Bulimia Nervosa: Comparison of Two Therapies
Bulimia Nervosa is a psychological disorder affecting approximately 2-3% of the female population and less than 1% of the male population. It predominantly begins its course in adolescence and may follow the individual into adulthood. The dramatic increase in the number of women seeking treatment for Bulimia Nervosa has led to a need for more effective treatment with decreased rates of relapse (Wilson, Fairburn, Agras, Walsh, & Kraemer, 2002). Although current treatments for Bulimia Nervosa, such as CBT and IPT are effective, their long-term effectiveness is yet to be determined.
Background Characteristics of Bulimia Nervosa
Although Bulimia Nervosa appears to be a fairly new disorder due to its rise in number of diagnosed cases, the disorder has a long history and has undergone many name changes. Before Bulimia Nervosa was entered into the DSM-IV-TR, some proposed names were: “bulimarexia, binge-purge syndrome, dietary chaos syndrome, (and) Bulimia Nervosa” (Gordon, 1990, p. 3). In 1980, the DSM-IV-TR recognized the eating disorder as a psychological disorder. The binge-purge eating disorder was added to the DSM-III and was given its present-day name: Bulimia Nervosa (Boskind-White & White, 1986). At this time, Bulimia Nervosa was characterized by the following two symptoms: “eating habits are markedly disturbed, (and) there is a characteristic set of disturbed attitudes to shape and weight, sometimes referred to as morbid fear of fatness” (Fairburn et al., 1991, p. 463).
Currently, Bulimia Nervosa is characterized by intense preoccupation with food and affects about 2- 3% of females (Bornstein, 2001). It is an eating disorder presented as “periodic episodes of uncontrolled binge eating alternating with periods of fasting, strict dieting, or purging via vomiting, diuretics, or laxatives” (Crandall, 1988, p. 588). The binge eating cycle is often accompanied by affective instability, with intense feelings of guilt, depression, and anxiety present in the individual’s cognition. In most cases, symptoms of Bulimia Nervosa originate in adolescence and remain with individuals throughout their lifespans (Shaffer, 2002). Once the behavior is established, it is very difficult to return to prior eating habits. The mean age of onset is in the late teens, but the average age of onset occurs between 10 and 17 years of age (Weiss, Katzman, ; Wolchik, 1985). Bulimia Nervosa almost always begins with cognitive distortions and failed attempts to gain control over one’s food intake.
Although researchers have not identified one specific cause of Bulimia Nervosa, there appears to be several factors that may contribute to its development. Possible causes of Bulimia Nervosa are: “biological vulnerabilities; particular patterns of family dynamics; cultural norms regarding food, eating, and ideal body size; and an array of predisposing personality and temperament variables” (Bornstein, 2001, p. 151). There are many areas in the lives of those with Bulimia Nervosa that may lead to or exacerbate symptoms of the disorder. In addition, there are traits that some individuals may have that could lead to the development of Bulimia Nervosa. The traits most closely related to bulimic individuals are “low self-esteem, impulsivity, affective lability, and a tendency to internalize anger, guilt, and other negative emotions” (Bornstein, 2001, p. 151).
One major indication of the interpersonal involvement in the etiology of Bulimia Nervosa is the high number of individuals with Bulimia Nervosa who also have personality disorders. It is unclear if Bulimia Nervosa precedes personality disorders or if the emotional disturbances are a result of the chaotic dietary patterns in which bulimics engage (Garner & Barry, 2001). Individuals with Bulimia Nervosa often undergo a high level of interpersonal stress, which leads to intense “feelings of helplessness and ineffectiveness, along with an array of psychological symptoms and self-defeating behaviors” (Bornstein, 2001, p. 152). They often feel depressed and out of control, which further exacerbates the vicious eating cycle in which they engage.
