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Psychotherapy for bulimia: A controlled study
J. psychor. Res.. Vol. 19, No. 2/3, PD. 473-478. Printed in Great Britain
1985
0022-3956/M 53.00+ .W Pergamon Press Ltd.
PSYCHOTHERAPY FOR BULIMIA: A CONTROLLED STUDY CHRISTOPHER FREEMAN, FIONA SINCLAIR, JANE TURNBULL and ANNETTE ANNANDALE Department of Psychiatry, Edinburgh University, U.K. Summary-A psychotherapy study for bulimia is described. The preliminary results of a random allocation control trial comparing cognitive behaviour therapy, behaviour therapy and group psychotherapy with a waiting list control are presented. The results of the first 60 subjects in active treatment are shown. They indicate that all three treatments are effective in dramatically reducing the behavioUra1 symptoms of the bulimia syndrome. There is evidence that cognitive therapy has a greater effect on symptoms of depression and self-esteem. No evidence is yet available on the longterm outcome of the three treatments.
INTRODUCTION THIS paper
presents
the results
of the first eighteen
months
of a psychotherapy
study
into the treatment of bulimia being carried out in Edinburgh. The study was designed to answer the following questions: Are specific treatments for bulimia effective and more effective
than waiting
list control?
Are there differences
in efficacy
between
and group treatments? Are treatments which address the specific abnormal beliefs that occur in bulimia more effective than those which concentrate disordered
behaviour.
administered: 1. By relatively
The treatments
inexperienced
were specifically
designed
individual
thoughts and only on the
so that they could
be
therapists;
2. Within the National Health Service; 3. To a group of individuals who were usually engaged in full-time
study or employment.
There have been several controlled treatment studies of drug therapies for bulimia but as far as we are aware this is the first controlled trial of psychotherapeutic intervention. METHOD
Treatments Three active treatments were compared. of therapists are given in Table 1. TABLE 1
Cognitive
2 3
Behaviour therapy Group therapy (all above treatments Waiting list control
4
Details of duration
1. STUDY
therapy
of treatment
DESIGN Therapist
A or Therapist
B
Therapist A or Therapist B Therapist A and B together 15 sessions 1 hour/week) 15 weeks 473
and allocation
474
CHRISTOPHER FREEMANet al.
Behaviour therapy This involved diary self-monitoring, attempts to systematically modify eating behaviour, teaching of alternative coping strategies, relaxation training, training in problem-solving techniques and in some cases exposure and response prevention. Each session ended with the subject setting herself limited but clearly defined behavioural tasks. Treatment was aimed at trying to establish a regular eating pattern consisting of three meals a day, snacks between meals and the inclusion of trigger foods in the diet. Subjects were encouraged to focus on their eating pattern and behaviour during treatment rather than on their weight. As the treatment progressed there was some attempt to deal with areas such as selfesteem, assertiveness and interpersonal relationships. Cognitive behaviourai therapy This treatment followed closely the model set out by BECK (1976) for the treatment of depression. As well as the self monitoring described above, the patients were trained to identify automatic thoughts. They kept regular automatic thought records, and by means of Socratic questioning these thoughts were challenged. At the start of therapy maladaptive cognitions relating to eating and weight were most often tackled. As therapy progressed other issues such as depressive thoughts, self-esteem and assertiveness were discussed. There was much less attempt made in this treatment to specifically alter abnormal behaviour though self-monitoring was used throughout both treatments. Group therapy The groups were semi-structured in that in the first ten minutes of each session a specific topic was dealt with by the two therapists. The groups were designed to be educational, supportive and explorative. Videos were occasionally used to stimulate discussion. Again self-monitoring was continuous. Groups usually began with eight subjects. Control group A randomly selected group of women who met the entry criteria for the study constituted the control group. These were then seen twice; the first time to confirm that they met the criteria and complete baseline measures. At a second, brief interview one week later control subjects handed over a food diary, which enabled diagnosis and present rate of bulimic behaviour to be confirmed. Fifteen weeks later they returned and were reassessed before beginning treatment. All treatments were on an outpatient basis. En try criteria Subjects had to meet DSM-III (1980) criteria for bulimia: they had to be female, with no past history of psychotic illness, over 16 yr of age and have binged at least four times in the past month. They had to have a history of at least six months of continuous bulimia. They were not receiving any concurrent treatment for bulimic symptoms, e.g. depression. Study design The subjects were assessed by an independent rater on a large number of dependent variables. Standard eating disorder inventories (GARNERet al., 1979, 1982, 1983; FREEMAN
