behaviour therapy (34). However, this study did not include satisfactory measures of the core cognitive variables, the disturbed attitudes to shape and weight, nor was there follow-up. Similar criticisms apply to the second study (39) which obtained generally poor results possibly because treatment was short (8 weeks) and administered in a group format. In the third study, both behavioural and cognitive variables were measured and patients were entered into a 12-month closed period of follow-up (37.45). The findings, both at the end of treatment and at follow-up, clearly supported the full cognitive behavioural treatment.
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Exposure with Response Prevention The exposure with response prevention treatment of Rosen & Leitenberg (6) is based on an anxiety model of bulimia nervosa. According to this model, binge-eating elicits anxiety which is then reduced by the act of vomiting. The analogy is to the behavioural view of obsessive-compulsive disorders in which compulsive rituals reduce anxiety. Once patients with bulimia nervosa learn to vomit, binge-eating is no longer inhibited by anxiety about weight gain. This negative reinforcement is said to be the ‘driving force’ behind bulimia nervosa, and hence vomiting becomes the major target of treatment. The technique of exposure with response prevention is designed to expose the patient systematically to anxiety-eliciting cues (perceived or actual overeating) and then prevent vomiting. Although the technique has been implemented in somewhat different ways in different studies (50),the hallmark is that patients are requested to bring to each treatment session the foods on which they typically ‘binge’, and then eat them until they reach the point at which they would typically induce vomiting. Under the guidance of the therapist, patients are encouraged not to vomit but to learn to cope with the resulting anxiety and learn that it will decline over the remainder of the session. It is argued that this technique uncouples the learned association between eatinginduced anxiety and vomiting. There have been four controlled studies of this form of treatment. In each case the technique of exposure with response prevention has been combined with the procedures that characterize the cognitive behavioural approach. In the first study, Wilson and colleagues (30) compared exposure with response prevention with verbal cognitive restructuring alone. The exposure treatment was superior to cognitive restructuring. However, the sample size was small and there was no comparison group at follow-up. More importantly, the cognitive restructuring treatment lacked many of the behavioural features of the full cognitive behavioural approach. As a result, the superiority of the exposure treatment does not indicate that this specific technique enhances the effectiveness of cognitive behaviour therapy. The three other controlled studies compared more representative cognitive behavioural treatments, with and without exposure with response prevention (35, 36, 38). All three found no significant advantage came from adding the technique.
Other Treatment Approaches PharmacoiogicalTreatments Various pharmacological treatments, apart from antidepressant drugs, have been evaluated including appetite suppressants (51, 52), opiate antagonists (53-55), antiepileptic drugs (56-60) and lithium (61, 62). None seems promising and their use is not recommended.
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Psychological Treatments Other than cognitive behaviour therapy, the only established psychological treatment that appears promising (as discussed above) is interpersonal psychotherapy (37, 45,48).
Educational Approaches
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There is some evidence that brief educational approaches benefit some patients with bulimia nervosa (63, 64). It has yet to be established which patients benefit most and whether the changes are lasting. A form of 'nutritional counselling' (which closely resembles cognitive behaviour therapy) also appears helpful (65).
Other Approaches to Treatment The bulk of research on the treatment of bulimia nervosa has focused on out-patient treatment conducted on a one-to-one basis. Group treatment may be a cost-effective alternative although direct comparison of a group and individual version of the same form of treatment has yet to be conducted. Self-help approaches are also an attractive cost-effective alternative but have yet to be satisfactorily evaluated. With regard to patients who do not respond to out-patient treatment, there is evidence that day-patient treatment may be as effective as inpatient treatment (66-68). This approach has the advantage over in-patient treatment not only of being less expensive but also of allowing patients to remain in contact with situations which they find problematic, an important therapeutic advantage.