There have been studies reporting a relationship between Bulimia Nervosa and personality disorders. Bulimia Nervosa is associated with some personality disorders, which may suggest an interpersonal deficit common in Bulimia Nervosa (Maranon, Echeburua, & Grijalvo, 2004). One potential cause of Bulimia Nervosa is frequent unstable and problematic interpersonal relationships. It was also discovered that for Bulimia Nervosa, Schizotypal Personality disorder occurs at a “higher than expected frequency” (Bornstein, 2001, p. 159). Cognitive-Behavioral and Interpersonal Therapy appear to effectively treat Bulimia Nervosa and some personality disorders (Birchall, 1999).
Cognitive-Behavioral Therapy as Utilized for Bulimia Nervosa
Although there is no absolute answer, one of the primary goals of cognitive-behavioral treatment for Bulimia Nervosa is to change the individual’s thought processes and belief system. Patients with Bulimia Nervosa tend to function under the Thinness Belief System, which is a system of cognitions and beliefs about the self in regards to weight, characterized by cognitive distortions (Johnson ; Holloway, 1988). Individuals with Bulimia Nervosa believe that they are not worthy of love and respect and are often disgusted with their own physical appearance. They develop cognitive distortions of, “perfectionism, magical thinking, egocentrism, cognitive narrowing, and cognitive diffusing” (Johnson ; Holloway, 1988, p. 251). Due to the strength of these cognitive distortions, it becomes extremely difficult to change the cognitions of the bulimic individual. However, cognitive-behavioral therapy (CBT) appears to effectively eliminate cognitive distortions and decrease the binge-purge cycle.
CBT is a therapeutic technique that combines both cognitive and behavioral components. Fairburn was the first to utilize CBT for Bulimia Nervosa treatment exclusively. He developed a treatment manual for Bulimia Nervosa in 1985, which has been revised and is still currently in use (Wilson ; Fairburn, 2002). Fairburn continues to investigate Bulimia Nervosa treatment and has been actively revising and implementing new treatment strategies to effectively alter cognitions and change destructive eating behaviors (Fairburn, 1998). Although Fairburn’s model has a strong cognitive component, the following behavioral mechanisms of change are also utilized: assertiveness training through backwards chaining, self-monitoring to change behaviors, and conduction of behavioral experiments to change maladaptive behaviors.
With CBT, therapists base their interventions on the idea that prior experiences have created negative cognitions and are currently having maladaptive consequences in the individual’s life (Brewin, 1996). Therefore, if the therapist can identify the maladaptive processes, they can be altered and replaced with more productive thoughts and behaviors. The CBT therapist remains very active throughout the treatment, rendering CBT a “highly structured and didactic” treatment (Peterson ; Mitchell, 1999, p. 687). In addition, the cognitive framework traces the onset of Bulimia Nervosa to “problematic beliefs about the self and perceived lack of control” (Bornstein, 2001, p. 152). Individuals with Bulimia Nervosa are often struggling to gain a sense of control in their lives; as a result, CBT utilizes self-monitoring and other techniques to place control in the hands of the individual.
CBT treatment for Bulimia Nervosa primarily progresses through three stages. The first stage of treatment focuses on the individual’s thought processes. This stage involves education about Bulimia Nervosa and also attempts to identify cognitive factors involved in the eating disordered behavior (Wilson & Fairburn, 2002). In addition, the therapist actively engages the client and attempts to establish a therapeutic alliance.
The second stage of CBT for Bulimia Nervosa is an expansion of the groundwork laid in the first stage. The second stage focuses more on the cognitive distortions maintained by the bulimic individual. The CBT therapist attempts to foster skills in order to decrease binge eating. Beck’s cognitive theory is utilized as a guideline for the therapist (Wilson ; Fairburn, 2002). Beck identified that fact that maladaptive thoughts lead to maladaptive behaviors. Therefore, the therapist attempts to identify maladaptive thought processes and replace them with alternative thoughts.
In the third and final stage of CBT treatment for Bulimia Nervosa, the focus of treatment is shifted. This stage begins to focus on relapse prevention (Wilson ; Fairburn, 2002). Therapists attempt to instill skills necessary to prevent relapse in the future, thus allowing for lasting change. As a result, it is believed that binge-eating behaviors will be halted and will not return in the future. It may be difficult for the individuals to halt binge-purge behaviors because, “purging itself helps maintain binge eating by temporarily reducing the anxiety about potential weight gain” (Wilson ; Fairburn, 2002, p. 562). Therefore, in this third and final stage, therapists must teach alternative coping mechanisms to handle anxiety in order to promote long-term change.