A STUDY OFPSYCHOTHERAPY FOR BULIMIA TABLE
Dependent variable
2. MEASURE OFCHANGE
AND TIMING
Pre-treatment
Personal History Questionnaire Weight and Eating Questionnaire Binge Eating Questionnaire EDI EAT Restraint Questionnaire Hunger and Satiety Questionnaire Locus of Control Self Esteem Questionnaire Montgomery Asberg Depression Scale (MAD) I.D.A. Self Rating Scales Self Monitoring
+ + + + + + + + + + +
OFASSESSMENTS
Mid-treatment
-
475
End-treatment
Follow-up every 3 months for 1 yr
+ + +
+ + +
+ + +
+ +
+ + + +
+ + +
continuous
+
and HENDERSON, 1985) and self-rating personality scales (CAINE et al., 1976; HERMAN and POLIVY, 1975; MONTGOMERY and ASBERG, 1979; SNAITH et al., 1978; SPIELBERGER et al., 1969; ZUCKERMAN et al., 1964) were administered, and repeated at various times during therapy and follow-up (cf. Table 2 for details). Allocation to treatment was by restricted randomisation, the ratio of allocation to group and individual treatments being altered in favour of group treatment during the weeks leading up to a new group starting. This variable ratio randomisation was necessary to ensure that the time elapsed between completing assessment and beginning therapy was minimised for all subjects.
Adequacy and separateness of treatments To control for therapist variables we felt it essential that each treatment should be administered by both therapists (see Table 1). Neither therapist had any particular bias in favour of a given treatment. Both were of equal training and experience though one was a nurse therapist and the other a clinical psychologist. To check for contamination of one treatment modality by another some treatment sessions were videoed and rated by an independent observer. RESULTS The subjects were referred by local general practitioners, self-help groups, a women’s health shop and contraceptive clinics. In the first fifteen months of the study 86 persons were assessed. Of these 25% failed to meet our criteria. Five met the DSM-III criteria for anorexia nervosa, three stopped bingeing during the assessment period, eight did not binge or binged less frequently than four times a month, two were male, two psychotic and one repeatedly induced vomiting but had none of the other psychopathology of bulimia. Of the remaining 65 women, three dropped out during assessment or decided not to enter therapy and two lived too far away for feasible regular attendance. The remaining 60 subjects were entered into the study. All met DSM-III criteria, and 40 met the criteria laid down by RUSSELL (1979). Their ages ranged from 16 to 42 with a mean of 24.3. Eight were married or separated and the rest single. They had a history of bulimia from six
CHRISTOPHERFREEMAN
476
etal. ICI
(bl
Ial nllw FRWOm T
T
EATING AllMlfSTEST IEAII
MoNlGo!4mrssERG oEPKssw SCALEIWI
1
T cogm cp 1.9 50 6.5 FIX Cop= Copnittte Therapy ft8h: bharlouf Mapy Sp I Gmup Thempy
CogMb
0.25 042 0.25 POSl
wr
GP 37.5 39.6 11.8
Cog
lL.2 13.9 lo.5
PM
T
T
r
I-.
POST
118
U.6
PM
11.3
2-s
8.0
5.3
msl
figures am mean scores on mting xalrr lines thmugh bar graphs repmsat standard dcwation Fro. I.
months to 18 yr with a mean of 6.5 yr. The mean age at onset of bulimia was 17.8 yr with range of onset from 10 to 30 yr. No significant differences were apparent between subjects when self-referrals were compared with those referred by general practitioner. Drop-outs during treatment Fourteen of the 60 subjects did not complete treatment. The drop-out rate was twice as high in the group compared with the individual treatments. There were three main reasons for failing to complete treatment. Four subjects required antidepressants and were therefore excluded. In group treatment, drop-outs seemed to be related mainly to the lack of improvement and dissatisfaction with the treatment modality. In individual therapy this reason was rare and drop-out seemed to be more related to improvement and an unwillingness to continue with regular treatment sessions. Results of those completing treatment Space precludes the detailed analysis of all outcome variables. Some of the more important measures are shown in Fig. 1. As far as the behavioural aspects of the bulimia syndrome were concerned, all three treatments produced clinically and statistically significant improvements in bingeing, vomiting and purgative abuse. There were no significant differences between treatments and in the vast majority of cases, such behaviour was reduced to zero or to a minimal level by the end of treatment. All three treatments produced significant improvement in levels of depression, but this effect was most pronounced in the cognitive therapy treatment (see Fig. 1).
