- Email: [email protected]
A cognitive behavioural group approach for the treatment of bulimia nervosa — A preliminary study
Journal of Psychosomatic Research, Vol. 32, No. 3, pp. 285-290, Printed in Great Britain.
1988.
A COGNITIVE BEHAVIOURAL THE TREATMENT -
0022-3999/L% $3.00 + .@I cQ 1988 Pergamon Press plc
GROUP APPROACH FOR
OF BULIMIA NERVOSA
A PRELIMINARY STUDY
PAUL A. DEDMAN,* SHARON F. NUMA and ANTHONY WAKELING (Received 7 March 1986; accepted in revised form 22 January 1988)
Abstract-A group treatment for bulimia nervosa based on a cognitive behavioural approach is described. Eight women with a self reported average of 14 binging episodes per week attended a weekly group for 15 weeks. The techniques used in the group are described. Outcome measures included self reported frequency of binging episodes, eating attitudes, depression and anxiety. These were assessed both pre and post treatment. In addition binge frequency was assessed at 3 and 6 month follow up. Binging frequency decreased over the treatment period to an average of 1.1 per week and of 1.9 per week at 6 month follow up. Significant changes in eating attitudes, and a reduction in depression and anxiety were obtained over the treatment period. Although this study was not controlled it may represent a promising step towards the development of a cost-effective treatment for this common condition. INTRODUCTION MEDICAL attention has focused on binge-eating since the delineation of the syndrome bulimia nervosa [l]. This syndrome is characterised by powerful and intractable urges to overeat which result in extremely large quantities of food being consumed in a short time (binge-eating). The sufferer, who also has the morbid fear of being fat, attempts to avoid weight gain by self-induced vomiting or purgative abuse. Russell described this syndrome as ‘an ominous variant of anorexia nervosa’ as the majority of his subjects, who were part of an inpatient population, had previously suffered from this condition. There now appears to be good evidence that bulimia nervosa is relatively common and by virtue of, among other things, normal or near normal weight the majority of cases escape detection or medical intervention [2, 31. The typical sufferer is female, in her early twenties - although the age range tends to be from late teens to middle age. She usually has no history of anorexia nervosa. There is no current consensus with regard to treatment of this condition. Russell reported a poor prognosis with inpatient treatment involving nurses taking responsibility for the patients’ diet. Several psychological treatments have employed behavioural techniques applied to individuals [ 1, 41. Fairburn has developed a cognitive behavioural approach to treatment conducted with outpatients who are seen individually, employing an initial period of intensive input where patients are seen up to two to three times a week using educative and behavioural techniques [5]. This is then followed by attempting to help the patient develop more adaptive ways of coping with events and mood states liable to trigger off binges, including the use of problem solving and other techniques [6]. Promising results have been reported, although the demands of this form of therapy are heavy in terms of therapists’ time. The Academic Dept of Psychiatry, The Royal Free Hospital, Pond Street, London NW3, U.K. *Correspondence to: Dr P. Dedman, 24 Marlborough Road, London N19 4NB, U.K. 285
286
PAUL A. DEDMAN et al.