Implications of the Research for Clinical Practice The research on treatment indicates that the overall approach of choice is the cognitive behavioural one. Therefore, if clinicians are to use one single form of treatment, this is the one to adopt. Detailed manuals have been written describing the treatment (43, 44) and with practice it can be successfully used even without specialist training. It is our view that all those who see patients with eating disorders should include cognitive behaviour therapy in their therapeutic armamentarium. The cognitive behavioural approach is neither necessary nor sufficient for all patients with bulimia nervosa For some patients it is probably unnecessarily intensive. It is for these patients that simple brief interventions are appropriate. For other patients cognitive behaviour therapy is insufficient. There is therefore a need to develop and evaluate treatments for those who do not respond. Combining cognitive behaviour therapy with antidepressant drugs does not seem to be worthwhile, although it is worth trying with patients who have severe unremitting depressive symptoms in case a co-existing depressive disorder is interfering with treatment. Transferring non-responders over to interpersonal psychotherapy is sometimes helpful when treating patients with
Hay diabetes who have an eating disorder (69), and it is possible that this strategy might also benefit those without diabetes. A period of day-patient treatment is another option, but this would need to be followed by treatment on an out-patient basis. The place of antidepressant drugs in the treatment of bulimia nervosa is far from clear. Whilst they are simpler to administer than cognitive behaviour therapy, they may not be as cost-effective. Drug treatment is not welcomed by these patients and is associated with a greater attrition rate than cognitive behaviour therapy (8, 16). Side-effects may also be a problem. These disadvantages, together with suspect maintenance of change, suggest that they should not be used as a firstline treatment. The paper is based in part on a book chapter written by the first author in conjunction with Terry Wilson and Stewart Agras (2). The chapter was prepared whilst the authors were Fellows at the Center for Advanced Study in the Behavioral Sciences at Stanford. This Fellowship was supported by grants from the FoundationFund for Research in Psychiatry and the MacArthur Foundation. C.G.F. is supported by a Senior Lectureship award from the Wellcome Trust P.J.H. is supported by a Nuffield Medical Fellowship and a Girdlers' Junior Research Fellowship.
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ISSN: 0785-3890 (Print) 1365-2060 (Online) Journal homepage: http://www.tandfonline.com/loi/iann20
The Treatment of Bulimia Nervosa Christopher G. Fairburn & Phillipa J. Hay To cite this article: Christopher G. Fairburn & Phillipa J. Hay (1992) The Treatment of Bulimia Nervosa, Annals of Medicine, 24:4, 297-302, DOI: 10.3109/07853899209149958 To link to this article: http://dx.doi.org/10.3109/07853899209149958
Published online: 08 Jul 2009.
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Date: 17 April 2016, At: 23:10
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The Treatment of Bulimia Nervosa
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Christopher G. Fairburn' and Phillipa J. Hay2
Bulimia nervosa is a significant source of morbidity amongst young women. There has been a considerable body of work on Its treatment since it was first described In 1979. Three treatments have shown particular promise: antidepressant drug treatment, cognitive behavlour therapy and exposure with response prevention. The research findings indicate that the approach of choice is cognitive behaviour therapy, with most patlents benefiting significantly and the changes being well maintained. However, Cognitive behaviour therapy is neither necessary nor sufflcient for all patlents with bulimia nervosa: some benefit from simpler interventions whilst others fail to respond. At present, too little is known about the factors that predict response to particular forms of treatment to allow the matchlng of patients with treatments. Key words: bulimia nervosa; treatment; cognitive behaviour therapy; antidepressant drugs. (Annals of Medicine 2 4 297-302,1992)
Introduction Much has been learned about the treatment of bulimia nervosa since the disorder was first described in 1979 (1). Over 25 controlled treatment trials have been conducted and more are in progress (2). Three approaches have shown particular promise: treatment with antidepressant drugs (3, 4); a specific form of cognitive behaviour therapy (5); and exposure with response prevention (6). This paper reviews the research on these three forms of treatment.
across the studies only about a quarter of patients are reported to have stopped overeating and purging by the end of treatment. Even this modest figure should be interpreted with caution since, in most studies, abstinence rates are based on a short time frame of just 1-2 weeks. There is evidence that whilst antidepressant drugs produce a reduction in the frequency of overeating, they have little effect on the extreme dieting that is characteristic of these patients (20, 21). It might be predicted that treatments which simply reduce the frequency of overeating, without lessening the degree of dietary restraint, would lead to weight loss and possibly anorexia
Treatment with Antidepressant Drugs The main controlled studies of antidepressant drugs are listed in Table 1. It is clear from these studies that antidepressant drugs are superior to placebo at reducing many of the features of bulimia nervosa There is generally a marked reduction in the frequency of overeating and self-induced vomiting (in the region of 60%) which is accompanied by an enhanced sense of control over eating, and substantial improvement in general psychiatric disturbance. However, most patients remain symptomatic. 'Abstinence' rates are often quoted and 'Wellcome Trust Senior Lecturer and "uff ield Research Fellow. Address and reprint requests: Christopher G. Fairburn, M.D., University Department of Psychiatry, Warneford Hospital, Oxford OX3 7JX, U.K.