A STUDYOFPSYCHOTHERAPY FORBULIMIA TABLE3. SELFRATING
417
SCALES (IDA)
Cognitive therapy
Significant reduction
in in in
Depression Anxiety Outward irritability
Behaviour therapy
Significant reduction
in in in in
Depression Anxiety Outward irritability Inward irritability
Group therapy
Significant reduction
in
Inward irritability only
The I.D.A. self-rating scale for anxiety, depression and inward and outward irritability showed that cognitive and behaviour therapy produced greater improvement than did group therapy (see Table 3). Waiting list control For technical reasons, this group was started later than the three active treatments. This was so that the therapists could be fully employed from the start of the study. So far this group numbers ten subjects and there is little evidence of any change in bulimic behaviour over the 15 week waiting period.
DISCUSSION
These results are preliminary, and the study is still in progress. We plan to continue until there are at least 35 subjects in each group. Initial analysis suggests that all three treatments are effective at reducing the frequency of bulimic behaviour, implying that the most economical way of doing this would be in a group setting. There are already some definite indications that cognitive therapy appears to be most effective at altering depressive thoughts, self-esteem and feelings of control. The high drop-out rate for group treatment has not been reported by other authors. Final confirmation and explication of these findings will be available when the main part of the study is concluded. The crucial test of the treatments however will be the rates of relapse when treatment is finished. Accordingly we intend to follow up subjects for at least a year, and longer if possible. REFERENCES CAINE, T. M., FOULDS,B. A. and HOPE, K. (1967) Monuol of the Hostiiity and Direction of Hostility Question-
noire (HDHQ). University of London Press, London. Diagnostic ond Stotisticol Monuol of Mentol Disorders (1980), 3rd Edn. American Psychiatric Association, Washington, D.C. FREEMAN,C. P. L. and HENDERSON,M. (1985) The Bulimic Investigatory Test. Edinburgh (B.I.T.E.), in press. GARNER, D. M., OLMS~ED,M. P. and POLIVY,J. (1983) The development and validation of a multi-dimensional eating disorder inventory for anorexia nervosa and bulimia. Int. J. Eoting Disord. 2.15-34. GARNER,D. M., OLMSTED,M. P., BOHR, Y. and GARFINKEL,P. E. (1982) The Eating Attitudes Test; psychometric features and clinical correlates. Psychof. Med. 12.871-878. GARNER,D. M. and GARFINKEL,P. E. (1979) The Eating Attitudes Test: an index of the symptoms of anorexia nervosa. Psycho/. Med. 9,273-279.
478
CHRISTOPHERFREEMAN et al.
HEWAN, C. P. and POLIVY.J. (1975) Anxiety, restraint and eating behavior. J. abnorm. Psycho/. 84.666-672. MONTOOM~RY, S. A. and ASBERG, M. A new depression scale designed to be sensitive to change. Br. J. Pry&at. 134,382-389. Russa~~, G. F. M. (1979) Bulimia nervosa: an ominous variant of anorexia nervosa. Psyc/tol. Med. 9,429-448. SNNTH, R. P.. CONSTANTOPO~ILOS, A. A., JARD~N~,M. Y. and McGt.nnn~. P. 1978) A clinical scale for the self-assessment of irritability. Br. J. Psychiat. 132, 164-171. SPIELBKROHR,C. D. GXt.WCH, R. L. and LUSHENB,R. (1969) The State-Trait Anxiety Inventory Form X-I. The Consulting Psychologists Press, Palo Alto. California. ZUCKE~WAN,M.. KOLIN, E. A., PRICE, L. and Zooa. I. (1964) Development of a Sensation Seeking Scale. J. Consult. Psychol. t8(b), 477-482.
1985
0022-3956/M 53.00+ .W Pergamon Press Ltd.