The high prevalence of bulimia nervosa, 1.9% of adult women [7], highlights the need for a more economical approach involving non-specialist therapists. Boskind-Lodhal and White [8] report some success with a group employing a variety of behavioural and experimental techniques including assertiveness training and guided fantasy exercises. Lacey [9] reported a combined time limited individual and group approach using a variety of techniques, claiming considerable success which was retained at 2 yr follow up. The actual techniques used by Lacey however are not described fully enough for replication. Our study involves an adaptation of Fairburn’s approach to a group situation. PATIENTS
Patients were selected from GP referrals to the Academic Department of Psychological Medicine at the Royal Free Hospital, a department well known for its work with eating disorders, and were taken in chronological order from the waiting list. Nine patients were contacted of which eight eventually joined the group. All eight were female with a mean age of 24.6 (range 18-26). All conformed to DSM III [lo] criteria for bulimia, and all experienced periodic episodes of loss of control over their eating. None was sufficiently underweight to satisfy diagnostic criteria for anorexia nervosa but one had done so in the past. The mean duration of bulimic symptoms was 7.13 yr (range 2-15 yr) and the mean weight was 96% [range 82-112% of the matched population mean weight (MPMW)] [ll]. All subjects were unmarried but four were living with a partner and two were living alone. Five were in regular employment, two were full-time students and one was working sporadically in a freelance capacity. Table I summarises these details. MEASURES (1) Self-reported frequency of hinging and vomiting: this was estimated on a weekly basis by each subject with reference to a daily diary. (2) Eating attitudes: the Eating Attitudes Test (EAT) [12], a questionnaire providing a measure of attitudes towards food and dieting. (3) Anxiety: the Taylor Manifest Anxiety Scale, a self-report subjective measure of anxiety [13]. (4) Depression: the Beck Depression Inventory [14], an inventory of the severity of depressive symptoms. Measures were administered before treatment, at week 7 of treatment, at the end of the treatment period and at 3 and 6 month follow ups.
TREATMENT Patients were seen individually for initial assessment and history patient basis and took the form of a closed group which met weekly half hour’s duration. The group was led by two conductors (PD and variety of group work. Treatment employed a variety of techniques and cognitive therapies, and was divided into two phases.
taking. Treatment was on an outfor 15 sessions each of one and a SN), both having experience in a derived from behaviour therapies
Phase 1. Weeks 1-7 The aim was to facilitate awareness of the function of bulimic behaviours, to share experience and to achieve a gradual change towards a more normal diet in the setting of a cohesive group. This was effected by the members’ use of diaries in which an itemised record of all food ingested. all episodes of vomiting, laxative use or other drug use was kept daily. This was then used as a basis for each group member to discuss the events of the past week in the sessions, with other members participating. Members were encouraged to think of binging episodes in terms of possible events which had precipitated
The treatment
of bulimia
nervosa
287
the episode, their feelings and emotions at the time and the way in which these were altered after the episode. In addition members were encouraged to set for themselves, and often with the help of other group members, weekly goals leading towards an ultimate target of regular meals, three times daily. The emphasis throughout was on the addition of desirable behaviour, such as eating a defined, circumscribed meal, rather than an attempt to avoid binging per se. Most members found eating breakfast the most easily attainable first target and also the one from which it was easiest to progress to further targets. By the end of this phase most members had achieved the target of three meals a day with an associated reduction in dietary chaos and binging.
PAUL A. DEDMAN et al.
288
Phase 2. Weeks 8-15. The emphasis during this phase of treatment was on the cognitive processes involved in chaotic eating patterns. The format of the groups remained unchanged, with members disclosing details of the past week and arriving at a behavioural target for the next week. However, elements of the cognitive therapies [15, 161 were introduced by the therapists, including the recognition of cognitive distortions operating in relation to eating habits and the identification of the ‘automatic thoughts’ underlying any particular assumption. In addition, limited use was made of role playing, and instruction in problem solving [17] was given. Members were encouraged to eat formerly ‘forbidden’ foods such as high carbohydrate foodstuffs. Members were not discouraged from contacting each other outside of group time and they spontaneously decided to exchange telephone numbers so that they could use each other as a ‘crisis line’. At the end of treatment members discussed forming a self-help group but never put this into practice in a regular way.
