Bulimia Nervosa

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Initial assessment of the patient with bulimia nervosa for psychotherapeutic readiness, to assess comor-bid psychiatric states and attend to them, and to determine what approaches are likely to be most helpful for the given individual is of critical importance to maximize the likelihood of successful treatment. Eor patients with comorbid substance abuse or dependence disorder, successful treatment of bulimia nervosa ordinarily requires that the substance abuse disorder be attended to first, or at least concurrently. The odds of successfully treating bulimia nervosa in the presence of untreated substance abuse or dependence disorder are extremely small. As with any psychotherapeutic treatment, the clinician must remain alert to resistances and negative therapeutic reactions, some of which may result from patient factors and some from therapist in-sensitivities or errors in assessment or judgment. Quick attention to problems as soon as they are identified may be necessary to save treatments that might otherwise end prematurely and unsuccessfully.

The fact that binge eating and purging episodes are relatively easily counted has stimulated and facilitated psychotherapy research for this disorder. Accordingly, a large number of studies have examined the efficacy of several different types of individual and group psy-chotherapies for bulimia nervosa. Cognitive-behavior therapy (CBT) has been most extensively researched, and is the approach for which most substantial evidence for efficacy exists. Twelve to 20 sessions of CBT treatments, often manualized to permit reliable duplication from center to center, have proven to be highly effective in reducing the number of binge eating and purging episodes and in changing dysfunctional attitudes regarding weight and shape. The treatment is usually conducted in several distinct phases. Initial sessions are usually devoted to helping patients restore healthy patterns of eating and nutrition, enabling them to consume sufficient food without purging so that periods of hunger are avoided. Because hunger pangs are thought to trigger more than 50% of eating binges, reducing hunger often reduces binge eating. The initial phases of CBT involve careful quantitative assessments and diary keeping concerning eating patterns; the types, quantity, and time-course of food consumed during the day without purging; eating binges; purges; exercise; and associated antecedant, concurrent, and consequent thoughts, emotions, and associated behaviors. By the very act of keeping these diaries, patients already indicate their compliance, acknowledge concern about their problems, and show sufficient motivation to invest necessary time and psychological energy into recovery. Diary keeping promotes increased awareness of symptoms, so that eating binges and purges are less likely to occur "automatically" in semidissociated states, and also signifies that patients will share their behaviors publicly (at least with their clinicians). These factors may both contribute to the therapeutic benefits derived from this simple procedure.

The middle sessions of CBT are devoted to explicating and dealing with eating disorders related thoughts and emotions—to recognize, elicit, label, examine, and counter the underlying negative and pathological cognitions concerning eating, weight, and shape in relation to self-evaluation and self-esteem. The late phases of CBT focus on helping patients better cope with the frustrations related to interpersonal and intrapsychic events that often trigger binge eating episodes. About 60% of patients with uncomplicated bulimia nervosa obtain substantial symptomatic relief from this treatment, even without the concurrent use of medications. After the initial series of CBT sessions have concluded, booster sessions, usually scheduled on a monthly basis for a year or two, have been helpful for maintaining improvements and preventing relapse.

Research suggests that for those patients for whom CBT will be an effective intervention, clear-cut improvements should be seen within 6 to 8 weeks. The absence of improvement during that time frame suggests that the patients will require an additional or different modality, for example, the addition of medication such as selective serotonin re-uptake inhibitors (SSRIs) such as fluoxetine to obtain substantial improvement. Some research suggests that adding SSRIs to CBT results in overall better outcomes in bulimia nervosa.

The extent to which complete abstinence from binge eating and purging is achieved varies from study to study, with remission reportedly averaging about 36% for CBT-based psychotherapy alone versus 42 to 49% for studies in which CBT is combined with medication.

Bulimia nervosa has also been successfully treated with interpersonal psychotherapy (IPT), based on the approach of Gerald Klerman and colleagues. Studies have shown that initial posttreatment responses to IPT are not as robust as those to CBT, but that over longer term 2 to 5 years follow-ups, the outcomes for IPT and CBT are similar with respect to reducing binge eating symptoms. Furthermore, since the forms of IPT used in these research studies were intentionally and systematically stripped of all reference to eating problems that could confound them with CBT, they were artificially devoid of subject matter that clinicians treating these disorders would ordinarily discuss and consider with their patients. Taken as a whole, these studies suggest that although CBT principles are more effective than IPT in reducing disturbed attitudes toward shape, weight, and restrictive dieting, a proper integration of IPT strategies in treatment may also be helpful. These strategies may afford reduced emotional tension and better ways of coping with IPT-related concerns of loss, disputes, role transitions, and interpersonal deficits, and thereby contribute to sustained and enduring improvement.

After symptom remission, traditional psychodynamic psychotherapies may be helpful for exploration of longstanding issues concerning development, enduring psychological conflicts, repetitive self-destructive patterns, and enduring maladaptive aspects of the personality

Studies of purer forms of behavior therapy without cognitive components have yielded conflicting results. In these studies, for example, researchers have utilized exposure and response prevention techniques, in which individuals who binge eat are prevented from purging. Results are conflicted, but some studies suggest that this treatment does not add to a solid core of CBT.

Several studies have shown CBT in group settings to be moderately effective. Group CBT programs requiring diary keeping, dietary counseling, and dietary management are more effective than those without such components, and programs requiring more frequent sessions at the beginning of treatment (e.g., several times per week) and longer sessions are more effective than those meeting less extensively. In practice, many clinicians favor combining individual and group psychotherapy for bulimia nervosa.

A sizable minority of patients with uncomplicated bulimia nervosa, on the order of 20%, may achieve significant benefit from working through structured, self-guided CBT-based manuals on their own. A number of self-guided programs have been devised and are widely available. For several of these manuals accompanying guides for therapists have been written as well.

Some research suggests that for some patients with bulimia nervosa certain forms of intense psychoeduca-tion may be as effective as CBT. Anecdotal reports hint that some patients with bulimia nervosa may benefit from 12-step oriented programs and that programs such as Overeaters Anonymous may serve as useful adjuncts. Several investigators report that 12-step programs have generally not been successful for patients with anorexia nervosa.

Because large numbers of patients with bulimia nervosa suffer from concurrent mood disorders (primarily recurrent major depressive disorders, dysthymic disorders, and bipolar II disorders), and substantial numbers suffer from anxiety disorders, personality disorders (often demonstrating cluster B and C traits and qualities), histories of psychological, physical, and sexual traumas, and substance abuse disorders, treatment planning must take the comorbid features into consideration, and psychotherapy and psychosocial treatments must be modified to deal with these problems as well. Experimental psychotherapy programs directed by Stephen Wonderlich and colleagues are being tested for difficult to treat so-called multi-impulsive bulimia nervosa patients, that is, patients who in addi tion to having difficulty regulating eating behaviors also exhibit difficulties regulating emotions (particularly anger, irritability, and depression) and a variety of behaviors including sleeping (chaotic), shopping (overspending and shoplifting), sex (often impulsive, sometimes promiscuous), and substance use (abuse and/or dependence is common). For such patients, in addition to using traditional eating disorder-related CBT programs and medications as indicated, treatment programs may employ elements of dialectic behavior therapy (DBT) developed by Marcia Linehan and colleagues for patients with parasuicidal behaviors and borderline personality disorder, and intensive outpatient psychotherapies in which patients may be seen even several times per week as well as on a crisis basis.

As with anorexia nervosa, at some stages of treatment incorporation into psychotherapy of more traditional psychodynamic, feminist, and relational themes may be helpful.

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