Enhanced CBT Bests Psychoanalysis for Bulimia

Megan Brooks

December 03, 2013

An enhanced form of cognitive-behavioral therapy (CBT) for bulimia nervosa (BN) is far more effective than psychoanalytic psychotherapy, new research shows.

"CBT is a highly effective treatment for bulimia nervosa and clearly more effective than the version of psychoanalytic psychotherapy tested in this trial," study investigator Stig Poulsen, PhD, associate professor, the University Clinic, Department of Psychology, University of Copenhagen, in Denmark, told Medscape Medical News.

"Still, a large percentage of the patients were not helped sufficiently for their bulimia by CBT. This suggests that further development of treatments for bulimia nervosa is still relevant," Dr. Poulsen said.

The study was published online November 26 in the American Journal of Psychiatry.

CBT Significantly More Effective

BN is characterized by recurrent episodes of binge eating, extreme weight control behaviors, and overevaluation of shape and weight. The researchers note that in Denmark and other European countries, psychotherapy is the mainstay of treatment for eating disorders.

Recent research suggests that although psychotherapy is as effective as CBT for BN, it is "slower to operate."

To compare psychoanalytic therapy and CBT, the investigators conducted a randomized, controlled trial in which 70 adults with BN were randomly assigned to 2 years of weekly 50-minute sessions of psychoanalytic psychotherapy or 20 sessions of enhanced CBT delivered during a period of 5 months.

The psychoanalytic psychotherapy for BN was developed by Dr. Poulsen and a colleague and is based on the assumption that bulimic symptoms are rooted in a need to ward off inner feelings and desires and in difficulties acknowledging and regulating those feelings.

Accordingly, the therapy strives to increase the capacity to reflect on and tolerate affective experience and to facilitate insight into the mechanisms hiding unconscious and disavowed aspects of the patients, the authors explain.

The enhanced CBT was developed by Christopher Fairburn, FMedSci, FRCPsych, who also worked on the current study. It aims to actively engage patients in modifying their eating disorder psychopathology with procedures and strategies addressing dietary restraint, concerns about shape and weight, events and associated mood changes influencing eating, and the development of skills to deal with setbacks.

In the study, both treatments led to improvement in BN symptoms, but CBT was much more effective.

After 5 months, 42% of the CBT group and 6% of the psychoanalytic psychotherapy group had stopped binge eating and purging (odds ratio [OR], 13.40; 95% confidence interval [CI] 2.45 - 73.42; P < .01).

At 2 years, 44% of the CBT group and 15% of the psychotherapy group had stopped binge eating and purging (OR, 4.34; 95% CI, 1.33 - 14.21; P = .02).

Both treatments led to substantial improvements in effects on global eating disorder features and general psychopathology, but in general, these improvements took place more rapidly in the patients in the CBT arm.

"CBT is the preferred treatment for the disorder when compared with the version of psychoanalytic psychotherapy tested in this trial," the investigators write.

But the fact that at 2 years, 56% of the patients in CBT still had episodes of binge eating and purging and 31% still met the diagnostic criteria for BN means "further treatment developments are needed," they add.

Shorter Duration, Less Costly

Commenting on the study for Medscape Medical News, Riccardo Dalle Grave, MD, Department of Eating and Weight Disorders, Villa Garda Hospital, Garda, Italy, who was not involved in the study, said the findings "contradict the general opinion that all psychological treatments produce similar outcomes because they work through common nonspecific factors."

Enhanced CBT "not only was markedly more effective than psychoanalytic psychotherapy but achieved this outcome with a shorter and consequently less costly treatment," Dr. Dalle Grave added.

In addition, he said, the study had "a good internal and external validity, a combination rarely achieved by the randomized, controlled trials of psychological treatments."

As noted by the authors, Dr. Dalle Grave also pointed out that the small sample size is a limitation of the trial. The lack of a control group is another limitation, one that makes it unclear whether similar improvements of global eating disorder psychopathology and general psychopathology observed after 24 months is attributable to the 2 psychological treatments or to other factors.

The study was supported by the Danish Council for Independent Research/Humanities, the Egmont Foundation, and the Ivan Nielsen Foundation. Dr. Fairburn reports receiving royalties from the sales of the CBT-E Treatment Manual. The other authors and Dr. Dalle Grave report no relevant financial relationships.

Am J Psychiatry. Published online November 26, 2013. Abstract


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