RESULTS
Table II summarises the principal clinical findings. Over the treatment period the main frequency of bulimic episodes decreased from 14 to just over one per week, with six out of the eight patients managing to achieve a figure of one or no bulimic episodes per week. There were no significant changes in body weight. At
TABLE II. -PRINCIPAL
CLINICAL FINDINGS
Frequency of binging episodes per week
Patient
At onset of treatment
Mean Number reporting no bulimic episodes
At week 7
0
At week 15
VIZfollow up
VIZfollow up
19 4 20 3 6 8 14 40
0 1 0 0 0 3 12
1 1 0 0 3 0 3 1
0 1 7 3 1 0 0 20
10 0 0 0 1 0 0 4
14
2.0
1.1
4.0
1.9
0
5
3
5
3
TABLEIIL-t TESTSONPRETOPOSTTREATMENTSCOREMEANSFORTHE BECK DEPRESSION INVENTORY, THE EAT AND THE TAYLOR SCALE
Post treatment
Pretreatment
Eat Beck Taylor
N
Mean
SD
N
Mean
SD
8 8 8
62 18 25.6
8.32 6.04 5.13
8 8 8
24 9 19.6
14.9 8.63 4.16
*df 14 = P = 0.005. tdf 8 = P = 0.05. Sdf 8 = P = 0.05.
t 6.29* -1.91t -2.03$
The treatment of bulimia nervosa
289
6 month follow up improvement appears to have been maintained in all but two of the patients. A significant pre to post treatment difference was demonstrated on the Eating Attitudes Test representing a reduction in anorexic attitudes. There was also a significant reduction in measured levels of both depression and anxiety over the treatment period as detailed in Table III.
DISCUSSION
With 60% of our sample binge-free at 6 month follow up the results of our study compared favourably with those of the similar 16 week group treatment reported by Schneider and Agras [18] where 45% were binge-free at 6 month follow up, but less impressive than those of the individual treatment reported by Fairburn. Schneider and Agras’ groups involved similar numbers of patients, (13 divided into two groups) with a higher mean frequency of bulimic episodes (12 per week compared with 14 in our group). Their sample were slightly less chronic than our group, (median duration of symptoms being 5 yr as opposed to our median duration of 6 yr), but were significantly depressed as measured on the Beck Scale, whereas our group fell into the normal range on the Beck score. Fairburn’s regime, in addition to being on an individual basis, differed in the length of treatment, which averaged 28 weeks. Fairburn’s patients were comparable with our group with respect to the frequency of bulimic symptoms, (mean 12 episodes weekly) but were less chronic (mean duration of symptoms being 3-9 yr). Feedback from the group members together with good attendance at groups suggested that our treatment programme was acceptable to patients and experienced as relevant to their needs. It was also our impression that the control of binging produced an effect which generalized to other areas of life, producing an increase in purpose and self assertion, and reduction in self deprecation. Indeed, several members of the group were able to finish unsatisfactory intimate relationships during the treatment period and improve their job situations. The success of our programme with its emphasis on encouraging the eating of three meals a day and not concentrating on reduction of binging per se seems to lend support to the theoretical perspective of viewing binge-eating as a consequence of dietary restraint [19]. The high prevalence of eating disorders emphasises the need to develop a treatment approach which is cost-effective and could become widely available possibly in a primary care setting. Our approach fulfils some of these criteria as it is of limited duration and is suitable for use by trained members of a variety of health care professions. We recognise that our study was uncontrolled, but feel that our results are promising enough to merit further pursuance of similar controlled treatment studies. If this treatment package can be shown to be effective it will then be necessary to examine in more detail which components are implicated in a successful outcome.
PAUL A. DEDMAN et al.
290
REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9.
10. 11. 12. 13. 14. 15. 16. 17.