PSYCHOTHERAPY FOR BULIMIA: A CONTROLLED STUDY CHRISTOPHER FREEMAN, FIONA SINCLAIR, JANE TURNBULL and ANNETTE ANNANDALE Department of Psychiatry, Edinburgh University, U.K. Summary-A psychotherapy study for bulimia is described. The preliminary results of a random allocation control trial comparing cognitive behaviour therapy, behaviour therapy and group psychotherapy with a waiting list control are presented. The results of the first 60 subjects in active treatment are shown. They indicate that all three treatments are effective in dramatically reducing the behavioUra1 symptoms of the bulimia syndrome. There is evidence that cognitive therapy has a greater effect on symptoms of depression and self-esteem. No evidence is yet available on the longterm outcome of the three treatments.
INTRODUCTION THIS paper
presents
the results
of the first eighteen
months
of a psychotherapy
study
into the treatment of bulimia being carried out in Edinburgh. The study was designed to answer the following questions: Are specific treatments for bulimia effective and more effective
than waiting
list control?
Are there differences
in efficacy
between
and group treatments? Are treatments which address the specific abnormal beliefs that occur in bulimia more effective than those which concentrate disordered
behaviour.
administered: 1. By relatively
The treatments
inexperienced
were specifically
designed
individual
thoughts and only on the
so that they could
be
therapists;
2. Within the National Health Service; 3. To a group of individuals who were usually engaged in full-time
study or employment.
There have been several controlled treatment studies of drug therapies for bulimia but as far as we are aware this is the first controlled trial of psychotherapeutic intervention. METHOD
Treatments Three active treatments were compared. of therapists are given in Table 1. TABLE 1
Cognitive
2 3
Behaviour therapy Group therapy (all above treatments Waiting list control
4
Details of duration
1. STUDY
therapy
of treatment
DESIGN Therapist
A or Therapist
B
Therapist A or Therapist B Therapist A and B together 15 sessions 1 hour/week) 15 weeks 473
and allocation
474
CHRISTOPHER FREEMANet al.
Behaviour therapy This involved diary self-monitoring, attempts to systematically modify eating behaviour, teaching of alternative coping strategies, relaxation training, training in problem-solving techniques and in some cases exposure and response prevention. Each session ended with the subject setting herself limited but clearly defined behavioural tasks. Treatment was aimed at trying to establish a regular eating pattern consisting of three meals a day, snacks between meals and the inclusion of trigger foods in the diet. Subjects were encouraged to focus on their eating pattern and behaviour during treatment rather than on their weight. As the treatment progressed there was some attempt to deal with areas such as selfesteem, assertiveness and interpersonal relationships. Cognitive behaviourai therapy This treatment followed closely the model set out by BECK (1976) for the treatment of depression. As well as the self monitoring described above, the patients were trained to identify automatic thoughts. They kept regular automatic thought records, and by means of Socratic questioning these thoughts were challenged. At the start of therapy maladaptive cognitions relating to eating and weight were most often tackled. As therapy progressed other issues such as depressive thoughts, self-esteem and assertiveness were discussed. There was much less attempt made in this treatment to specifically alter abnormal behaviour though self-monitoring was used throughout both treatments. Group therapy The groups were semi-structured in that in the first ten minutes of each session a specific topic was dealt with by the two therapists. The groups were designed to be educational, supportive and explorative. Videos were occasionally used to stimulate discussion. Again self-monitoring was continuous. Groups usually began with eight subjects. Control group A randomly selected group of women who met the entry criteria for the study constituted the control group. These were then seen twice; the first time to confirm that they met the criteria and complete baseline measures. At a second, brief interview one week later control subjects handed over a food diary, which enabled diagnosis and present rate of bulimic behaviour to be confirmed. Fifteen weeks later they returned and were reassessed before beginning treatment. All treatments were on an outpatient basis. En try criteria Subjects had to meet DSM-III (1980) criteria for bulimia: they had to be female, with no past history of psychotic illness, over 16 yr of age and have binged at least four times in the past month. They had to have a history of at least six months of continuous bulimia. They were not receiving any concurrent treatment for bulimic symptoms, e.g. depression. Study design The subjects were assessed by an independent rater on a large number of dependent variables. Standard eating disorder inventories (GARNERet al., 1979, 1982, 1983; FREEMAN