Table 1. The main controlled studies on the use of antidepressant drugs to treat bulimia nervosa.
lmiprarnine Mianserin Amitriptyline Desipramine
lsocarboxazid Phenelzine Bupropion
Pope 81 al. 1983 (7) Mitchell et al. 1990 (8)" Agras et al. 1987 (9) Sabine et al. 1983 (10) Mitchell & Groat 1984 ( 7 1) Hughes et al. 1986 (12) Barlow et al. 1988 (13) McCann & Agras 1990 (14) Walsh et al. 1991 (15) Agras et al. 1992 (16)* Kennedy et al. 1988 (17) Walsh et al. 1988 (18) Horne et al. 1988 (19)
'Studies involving a comparison with cognitive behaviour therapy.
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nervosa (assuming that the drug effect is maintained). Alternatively, it might be predicted that the maintenance of the drug effect would be poor given the continuing presence of extreme dietary restraint, especially since there is evidence that the latter promotes overeating (22, 23). The few studies that have investigated maintenance of change following treatment with antidepressant drugs have found the topic difficult to study, since few patients respond sufficiently well to enter a maintenance phase; for example, Pyle and colleagues (24) could only study nine patients because only 17%had responded (9/54) in the acute phase of their study. In the largest and most rigorous study to date, Walsh and colleagues (15) found that fewer than half their subjects (29/71, 41%) had improved sufficiently to enter a 4-month maintenance phase, and of those who could be entered, only half maintained their improvement. With regard to the time course of the drug effect, it seems that the onset of treatment response resembles that in depression with the effect being gradual rather than immediate. Systematic dose-response studies have yet to be conducted, except for fluoxetine where it has been found that a 60 mg dose is more effective than the dose of 20 mg conventionally used to treat depression (see review by Walsh (25)).Interestingly, no consistent predictors of treatment response have been identified. It is of note that patients without significant depressive symptoms appear to respond as well as those who are, depressed (12, 14, 17, 18). .Two recent studies have compared antidepressant drugs with psychological treatments, both alone and in combination. Mitchetl and colleagues (8) found that group cognitive behaviour therapy was more effective than imipramine and that no advantage came from combining the two treatments, other than on anxiety and depressive symptoms. Agras and colleagues (t6) obtained similar findings when comparing desipramine, cognitive behaviour therapy (of a less intensive and more conventional type), and their combination, although there was some evidence favouring the combination. There was no follow-up.
Cognitive Behaviour Therapy The studies of psychological treatments for bulimia nervosa have been mostly of a higher quality than the drug studies, particularly with respect to their use of more sophisticated and comprehensive assessment measures and their evaluation of maintenance of change. The focus has been on cognitive behavioural treatments for this disorder and the main studies are listed in Table 2. Cognitive behavioural treatments for bulimia nervosa have three properties in common. First, they are based upon the cognitive view of the maintenance of bulimia nervosa (40, 41). According to this view, these patients' extreme concerns about shape and weight are a central feature of the disorder. On a priori grounds it is argued that mast of the other features are secondary to these concerns and that these concerns are therefore of pri-
Hay main controlled studies of cognltive behavloural treatments for bullrnla newosa (including studies of exposure with response prevention). Table 2. The
Yates & Sornbrailo 1984 (26) Ordman & Kirschenbaum1985 (27) Kirkley et al. 1985 (28) Fairburne t al. 1986 (29) Wjlson et al. 1986 (30)' Lee & Flush 1986 (31) Wolchik et al. 1986 (32) Laessls et al. 1987 (33) Freeman et a!. 1988 (34) Leitenberg et al. 1988 (35)' Agras et al. 1989 (36)' Mitchell et al. 1990 (8)t Fairburn et al. 1991 (37) Wilson & Eldredge 1991 (38)' Wolf & Crowther 1992 (39) Agras et al. 1992 (I6)t 'Studies of exposure with response prevention tStudies involving a comparison with antidepressant drugs.