RUSSELL GFM. Bulimia nervosa: an ominous variant of anorexia nervosa. Psychol Med 1979; 9: 429-448. FAIRBURN CG. A cognitive behavioural approach to the treatment of bulimia. Psychol Med 1981; 11: 707-711. FAIRBURN CG, COOPER PJ. Self-induced vomiting and bulimia nervosa: an undetected problem. Br med J 1982; 284: 1153-1155. WELCH GJ. The treatment of compulsive vomiting and obsessive thoughts through graduated response delay, response prevention and cognitive correction. .I Behav Ther Exp Psychiat 1979; 10: 77-82. MAHONEY ML, MAHONEY K. Permanent Wei,eht Control. New York: WW Norton, 1961. MEICHENBAUM D. Cognitive Behaviour Modij&ation. New York: Plenum, 1977. COOPER PJ, FAIRBURN CG. Binge-eating and self-induced vomiting in the community: a preliminary study. Br J Psychiat 1983; 142: 139-144. BOSKIND-LODAHL M, WHITE W. The definition and treatment of bulimarexia in college women - a pilot studv. J Am Co11 Health 1978; 21: 84-97. LA&Y HJ. Bulimia nervosa, binge eating, and psychogenic vomiting; a controlled treatment study and long term outcome. B med .7 1983; 286: 1609-1613. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM III): Washington, 1980. DIEM C (ed). Documenta Geigy Scientific Tables. 6th Edn. Manchester: Geigy Pharmaceuticals, 1962. GARNER DM, GARFINKEL PE. The Eating Attitudes Test: an index of the symptoms of anorexia nervosa. Psycho1 Med 1979; 9: 273-279. TAYLOR JA. A personality scale of manifest anxiety. J abnorm Psycho1 1953; 48: 285-290. BECK T, WARD C, MENDELSON M. An inventory for measuring depression. Archs gen Psychiat 1961; 4: 561-571. BECK T, RUSH AJ, SHAW BF, EMERY G. Cognitive Therapy of Depression. Chichester: John Wiley, 1979. BYRNE D. Feeling Good: The New Marvel Therapy. New York: Signet, 1980. D’ZURILLA TJ, GOLDFRIED MR. Problem solving and behaviour modification. J abnorm Psycho1 1971; 78: 107-126.
SCHNEIDER JA, AGRAS WS. Cognitive behavioural group treatment of bulimia. Br J Psychiat 1985; 146:66-69. 19. WARDLE J, BEINHARTH. Binge eating: a theoretical review. BrJclin Psycholl981; 20: 97-109.
18.
1988.
A COGNITIVE BEHAVIOURAL THE TREATMENT -
0022-3999/L% $3.00 + .@I cQ 1988 Pergamon Press plc
GROUP APPROACH FOR
OF BULIMIA NERVOSA
A PRELIMINARY STUDY
PAUL A. DEDMAN,* SHARON F. NUMA and ANTHONY WAKELING (Received 7 March 1986; accepted in revised form 22 January 1988)
Abstract-A group treatment for bulimia nervosa based on a cognitive behavioural approach is described. Eight women with a self reported average of 14 binging episodes per week attended a weekly group for 15 weeks. The techniques used in the group are described. Outcome measures included self reported frequency of binging episodes, eating attitudes, depression and anxiety. These were assessed both pre and post treatment. In addition binge frequency was assessed at 3 and 6 month follow up. Binging frequency decreased over the treatment period to an average of 1.1 per week and of 1.9 per week at 6 month follow up. Significant changes in eating attitudes, and a reduction in depression and anxiety were obtained over the treatment period. Although this study was not controlled it may represent a promising step towards the development of a cost-effective treatment for this common condition. INTRODUCTION MEDICAL attention has focused on binge-eating since the delineation of the syndrome bulimia nervosa [l]. This syndrome is characterised by powerful and intractable urges to overeat which result in extremely large quantities of food being consumed in a short time (binge-eating). The sufferer, who also has the morbid fear of being fat, attempts to avoid weight gain by self-induced vomiting or purgative abuse. Russell described this syndrome as ‘an ominous variant of anorexia nervosa’ as the majority of his subjects, who were part of an inpatient population, had previously suffered from this condition. There now appears to be good evidence that bulimia nervosa is relatively common and by virtue of, among other things, normal or near normal weight the majority of cases escape detection or medical intervention [2, 31. The typical sufferer is female, in her early twenties - although the age range tends to be from late teens to middle age. She usually has no history of anorexia nervosa. There is no current consensus with regard to treatment of this condition. Russell reported a poor prognosis with inpatient treatment involving nurses taking responsibility for the patients’ diet. Several psychological treatments have employed behavioural techniques applied to individuals [ 1, 41. Fairburn has developed a cognitive behavioural approach to treatment conducted with outpatients who are seen individually, employing an initial period of intensive input where patients are seen up to two to three times a week using educative and behavioural techniques [5]. This is then followed by attempting to help the patient develop more adaptive ways of coping with events and mood states liable to trigger off binges, including the use of problem solving and other techniques [6]. Promising results have been reported, although the demands of this form of therapy are heavy in terms of therapists’ time. The Academic Dept of Psychiatry, The Royal Free Hospital, Pond Street, London NW3, U.K. *Correspondence to: Dr P. Dedman, 24 Marlborough Road, London N19 4NB, U.K. 285
286
PAUL A. DEDMAN et al.
