Patients in the CBT group stopped binge-eating and purging faster.
Reprinted from Eating Disorders Review
September/October Volume 25, Number 5
In a study from Copenhagen, 20 sessions of a new enhanced form of cognitive behavioral therapy (CBT) conducted over 5 months was found to more effective than 2 years of psychoanalytic psychotherapy among patients with bulimia nervosa (BN) (Am J Psychiatry 2014; 171:109).
Stig Poulsen, PhD, and a team of researchers compared the two forms of treatment among 70 patients with BN. Patients either received 5 months of CBT or 2 years of weekly psychoanalytic psychotherapy. Thirty-four patients were randomly selected to receive psychoanalytic psychotherapy and 36 for the CBT group.
The psychoanalytic psychotherapy involved weekly 50-minute sessions over 2 years. The psychoanalytic approach was based on the assumption that bulimic symptoms “are rooted in a need to ward off inner feelings and desires,” and in problems regulating those inner feelings. The treatment involved three phases: an initial phase focusing on establishing the therapeutic alliance and addressing the bulimic symptoms; next, a work phase, where focus on the transference relationship was added, and, finally, a termination phase.
The “enhanced” version of the original CBT includes basic elements of CBT for BN but with an emphasis on engagement, and emphasizes modifying concern about shape and weight, and on developing skills to deal with setbacks. Enhanced CBT has both focused and broader forms; in this study, the form emphasized eating disorder psychopathology. The treatment was given in 20 sessions lasting 50 minutes. For the first 4 weeks, the sessions were held twice a week, then weekly for 10 weeks, and then every 2 weeks over the final 6 weeks.
The authors assessed the outcome with the Eating Disorders Examination interview, administered blind to treatment condition at baseline, after 5 months, and after 2 years.
While both treatments led to improvement of symptoms, after 5 months of therapy (the end of CBT point), 42% of patients in the CBT group and 6% of patients in the psychoanalytic psychotherapy group had stopped binge-eating and purging. At the 2-year follow-up point (end of psychoanalytic psychotherapy), 44% of the CBT group and 15% of the psychoanalytic psychotherapy group had stopped binge-eating and purging.
In an editorial in the same issue (Am J Psychiatry 2014; 17:13), Drs. Steven D. Hollon of Vanderbilt University and G. Terrence Wilson from Rutgers University noted that the study was conducted in a psychoanalytically oriented clinic, and allegiance factors would have worked against the observed effect. The relationists suggest the benefits for CBT were due to several features. First, CBT directly addressed the overvaluation of body shape and weight, extreme dietary restraint, and sensitivity to adverse events and moods. Next, the individualized approach improved engagement due to providing a comprehensible and credible account of why their eating problem is “self-perpetuating.” It was individualized so that it matched the individual’s needs. Third, it engaged even the most ambivalent patient by providing a comprehensible and credible account of why the eating problem was self-perpetuating and what needed to be done to overcome this. Last, it used real-time self-monitoring and a formal relapse prevention component.