QUESTIONS AND ANSWERS: Evaluating Rapid Symptom Changes after CBT

Q. I hope you can help us. A 30-year-old patient with bulimia responded very quickly to cognitive behavioral therapy (CBT), but then over time we began to notice increases in his symptoms. I have always considered a good early response as a predictor of good long-term outcome, so this caught me off guard. What could have caused this? (L.G., Dayton, Ohio)

A. There may be more complexities to consider with early response during treatment. While CBT for BN can be a very effective tool for persons with very irregular eating when they are first seen, it might lead to poorer long-term outcomes for those not using significant dietary restraint between binge eating/compensatory episodes, according to a study from Drexel University, Philadelphia (Eat Weight Disord. 2022. doi: 10.1007/s40519-021-0138-5. Published online before print). This study analyzed response patterns in 56 people with BN in more sophisticated detail—not merely a yes-or-no early treatment strong response. In particular, binge eating, compensatory behaviors, and regular eating were all considered.

The Philadelphia authors found that more nuanced classification of outcome response patterns provided better prediction. Six-month follow-up remission was significantly less common among patients with the medium-level binge eating decrease class compared to other classes.

They concluded that identifying a patient’s trajectory of change might help develop personalized interventions to improve long-term outcomes. And, although it is tempting to predict that rapid and seemingly positive changes in ED behaviors is a sign that treatment will always lead to long-term improvement of individuals with BN who are being treated with CBT, this early improvement may subside.

The study findings suggest the need for more individualized approaches based on more fine-grained consideration of treatment response. Will personalized treatment improve long-term outcomes? Time will tell, but this case is a reminder that personalized treatment approaches should be evaluated among individuals at risk of poorer long-term outcomes.


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