The high prevalence of bulimia nervosa, 1.9% of adult women [7], highlights the need for a more economical approach involving non-specialist therapists. Boskind-Lodhal and White [8] report some success with a group employing a variety of behavioural and experimental techniques including assertiveness training and guided fantasy exercises. Lacey [9] reported a combined time limited individual and group approach using a variety of techniques, claiming considerable success which was retained at 2 yr follow up. The actual techniques used by Lacey however are not described fully enough for replication. Our study involves an adaptation of Fairburn’s approach to a group situation. PATIENTS
Patients were selected from GP referrals to the Academic Department of Psychological Medicine at the Royal Free Hospital, a department well known for its work with eating disorders, and were taken in chronological order from the waiting list. Nine patients were contacted of which eight eventually joined the group. All eight were female with a mean age of 24.6 (range 18-26). All conformed to DSM III [lo] criteria for bulimia, and all experienced periodic episodes of loss of control over their eating. None was sufficiently underweight to satisfy diagnostic criteria for anorexia nervosa but one had done so in the past. The mean duration of bulimic symptoms was 7.13 yr (range 2-15 yr) and the mean weight was 96% [range 82-112% of the matched population mean weight (MPMW)] [ll]. All subjects were unmarried but four were living with a partner and two were living alone. Five were in regular employment, two were full-time students and one was working sporadically in a freelance capacity. Table I summarises these details. MEASURES (1) Self-reported frequency of hinging and vomiting: this was estimated on a weekly basis by each subject with reference to a daily diary. (2) Eating attitudes: the Eating Attitudes Test (EAT) [12], a questionnaire providing a measure of attitudes towards food and dieting. (3) Anxiety: the Taylor Manifest Anxiety Scale, a self-report subjective measure of anxiety [13]. (4) Depression: the Beck Depression Inventory [14], an inventory of the severity of depressive symptoms. Measures were administered before treatment, at week 7 of treatment, at the end of the treatment period and at 3 and 6 month follow ups.
TREATMENT Patients were seen individually for initial assessment and history patient basis and took the form of a closed group which met weekly half hour’s duration. The group was led by two conductors (PD and variety of group work. Treatment employed a variety of techniques and cognitive therapies, and was divided into two phases.
taking. Treatment was on an outfor 15 sessions each of one and a SN), both having experience in a derived from behaviour therapies
Phase 1. Weeks 1-7 The aim was to facilitate awareness of the function of bulimic behaviours, to share experience and to achieve a gradual change towards a more normal diet in the setting of a cohesive group. This was effected by the members’ use of diaries in which an itemised record of all food ingested. all episodes of vomiting, laxative use or other drug use was kept daily. This was then used as a basis for each group member to discuss the events of the past week in the sessions, with other members participating. Members were encouraged to think of binging episodes in terms of possible events which had precipitated
The treatment
of bulimia
nervosa
287
the episode, their feelings and emotions at the time and the way in which these were altered after the episode. In addition members were encouraged to set for themselves, and often with the help of other group members, weekly goals leading towards an ultimate target of regular meals, three times daily. The emphasis throughout was on the addition of desirable behaviour, such as eating a defined, circumscribed meal, rather than an attempt to avoid binging per se. Most members found eating breakfast the most easily attainable first target and also the one from which it was easiest to progress to further targets. By the end of this phase most members had achieved the target of three meals a day with an associated reduction in dietary chaos and binging.