Mechanisms of Change with CBT
There are three possible mechanisms of change present in the foundation of the CBT model that render the model effective. These mechanisms that follow have been proposed to establish a reason for the effectiveness of the model in decreasing binge-purge behaviors (Wilson et al., 2002). First, CBT aims for reduction in dietary restraint – the more patients adapt to healthy eating habits, the less likely they are to binge and purge. Second, CBT attempts to establish change in self-efficacy for coping with situations that trigger binge eating and purging. CBT develops alternative emotions for negative affect and personal stress. Preliminary evidence suggests that CBT enhances self-efficacy primarily through the reduction of binge-purge frequency. Third, CBT strives to modify dysfunctional attitudes about body weight and shape. Failure to reduce weight concerns often results in relapse.
Although all of these mechanisms of change appear to effect symptom reduction, it was discovered that “rapid change of dietary restraint” was the most effective mechanism of change (Wilson et al., 2002, p. 267). In order for CBT to effectively reduce bulimic symptoms, the therapists must focus on the reduction of binge-purge frequency and the implementation of proper eating habits.
Overview of IPT and Focus of Bulimia Treatment
The short-term version of IPT currently utilized was originally “developed for the New Haven-Boston Collaborative Depression Project” by Klerman and his colleagues (Fairburn, Jones, Peveler, Hope, ; O’Connor, 1993, p. 420). IPT focuses on problematic interpersonal relationships and seeks to establish adequate methods to obtain and maintain healthy relationships with others. Fairburn et al. (1993) described IPT as follows:
Interpersonal Therapy, as developed for depression, has three main phases. In the first phase, the depression is diagnosed and explained to the patient…. In the second phase, the interpersonal problems are addressed. In the third phase, feelings about the termination of therapy are discussed, progress is reviewed, and the remaining work is outlined. A manual has been written that describes a detailed description of IPT. (p. 420)
IPT is a brief nondirective therapy, which lasts approximately 15-20 sessions, and focuses on present-day interpersonal relationships in the patients “immediate social context” (Weissman & Markowitz, 1998, p. 4). IPT does not spend a great deal of time addressing past conflicts, but instead focuses on those current interpersonal relationships that are problematic in the individual’s daily life. IPT therapists focus on the social dysfunction of the patient, rather than underlying personality characteristics that may exacerbate symptoms (Weissman ; Markowitz, 1998).
In the treatment of Bulimia Nervosa, IPT focuses on the interpersonal problems purportedly underlying the eating disorder, rather than on the eating behaviors (Markowitz, 1999). IPT has three stages in Bulimia Nervosa treatment, similar to the stages in depression treatment. In the first session of therapy, as with all other therapeutic interventions, the therapist attempts to establish rapport with the client. The therapist also gathers background information regarding interpersonal relationships with the focus on interpersonal dysfunction (Fairburn, 1998). Although past relationships are not given much importance with IPT, it is still necessary to gain that information to identify a historical perspective on the individuals’ interpersonal behaviors. In addition, the interpersonal circumstances in which the individual overeats are identified (Fairburn, 1998). The therapist investigates the precursors to overeating, as well as interpersonal relationships that may contribute to the overeating behavior.
The first phase of treatment presents the client with a diagnosis, which allows them to take on the sick role (Weissman & Markowitz, 1998). In the sick role, the client does not have to be overwhelmed by external obligations and can focus on recovery. The sick role essentially excuses individuals from external demands and allows them to focus solely on their own recovery.
In the initial stages, the IPT therapist must also assess the client for medication needs. At this point, a psychiatrist may be consulted to determine medication needs. Once this goal is accomplished, the IPT therapist identifies in which of the four problem areas the client has deficits. The four areas assessed are: grief, interpersonal role disputes, role transitions, or interpersonal deficits (Weissman & Markowitz, 1998). Once the area of deficit is identified, the IPT therapist establishes the course of treatment.