mary importance in its maintenance.This view has clear implications for treatment in particular, it suggests that, if there is to be complete and lasting recovery, there must be change not just in these patients' behaviour but also in their attitudes towards their shape and weight. This is the goal of cognitive behavioural treatments for bulimia nervosa This view on the maintenance of the disorder is presented explicitly to patients and provides the rationale for most of the treatment procedures. The second property shared by cognitive behavioural treatments is the aim to change both these patients' behaviour and their attitudes to shape and weight. Their third common characteristic is the use of a combination of cognitive and behavioural procedures. Cognitive behavioural treatments tor bulimia nervosa are usually 3-6 months in duration and involve 10-20 treatment sessions. The following techniques are commonly used: cognitive restructuring using techniques simifar to those developed by Beck and colleagues for the treatment of depression (42); self-monitoring of relevant thoughts and behaviour; education; the use of self-control measures to establish a pattern of regular eating; and the introduction of avoided foods into the patient's diet. Some programmes include additional elements such as relapse prevention techniques, training in problem-solving, anxiety management training, and formal exposure with response prevention (see below). Detailed descriptions of the treatment are available (43, 44). Across the studies of cognitive behaviour therapy, it has been found that the average reduction in the frequency of overeating and purging is at least as great as that obtained with antidepressant drugs. Accompanying this reduction is a decrease in the level of general psychopathology and an improvement in social functioning. Dietary restraint, a key psychopathological feature, lessens (37) and there is evidence that there is an increase in the amount of food eaten outside bulimic episodes (20). Attitudes to shape and weight, another key feature, also improve (37,45). Most of the studies of
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Treatment of Bulimia Nervosa cognitive behaviour therapy have included at least a 6-month period of follow-up and in two studies follow-up has been for one year and has been closed (i.e. free from additional treatment) (29, 45). The findings in general suggest that, in contrast with treatment with antidepressant drugs, maintenance of change is good with there being little tendency to relapse. The cognitive behavioural approach has been shown to be superior to being allocated to a waiting-list control group (31, 35, 36, 46) and to treatment with antidepressant drugs (8, 16). In addition, it has been compared with a variety of non-behavioural psychological treatments. The Stanford group found group cognitive behaviour therapy to be superior to a form of supportive group therapy (with self-monitoring), although this difference was no longer present at 4-month follow-up (28). In a second study, individual cognitive behaviour therapy was found to be more effective than supportive psychotherapy (again with self-monitoring), both at the end of treatment and at 6-month follow-up (36). The Oxford group has compared cognitive behaviour therapy with two established alternative psychological treatments. In the first study cognitive behaviour therapy was compared with a form of brief focal psychotherapy (47) to which education and self-monitoring had been added. Whilst the results tended to favour cognitive behaviour therapy, the main finding was that both treatment groups improved substantially and that the changes were maintained (29). More recently, cognitive behaviour therapy was compared with an adaptation of interpersonal psychotherapy (48), the focal psychotherapy for depression (49). In this adaptation no attention was paid to eating habits or attitudes to shape and weight. As in the previous study, it was found that both treatment groups improved significantly. At the end of treatment, cognitive behaviour therapy was found to be more effective than interpersonal psychotherapy at reducing the patients’ level of dietary restraint and their degree of shape and weight concern, but this difference disappeared during follow-up (45). In view of the tempofal differences in the pattern of response to the two treatments, it is likely that they achieved equivalent outcomes through the operation of different mediating mechanisms. There have been three attempts to examine the value of the cognitive component of cognitive behaviour therapy by comparing the full treatment with a purely behavioural version. The results of the first study suggested that the immediate effects of behaviour therapy are as great as those of cognitive behaviour therapy (34). However, this study did not include satisfactory measures of the core cognitive variables, the disturbed attitudes to shape and weight, nor was there follow-up. Similar criticisms apply to the second study (39) which obtained generally poor results possibly because treatment was short (8 weeks) and administered in a group format. In the third study, both behavioural and cognitive variables were measured and patients were entered into a 12-month closed period of follow-up (37.45). The findings, both at the end of treatment and at follow-up, clearly supported the full cognitive behavioural treatment.