PAUL A. DEDMAN et al.
288
Phase 2. Weeks 8-15. The emphasis during this phase of treatment was on the cognitive processes involved in chaotic eating patterns. The format of the groups remained unchanged, with members disclosing details of the past week and arriving at a behavioural target for the next week. However, elements of the cognitive therapies [15, 161 were introduced by the therapists, including the recognition of cognitive distortions operating in relation to eating habits and the identification of the ‘automatic thoughts’ underlying any particular assumption. In addition, limited use was made of role playing, and instruction in problem solving [17] was given. Members were encouraged to eat formerly ‘forbidden’ foods such as high carbohydrate foodstuffs. Members were not discouraged from contacting each other outside of group time and they spontaneously decided to exchange telephone numbers so that they could use each other as a ‘crisis line’. At the end of treatment members discussed forming a self-help group but never put this into practice in a regular way.
RESULTS
Table II summarises the principal clinical findings. Over the treatment period the main frequency of bulimic episodes decreased from 14 to just over one per week, with six out of the eight patients managing to achieve a figure of one or no bulimic episodes per week. There were no significant changes in body weight. At
TABLE II. -PRINCIPAL
CLINICAL FINDINGS
Frequency of binging episodes per week
Patient
At onset of treatment
Mean Number reporting no bulimic episodes
At week 7
0
At week 15
VIZfollow up
VIZfollow up
19 4 20 3 6 8 14 40
0 1 0 0 0 3 12
1 1 0 0 3 0 3 1
0 1 7 3 1 0 0 20
10 0 0 0 1 0 0 4
14
2.0
1.1
4.0
1.9
0
5
3
5
3
TABLEIIL-t TESTSONPRETOPOSTTREATMENTSCOREMEANSFORTHE BECK DEPRESSION INVENTORY, THE EAT AND THE TAYLOR SCALE
Post treatment
Pretreatment
Eat Beck Taylor
N
Mean
SD
N
Mean
SD
8 8 8
62 18 25.6
8.32 6.04 5.13
8 8 8
24 9 19.6
14.9 8.63 4.16
*df 14 = P = 0.005. tdf 8 = P = 0.05. Sdf 8 = P = 0.05.
t 6.29* -1.91t -2.03$
The treatment of bulimia nervosa
289
6 month follow up improvement appears to have been maintained in all but two of the patients. A significant pre to post treatment difference was demonstrated on the Eating Attitudes Test representing a reduction in anorexic attitudes. There was also a significant reduction in measured levels of both depression and anxiety over the treatment period as detailed in Table III.
