Treatment of Bulimia
At one time, cognitive-behavioral therapy was considered to be the gold standard in the treatment of bulimia and binge eating disorder. In 1993, Stuart Agras, a prominent researcher from Stanford University, investigated the current treatment of binge eating, posing two complex questions. The first was whether some treatments were better than others or whether all treatments were equally effective. The second question was whether treatments provided specific or nonspecific effects and whether they worked by the same or different processes.
Agras emphasized the importance of learning which factors maintain binge eating and in which way a specific therapy influenced these factors. He discussed the variation in assessment methods that made comparisons between and across studies extremely difficult. He found that studies differed in diagnostic criteria, outcome criteria, and length of follow-up intervals. Agras (1993) found that only 32 patients out of every 100 entering treatment emerged eating disorder free 1 year or later.
Researchers performed a 2- to 9-year follow-up study on 52 women with the diagnosis of bulimia nervosa according to the DSM-III-R. The patients were treated in an inpatient eating disorders unit at a university hospital, using behavioral methods to address eating behaviors, individual psychotherapy, pharmacotherapy (if indicated), group therapy, and family therapy. Of the 52 women, 46 women were interviewed, 1 had died, and 5 could not be located. Of the 46 inpatient bulimic women, 39 percent had fully recovered and 41 percent were still symptomatic. The longer period of time after discharge, the greater percentage of patients recovered. At the end of year one, 15 percent had recovered versus 67 percent at the end of year 8. They found that the mean duration of recovery was more than two years.
Another group in 1999 found the same results as the previous group in that the number of women who were symptomatic for bulimia nervosa declined as the length of time post-treatment increases. Researchers strictly defined eating disorder outcome with both narrow and broad definitions. The narrow definition required a subject to be free of bulimic symptomotology for a period of six months, and in addition, for the subject not to use body weight and shape as a way of judging herself. The broad definition required the subject to be free of disordered eating behaviors for at least eight weeks with no restrictions on self-evaluation of perceived weight and shape.
Women who had not met criteria for full remission but who no longer met DSM-IV criteria were considered to be in partial remission. The researchers had a group of 173 women, with a mean duration of follow-up of 11.5 +/- 1.9 years.
This is the longest follow-up period in the English language literature on bulimia nervosa with the second largest sample size. At follow-up, one patient (0.6 percent) met full diagnostic criteria for anorexia nervosa and 19 women (11 percent) met clinical diagnostic criteria for bulimia nervosa. Thirty-two women (18.5 percent) met the criteria for ED NOS, including one woman with Binge Eating Disorder. When researchers reported the results according to the narrow definition of remission, they found that 28.3 percent of the women were in partial remission at follow-up and 41.6 percent were in full remission. When they reported the results according to the broad definition of remission, they found that 23.1 percent were in partial remission, and 46.8 percent were in complete remission.
Five short-term studies in which patients were followed for a year or more after treatment found that most patients do well at one year after treatment with at least 75 percent showing no bulimic symptoms. In six studies where patients have been followed for up to two years or more, about one-half of the patients were in remission at follow-up. It was concluded that 50 percent of bulimia nervosa patients were symptom free two to ten years after intake, that about 20 percent of patients remained persistently symptomatic, and that the remainder (about 30 percent) have a course of illness characterized by remissions and relapses or by persistent bulimic behavior that does not meet clinical definition.
In 1997, Fichter and Quadflieg, a pair of German researchers who are two of the best in the field, published the results of their 6-year long-term study of bulimia nervosa. They studied a group of 196 female patients who fulfilled the diagnostic criteria according to the DSM-IV for bulimia nervosa. The treatment they received focused on biological, social, and psychological perspectives. They assessed the patients pre-treatment, post-treatment, at 2-year follow-up and at 6-year follow-up. Treatment lasted for 95.5 +/- 43 days; upon admission, patients ranged 25.6 +/- 6.7 years of age; and patients had had bulimia nervosa for 8.1 +/- 4.9 years. At treatment discharge, 47 patients (24.1 percent) were significantly improved, 77 (39.5 percent) were markedly improved, 60 (30.8 percent) were slightly improved, and nine (4.6 percent) were unchanged, one patient (0.5 percent) was somewhat worse, and another one (0.5 percent) as decidedly worse.
Fichter and Quadfliegs data show that patients substantially improve during inpatient treatment, show a slight decline during the next 2 years and show further improvement until the last assessment at 6 years. They state that the longer the follow-up time, the number of recovered patients increases and mortality increases (6-year mortality for bulimia nervosa is 1.1 percent).
The 6-year outcome study based on the presence or absence of a clinical eating disorder showed a relatively favorable course in the treatment of bulimia nervosa. This study counted only the presence or absence of a full clinical diagnosis so it missed some of the sub-syndromal behaviors. The researchers presented the multidimensional data at four distinct points of time. The study showed that 59.9 percent of women participating in the study had a good outcome, 29.4 percent an intermediate outcome, 9.6 percent a poor outcome, and 1.1 percent were deceased. However, of the 133 females with no DSM-IV eating disorder at 6 year follow-up, 25 still showed marked symptoms, 26 had experienced no partial remission (or were unchanged), 45 showed residual symptoms, and 37 were rated as usual self (or were eating disorder free).
It is interesting to note that the above outcome studies do not remark upon what the clients were doing all of these years. Were they in outpatient treatment? Were they in individual psychotherapy for part of the time? Did they outgrow the disorder, indicating a maturation effect? More complete outcome studies are needed to further refine outcome research.
Jeanne Rust, PhD is the CEO and Founder of Mirasol, a treatment program for women with anorexia, bulimia, obesity, and binge eating disorder. Her treatment philosophy is integrative combining the best of the medical model of treatment with the most effective alternative ones.
Thank you, Mirasol, for saving my daughter's life.
My beloved daughter had been active in her eating disorder for over three years, in spite of two lengthy treatment episodes and years of outpatient treatment. We knew from past experience that just any treatment program would not work for our daughter.