In the middle phase of treatment, IPT therapists do not divulge past interpersonal deficits. Therapists remain focused on the here-and-now and only discuss present interpersonal deficits. To maintain present-day focus, therapists begin each session by asking, “How have things been since we last met?” (Weissman & Markowitz, 1998, p. 5). Therapists do not attempt to address past developmental issues or deep-rooted conflicts. Their main focus is to discover what is causing interpersonal relationship deficits in current relationships.
In the third and final stage of IPT, the therapist begins to discuss relapse prevention. The therapist reviews with the patient what has been discussed thus far in treatment and outlines instructions for generalization of behavior into real-life situations (Fairburn, 1998). In doing so, the therapist prepares the patient for continued difficulties in real-life situations that hinder progress made in therapy.
Although many studies thus far indicate that CBT is more effective in the short-term, IPT has proven to be more effective in one long-term follow-up. In subjects who received behavior therapy (BT), CBT, or IPT, for Bulimia Nervosa treatment, those receiving IPT were the most symptom free at a 6-year follow-up. In the BT group, 86% still met DSM-IV criteria for Bulimia Nervosa, 37% in the CBT group, and 28% in the IPT group at a 6-year follow-up (Fairburn, 1998). Therefore, more long-term studies should be conducted in order to determine if this finding would be consistent across studies. Overall, IPT has established efficacy in the treatment of Bulimia Nervosa (Fairburn, 1998). It is short-term and directly focuses on interpersonal relations, which CBT fails to adequately address. Therefore, it allows the individual being treated to focus on social acceptance and interpersonal deficits.
Mechanisms of Change
The mechanism of change in IPT is to focus on interpersonal relationships, which are proposed to be the underlying cause of symptom development. It is believed that if interpersonal deficits can be corrected, maladaptive symptoms will decrease. The interpersonal model hypothesizes that interpersonal dependency is one of the central components in the etiology of Bulimia Nervosa (Bornstein, 2001). In interpersonal theory, it is proposed that, separation difficulties from parents lead to a weak sense of self (Friedlander & Siegel, 1990). Individuals are striving for a sense of autonomy, but to no avail.
Parents who become overly enmeshed with their child prohibit the sense of autonomy from occurring. As a result, “the expression of frustrated autonomy needs via eating disorder symptoms reflects both intrapsychic dynamics and cultural messages regarding ideal body size and shape” (Bornstein, 2001, p. 152). Therefore, individuals cannot find solace in interpersonal relationships in their lives, so they resort to food. Individuals overindulge and find comfort in the food rather than in interpersonal relationships.
Although IPT has many uses, it has been proven effective for patients “in the midst of recent conflicts with significant others and for those having difficulty adjusting to an altered career or social role or other life transition” (Weissman & Markowitz, 1998, p. 2). Due to its focus on interpersonal relations and life transitions, IPT should be effective in treating individuals throughout the lifespan.
Comparison of Therapies and Integration Attempts
The features that both IPT and CBT have in common are as follows: treatment structure (number of sessions and frequency), amount of therapist-patient contact, provision of a rationale and instillation of hope, and focus on the here-and-now (Fairbum et al., 1991). The approaches differ on how much insight clients have into their emotions. Cognitive therapists are more willing to take their clients’ report of emotions at face value. Cognitive interventions rely heavily on the assumption that clients are reasonably accurate about what they claim they are feeling. Interpersonal practitioners, in contrast, put less trust in patients as accurate authorities of their inner states: patients might be motivated by anger or hostility without realizing it, might be reacting to an affect that they did not consciously acknowledge, or might link their affects to mistaken sources or targets.
As a result, understanding affects (and deciding what to do with them) in IPT seems more specific to the case formulation of each individual patient (e.g., the patient’s character structure, past relations with significant others, etc.). Whereas cognitive therapists’ primary intervention (modify thinking to reduce negative affect) transcends most individual cases, there are probably fewer hard and fast rules for what IPT practitioners generally “do” with patient affect.