DISCUSSION
With 60% of our sample binge-free at 6 month follow up the results of our study compared favourably with those of the similar 16 week group treatment reported by Schneider and Agras [18] where 45% were binge-free at 6 month follow up, but less impressive than those of the individual treatment reported by Fairburn. Schneider and Agras’ groups involved similar numbers of patients, (13 divided into two groups) with a higher mean frequency of bulimic episodes (12 per week compared with 14 in our group). Their sample were slightly less chronic than our group, (median duration of symptoms being 5 yr as opposed to our median duration of 6 yr), but were significantly depressed as measured on the Beck Scale, whereas our group fell into the normal range on the Beck score. Fairburn’s regime, in addition to being on an individual basis, differed in the length of treatment, which averaged 28 weeks. Fairburn’s patients were comparable with our group with respect to the frequency of bulimic symptoms, (mean 12 episodes weekly) but were less chronic (mean duration of symptoms being 3-9 yr). Feedback from the group members together with good attendance at groups suggested that our treatment programme was acceptable to patients and experienced as relevant to their needs. It was also our impression that the control of binging produced an effect which generalized to other areas of life, producing an increase in purpose and self assertion, and reduction in self deprecation. Indeed, several members of the group were able to finish unsatisfactory intimate relationships during the treatment period and improve their job situations. The success of our programme with its emphasis on encouraging the eating of three meals a day and not concentrating on reduction of binging per se seems to lend support to the theoretical perspective of viewing binge-eating as a consequence of dietary restraint [19]. The high prevalence of eating disorders emphasises the need to develop a treatment approach which is cost-effective and could become widely available possibly in a primary care setting. Our approach fulfils some of these criteria as it is of limited duration and is suitable for use by trained members of a variety of health care professions. We recognise that our study was uncontrolled, but feel that our results are promising enough to merit further pursuance of similar controlled treatment studies. If this treatment package can be shown to be effective it will then be necessary to examine in more detail which components are implicated in a successful outcome.
PAUL A. DEDMAN et al.
290
REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9.
10. 11. 12. 13. 14. 15. 16. 17.
RUSSELL GFM. Bulimia nervosa: an ominous variant of anorexia nervosa. Psychol Med 1979; 9: 429-448. FAIRBURN CG. A cognitive behavioural approach to the treatment of bulimia. Psychol Med 1981; 11: 707-711. FAIRBURN CG, COOPER PJ. Self-induced vomiting and bulimia nervosa: an undetected problem. Br med J 1982; 284: 1153-1155. WELCH GJ. The treatment of compulsive vomiting and obsessive thoughts through graduated response delay, response prevention and cognitive correction. .I Behav Ther Exp Psychiat 1979; 10: 77-82. MAHONEY ML, MAHONEY K. Permanent Wei,eht Control. New York: WW Norton, 1961. MEICHENBAUM D. Cognitive Behaviour Modij&ation. New York: Plenum, 1977. COOPER PJ, FAIRBURN CG. Binge-eating and self-induced vomiting in the community: a preliminary study. Br J Psychiat 1983; 142: 139-144. BOSKIND-LODAHL M, WHITE W. The definition and treatment of bulimarexia in college women - a pilot studv. J Am Co11 Health 1978; 21: 84-97. LA&Y HJ. Bulimia nervosa, binge eating, and psychogenic vomiting; a controlled treatment study and long term outcome. B med .7 1983; 286: 1609-1613. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM III): Washington, 1980. DIEM C (ed). Documenta Geigy Scientific Tables. 6th Edn. Manchester: Geigy Pharmaceuticals, 1962. GARNER DM, GARFINKEL PE. The Eating Attitudes Test: an index of the symptoms of anorexia nervosa. Psycho1 Med 1979; 9: 273-279. TAYLOR JA. A personality scale of manifest anxiety. J abnorm Psycho1 1953; 48: 285-290. BECK T, WARD C, MENDELSON M. An inventory for measuring depression. Archs gen Psychiat 1961; 4: 561-571. BECK T, RUSH AJ, SHAW BF, EMERY G. Cognitive Therapy of Depression. Chichester: John Wiley, 1979. BYRNE D. Feeling Good: The New Marvel Therapy. New York: Signet, 1980. D’ZURILLA TJ, GOLDFRIED MR. Problem solving and behaviour modification. J abnorm Psycho1 1971; 78: 107-126.
SCHNEIDER JA, AGRAS WS. Cognitive behavioural group treatment of bulimia. Br J Psychiat 1985; 146:66-69. 19. WARDLE J, BEINHARTH. Binge eating: a theoretical review. BrJclin Psycholl981; 20: 97-109.
18.