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Exposure with Response Prevention The exposure with response prevention treatment of Rosen & Leitenberg (6) is based on an anxiety model of bulimia nervosa. According to this model, binge-eating elicits anxiety which is then reduced by the act of vomiting. The analogy is to the behavioural view of obsessive-compulsive disorders in which compulsive rituals reduce anxiety. Once patients with bulimia nervosa learn to vomit, binge-eating is no longer inhibited by anxiety about weight gain. This negative reinforcement is said to be the ‘driving force’ behind bulimia nervosa, and hence vomiting becomes the major target of treatment. The technique of exposure with response prevention is designed to expose the patient systematically to anxiety-eliciting cues (perceived or actual overeating) and then prevent vomiting. Although the technique has been implemented in somewhat different ways in different studies (50),the hallmark is that patients are requested to bring to each treatment session the foods on which they typically ‘binge’, and then eat them until they reach the point at which they would typically induce vomiting. Under the guidance of the therapist, patients are encouraged not to vomit but to learn to cope with the resulting anxiety and learn that it will decline over the remainder of the session. It is argued that this technique uncouples the learned association between eatinginduced anxiety and vomiting. There have been four controlled studies of this form of treatment. In each case the technique of exposure with response prevention has been combined with the procedures that characterize the cognitive behavioural approach. In the first study, Wilson and colleagues (30) compared exposure with response prevention with verbal cognitive restructuring alone. The exposure treatment was superior to cognitive restructuring. However, the sample size was small and there was no comparison group at follow-up. More importantly, the cognitive restructuring treatment lacked many of the behavioural features of the full cognitive behavioural approach. As a result, the superiority of the exposure treatment does not indicate that this specific technique enhances the effectiveness of cognitive behaviour therapy. The three other controlled studies compared more representative cognitive behavioural treatments, with and without exposure with response prevention (35, 36, 38). All three found no significant advantage came from adding the technique.
Other Treatment Approaches PharmacoiogicalTreatments Various pharmacological treatments, apart from antidepressant drugs, have been evaluated including appetite suppressants (51, 52), opiate antagonists (53-55), antiepileptic drugs (56-60) and lithium (61, 62). None seems promising and their use is not recommended.
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Psychological Treatments Other than cognitive behaviour therapy, the only established psychological treatment that appears promising (as discussed above) is interpersonal psychotherapy (37, 45,48).
Educational Approaches
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There is some evidence that brief educational approaches benefit some patients with bulimia nervosa (63, 64). It has yet to be established which patients benefit most and whether the changes are lasting. A form of 'nutritional counselling' (which closely resembles cognitive behaviour therapy) also appears helpful (65).
Other Approaches to Treatment The bulk of research on the treatment of bulimia nervosa has focused on out-patient treatment conducted on a one-to-one basis. Group treatment may be a cost-effective alternative although direct comparison of a group and individual version of the same form of treatment has yet to be conducted. Self-help approaches are also an attractive cost-effective alternative but have yet to be satisfactorily evaluated. With regard to patients who do not respond to out-patient treatment, there is evidence that day-patient treatment may be as effective as inpatient treatment (66-68). This approach has the advantage over in-patient treatment not only of being less expensive but also of allowing patients to remain in contact with situations which they find problematic, an important therapeutic advantage.
Implications of the Research for Clinical Practice The research on treatment indicates that the overall approach of choice is the cognitive behavioural one. Therefore, if clinicians are to use one single form of treatment, this is the one to adopt. Detailed manuals have been written describing the treatment (43, 44) and with practice it can be successfully used even without specialist training. It is our view that all those who see patients with eating disorders should include cognitive behaviour therapy in their therapeutic armamentarium. The cognitive behavioural approach is neither necessary nor sufficient for all patients with bulimia nervosa For some patients it is probably unnecessarily intensive. It is for these patients that simple brief interventions are appropriate. For other patients cognitive behaviour therapy is insufficient. There is therefore a need to develop and evaluate treatments for those who do not respond. Combining cognitive behaviour therapy with antidepressant drugs does not seem to be worthwhile, although it is worth trying with patients who have severe unremitting depressive symptoms in case a co-existing depressive disorder is interfering with treatment. Transferring non-responders over to interpersonal psychotherapy is sometimes helpful when treating patients with
Hay diabetes who have an eating disorder (69), and it is possible that this strategy might also benefit those without diabetes. A period of day-patient treatment is another option, but this would need to be followed by treatment on an out-patient basis. The place of antidepressant drugs in the treatment of bulimia nervosa is far from clear. Whilst they are simpler to administer than cognitive behaviour therapy, they may not be as cost-effective. Drug treatment is not welcomed by these patients and is associated with a greater attrition rate than cognitive behaviour therapy (8, 16). Side-effects may also be a problem. These disadvantages, together with suspect maintenance of change, suggest that they should not be used as a firstline treatment. The paper is based in part on a book chapter written by the first author in conjunction with Terry Wilson and Stewart Agras (2). The chapter was prepared whilst the authors were Fellows at the Center for Advanced Study in the Behavioral Sciences at Stanford. This Fellowship was supported by grants from the FoundationFund for Research in Psychiatry and the MacArthur Foundation. C.G.F. is supported by a Senior Lectureship award from the Wellcome Trust P.J.H. is supported by a Nuffield Medical Fellowship and a Girdlers' Junior Research Fellowship.
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