Reprinted from Eating Disorders Review
March/April 2005 Volume 16, Number 2
©2005 Gürze Books
According to the American Psychiatric Association’s Diagnostic and Statistical Manual IV, there are six examples of eating disorders not otherwise specified (EDNOS). Two have mainly anorectic features, two have mainly bulimic features, and the two remaining subtypes are: repeatedly chewing and spitting out, but not swallowing, large amounts of food (EDNOS type 3); and binge eating disorder (BED). .
Until now, there have been no randomized controlled studies of the effects of cognitive behavioral therapy (CBT) or interpersonal psychotherapy (IPT) for patients with types of EDNOS other than BED. Drs. Lauri Nevonen of Queen Silvia Children’s Hospital, Goteborg, Sweden, and Anders G. Broberg, Goteborg University, designed a study to investigate the effectiveness of sequenced CBT followed by IPT for patients who repeatedly chew and spit out, but don’t swallow, large amounts of food (Eur Eat Disorders Rev 2005; 13:29).
Thirty-five patients were selected, and a randomized normal control group was composed of 3 groups of 315 women from the county administration’s civic registry. The patients were evaluated immediately before and after treatment, and at 1- and 2.5-year follow-up sessions. BN patients were included in a similar study comparing sequenced CBT followed by IPT.
Characteristics of the patients
The mean age of the patients was 20.5 years and the mean body mass index (BMI) was 21.4. The mean duration of illness was 4.5 years. The frequency of binge eating episodes was 1.3 times per week and the frequency of self-induced vomiting was 1.6 times per week. Thirty-four percent did not vomit at all, and 30% vomited more than 2 days per week. Fourteen percent of the patients had at least 2 binge eating episodes a week and 31% did not binge eat.
Group treatment consisted of 23 sessions over a period of 20 weeks. The group sessions were held for 2 hours in the evening (5-7 pm), twice weekly for the first 3 weeks and once a week thereafter for 17 more weeks. Individual sessions were scheduled for 50 to 60 minutes a week for 23 weeks.
The treatment model was based on 10 sessions of symptom-focused CBT followed by 13 sessions of IPT. CBT treatment focused on psycho-education, including self-esteem, dieting, body-weight-shape, binge eating, compensatory behaviors and physical consequences, identifying dysfunctional eating patterns with self-monitoring sheets, establishing regular eating patterns, coping strategies and prevention of relapse.
During the second phase of treatment with IPT, the authors concentrated on current interpersonal problems. Grief, interpersonal disputes, role transitions and interpersonal deficits were identified by each patient and put in an eating disorders context.
At one year: Group therapy was more effective at first
At the end of treatment, about 10% of each sample had recovered. At one-year follow-up, 83% of those in the group therapy group and 53% of those treated individually had recovered. By the 2.5-year follow-up, the recovery rate for those in the group treatment segment had fallen to 67% and the recovery rate for those treated with individual therapy increased to 59%.
At the end of treatment, about 40% of both groups were in remission. At one-year follow-up, 95% of those in the group treatment segment and 76% of those treated individually were in remission. At the 2.5-year follow-up, about 80% of persons in both groups were in remission.
Thus, was individual or group therapy more effective? In terms of binge eating and purging, the authors were not able to demonstrate any statistically significant changes between individual and group therapy. Group therapy produced larger effects, compared with individual therapy. The sequenced treatment was more effective overall for EDNOS patients compared with the group with bulimia nervosa.
According to Dr. Nevonen and colleagues, a patient with severe eating problems rather than interpersonal problems may be a good candidate for individual therapy. If, however, the patient has predominantly interpersonal problems, group therapy would be a good alternative. Group therapy is also generally more cost-effective than individual therapy and more patients can be treated sooner. Before the type of therapy is selected, however, the authors advise that the patient undergo a thorough assessment, including his or her eating disorder and interpersonally related symptoms.