Recent Research on Bulimia Nervosa

By James E. Mitchell, MD and Kristine J. Steffen, PharmD
University of North Dakota, Fargo
Reprinted from Eating Disorders Review
January/February 2008 Volume 19, Number 1
©2008 Gürze Books

In thinking about areas on which to focus this review, the possibilities seemed endless. Therefore, we have chosen a few representative areas but realize we do so at the expense of much very important work.

Two issues of ongoing concern are the health problems of patients with eating disorders and their use of health services. Spoor and colleagues (2007), using community-recruited samples, found that the total number of occurrences of binge eating and compensatory behaviors, or simply compensatory behaviors occurring twice a week, resulted in greater self-reported health-care utilization using items from the Health Survey Utilization Scale that assessed both mental and physical health care utilization.Mond and colleagues (2007), again using a community sample, found that women with bulimic-type eating disorders rarely received treatment for an eating disorder but often received treatment for other mental health problems and/or for weight loss.

Ecological momentary assessment (EMA) has emerged as a helpful tool, as shown in several studies. (EMA allows patients to record symptoms, affect, and behavior close in time to the experience. Using diaries, PDAs or cell phones, many events and experiences can be recorded by patients near the time they occur.) Negative affect has received increasing attention as a precipitant of binge eating in patients with bulimia nervosa (BN). Hilbert and Tuschen-Caffier (2007), using EMA, found that a patient’s mood was more negative before binge eating, which was followed by a further deterioration of mood. Also using EMA, Smyth and colleagues (2007) showed that days characterized by binge eating or vomiting were also marked by higher negative affect and higher anger/hostility and more self-reported stress. Within-day recordings showed that decreasing positive affect and increasing negative affect and anger/hostility reliably preceded BN events such as binge eating and purging. Engelberg and colleagues (2007), also using EMA, also found that negative affect as well as dissociation was elevated prior to binge eating episodes.

Treatment update

Relative to treatment of BN, a thorough review of BN treatment literature was reported by Shapiro and colleagues (2007), who researched six major databases for articles published between 1980 and 2005. These researchers found 47 studies that used medication only, behavioral interventions only, or a combination of the two. They concluded that the evidence for successfully treating BN with medication was strong, as was the evidence for cognitive behavioral therapy (CBT), but that the evidence for self-help was weak. There was no evidence that sociodemographic factors made a difference in outcome.

Vanderlindin et al. (2007) surveyed a large sample of eating disorder patients to find which elements in their treatment they thought were most helpful in their recovery. “Improving self-esteem,” “improving body experience,” and “learning problem-solving skills” were all considered core elements that helped recovery. All of these were very similar to the items endorsed by therapists as the most important therapeutic agents. Wilson (2007) reviewed psychological treatments for eating disorders, and concluded that manual-based CBT is presently the most effective treatment for BN. He also discussed various strategies for improving results obtained with CBT, including combining CBT with antidepressant medication, integrating CBT with alternative psychological therapies, and expanding the scope and flexibility of manual-based CBT. In what is the first randomized controlled trial of the treatment of adolescents with BN, le Grange and colleagues (2007) compared family-based treatment to supportive psychotherapy. Forty-one patients were randomized to family-based treatment and 39 to supportive psychotherapy. The family-based treatment showed a clinical and statistical advantage over supportive psychotherapy post-treatment and at a six-month follow-up.

Long-term outcome

Two studies evaluated the long-term outcome and natural course of eating disorders, including the outcome for patients with BN. As part of the Collaborative Longitudinal Personality Disorders Study, Grilo and colleagues (2007) found that the probability of remission for those with BN was 74% by 16 months and for those who had remissions, the risk of relapse was 47%. Fichter and Quadflieg (2007) found that the long-term outcome of BN was similar to that in subjects with binge eating disorder (BED), while subjects with anorexia nervosa had a considerably worse long-term outcome.

Comorbidity

Relative to comorbidity, Claes and Vandereycken (2007) found that patients who engage in self-injurious behaviors were more likely to report a history of physical and/or sexual abuse, as is now noted repeatedly in the literature. Swinbuorne and Touyz (2007) found that although the literature suggests an increase in the prevalence of anxiety disorders in patients with eating disorders relative to the rates of the general population, the research has striking inconsistencies, and much additional research in this area is indicated.

About the Authors

Dr. Mitchell, a founding member of EDR‘s Editorial Advisory Board, is President of the Neuropsychiatric Research Institute and Chair of the Department of Clinical Neuroscience at the University of North Dakota School of Medicine and Health Sciences.

Dr. Steffen is a Research Scientist at the Neuropsychiatric Research Institute.

References

Engelberg MJ, Steiger H, Gauvin L, Wonderlich SA. Binge eating antecedents in bulimic syndromes: an examination of dissociation and negative affect. Int J Eat Disord. 2007; 40:531.

Fichter MM, Quadflieg N. Long-term stability of eating disorder diagnoses. Int J Eat Disord. 2007; Nov; 40 Suppl:S61-6.

Grilo CM, Pagano ME, Skodol AE, et al. Natural course of bulimia nervosa and of eating disorder not otherwise specified: 5-year prospective study of remissions, relapses, and the effects of personality disorder. J Clin Psychiatry. 2007; 68:738.

Hilbert A, Tuschen-Caffier B. Maintenance of binge eating through negative mood: a naturalistic comparison of binge eating disorder and bulimia nervosa. Int J Eat Disord. 2007; 40:521.

leGrange D, Crosby RD, Rathous PH, Leventhal BL. A randomized controlled comparison of family-based treatment and supportive psychotherapy for adolescent bulimia nervosa. Arch Gen Psychiatry. 2007; 64:1049.

Mond JM, Hay PJ, Rodgers B, Owen C. Health service utilization for eating disorders: findings from a community-based study. Int J Eat Disord. 2007;40:399.

Shapiro JR, Berkman ND, Brownley KA, et al. Bulimia nervosa treatment: a systematic review of randomized controlled trials. Int J Eat Disord. 2007; 40:321.

Smyth JM, Wonderlich SA, Heron KE, et al. Daily and momentary mood and stress are associated with binge eating and vomiting in bulimia nervosa patients in the natural environment. J Consult Clin Psychol. 2007; 75:629.

Spoor STP, Stice E, Burton E, Bohon C. Relations of bulimic symptom frequency and intensity to psychosocial impairment and health care utilization: results from a community-recruited sample. Int J Eat Disord. 2007;40:505.

Swinbourne JM, Touyz SW. The co-morbidity of eating disorders and anxiety disorders: a review. Eur Eat Disord Rev. 2007; 15:253.

Vanderlinden J, Buis H, Pieters G, Probst M. Which elements in the treatment of eating disorders are necessary “ingredients” in the recovery process?—A comparison between the patient’s and therapist’s view. Eur Eat Disord Rev. 2007;15:537.

Wilson GT. Psychological treatment of eating disorders. Annual Rev Clin Psychol. 2005; 1:439.

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Kristine J. Steffen, PharmD

University of North Dakota, Fargo

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