Despite the consistent findings that CBT effectively reduces binge-purge behavior, the treatments currently available have difficulty preventing relapse. Due to the high number of social and interpersonal factors associated with Bulimia Nervosa, the need has arisen to create a treatment technique that identifies interpersonal issues and focuses on them in treatment. As a result, an integration of IPT with CBT appears to effectively treat the social-emotional factors associated with Bulimia Nervosa, as well as the disordered eating patterns involved (Fairbum et al., 1993).
CBT appears to be an effective treatment due to its ability to alter cognitions and decrease binge-purge behavior. However, it does not highlight the social implications which often contribute to the development of the disorder. It must be kept in mind that at any given time throughout the lifespan, individuals are vehemently trying to build an identity for themselves. This is often established by social relations. Therefore, acceptance by society is extremely important, and the individual with Bulimia Nervosa will often suffer any costs necessary to gain acceptance, even if it means physical or psychological harm. As a result, treatment must attend to social needs and interpersonal deficits that may further exacerbate bulimic symptoms (Fairbum et al., 1993).
IPT also appears to be an effective treatment for Bulimia Nervosa. IPT effectively appeals to the interpersonal deficits present in the bulimic individual, but often fails to focus on eating behaviors, which is an important part of the maintenance of Bulimia Nervosa. Therefore, it appears as though CBT combined with IPT would most effectively treat Bulimia Nervosa. If the two theories were combined in treatment, the binge-purge behavior would be reduced, which is the short-term goal, and the interpersonal difficulties would be attended to, which is a long-term goal. As a result, the relapse rate of Bulimia Nervosa should decrease dramatically. Utilizing CBT strategies first would help “overcome the diet-related obsessions and compulsions” and integrating IPT would “examine the clients conflicts over trusting others, (and) trusting her own feelings and sensations” (Friedlander ; Siegel, 1990, p. 77).
As proposed by Santostefano (1998), to integrate two therapies, one must identify the “doorway to enter first, the one leading to life metaphors, cognition, or modes of expression” (p. 284). In Bulimia Nervosa treatment, it would be essential to enter the doorway of interpersonal relationships. However, some Bulimic individuals may not be ready to discuss such issues, so entering at the level of eating behaviors and discovering the cycle in which they are engaged may be an adequate beginning.
Since IPT has a psychodynamic foundation, integrating the two models would call for an integration of both cognitive and relational properties. Santostefano (1998) proposes that the integration of the two theories would develop a treatment that,
operationalizes cognition, emotions, behaviors, change, and prosocial function in particular ways. In addition, the proposed goal leads to concepts and techniques that differ from those of cognitive-behavioral and psychodynamic therapies, yet integrates aspects of each. We observed that mainstream cognitive-behavioral therapies attempt to change behaviors directly, more or less ignoring their meanings, while psychodynamic therapies attempt to change the meanings of behaviors, more or less ignoring the behaviors themselves. The (integrative) technique views behaviors and their meanings as two sides of the same coin and attempt to change both simultaneously. (p. 283)
In integrating the two, it is hoped that both short-term and long-term effectiveness will result. It is hoped that CBT techniques will challenge the cognitive distortions; and IPT techniques will focus on social and interpersonal difficulties, thus creating a well-rounded treatment.
Although CBT and IPT are both effective, they approach treatment from two opposite angles. IPT attempts to discover what interpersonal difficulties attribute to the current disordered eating behaviors. IPT does not actually discuss the problematic eating, but instead focuses on interpersonal skills and relations. CBT, on the other hand, focuses directly on the eating behavior, creating eating diaries and thought stopping techniques to establish what thoughts possibly lead to the disordered eating habits. A combination of the two techniques allows the therapist to effectively decrease problematic eating patterns, as well as to identify the interpersonal factors that may keep the disordered eating active. As a result, the individual is able to refrain from relapse because the interpersonal difficulties contributing to the disordered eating are discovered and actively attended to.
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