A STUDY OFPSYCHOTHERAPY FOR BULIMIA TABLE
Dependent variable
2. MEASURE OFCHANGE
AND TIMING
Pre-treatment
Personal History Questionnaire Weight and Eating Questionnaire Binge Eating Questionnaire EDI EAT Restraint Questionnaire Hunger and Satiety Questionnaire Locus of Control Self Esteem Questionnaire Montgomery Asberg Depression Scale (MAD) I.D.A. Self Rating Scales Self Monitoring
+ + + + + + + + + + +
OFASSESSMENTS
Mid-treatment
-
475
End-treatment
Follow-up every 3 months for 1 yr
+ + +
+ + +
+ + +
+ +
+ + + +
+ + +
continuous
+
and HENDERSON, 1985) and self-rating personality scales (CAINE et al., 1976; HERMAN and POLIVY, 1975; MONTGOMERY and ASBERG, 1979; SNAITH et al., 1978; SPIELBERGER et al., 1969; ZUCKERMAN et al., 1964) were administered, and repeated at various times during therapy and follow-up (cf. Table 2 for details). Allocation to treatment was by restricted randomisation, the ratio of allocation to group and individual treatments being altered in favour of group treatment during the weeks leading up to a new group starting. This variable ratio randomisation was necessary to ensure that the time elapsed between completing assessment and beginning therapy was minimised for all subjects.
Adequacy and separateness of treatments To control for therapist variables we felt it essential that each treatment should be administered by both therapists (see Table 1). Neither therapist had any particular bias in favour of a given treatment. Both were of equal training and experience though one was a nurse therapist and the other a clinical psychologist. To check for contamination of one treatment modality by another some treatment sessions were videoed and rated by an independent observer. RESULTS The subjects were referred by local general practitioners, self-help groups, a women’s health shop and contraceptive clinics. In the first fifteen months of the study 86 persons were assessed. Of these 25% failed to meet our criteria. Five met the DSM-III criteria for anorexia nervosa, three stopped bingeing during the assessment period, eight did not binge or binged less frequently than four times a month, two were male, two psychotic and one repeatedly induced vomiting but had none of the other psychopathology of bulimia. Of the remaining 65 women, three dropped out during assessment or decided not to enter therapy and two lived too far away for feasible regular attendance. The remaining 60 subjects were entered into the study. All met DSM-III criteria, and 40 met the criteria laid down by RUSSELL (1979). Their ages ranged from 16 to 42 with a mean of 24.3. Eight were married or separated and the rest single. They had a history of bulimia from six
CHRISTOPHERFREEMAN
476
etal. ICI
(bl
Ial nllw FRWOm T
T
EATING AllMlfSTEST IEAII
MoNlGo!4mrssERG oEPKssw SCALEIWI
1
T cogm cp 1.9 50 6.5 FIX Cop= Copnittte Therapy ft8h: bharlouf Mapy Sp I Gmup Thempy
CogMb
0.25 042 0.25 POSl
wr
GP 37.5 39.6 11.8
Cog
lL.2 13.9 lo.5
PM
T
T
r
I-.
POST
118
U.6
PM
11.3
2-s
8.0
5.3
msl
figures am mean scores on mting xalrr lines thmugh bar graphs repmsat standard dcwation Fro. I.
months to 18 yr with a mean of 6.5 yr. The mean age at onset of bulimia was 17.8 yr with range of onset from 10 to 30 yr. No significant differences were apparent between subjects when self-referrals were compared with those referred by general practitioner. Drop-outs during treatment Fourteen of the 60 subjects did not complete treatment. The drop-out rate was twice as high in the group compared with the individual treatments. There were three main reasons for failing to complete treatment. Four subjects required antidepressants and were therefore excluded. In group treatment, drop-outs seemed to be related mainly to the lack of improvement and dissatisfaction with the treatment modality. In individual therapy this reason was rare and drop-out seemed to be more related to improvement and an unwillingness to continue with regular treatment sessions. Results of those completing treatment Space precludes the detailed analysis of all outcome variables. Some of the more important measures are shown in Fig. 1. As far as the behavioural aspects of the bulimia syndrome were concerned, all three treatments produced clinically and statistically significant improvements in bingeing, vomiting and purgative abuse. There were no significant differences between treatments and in the vast majority of cases, such behaviour was reduced to zero or to a minimal level by the end of treatment. All three treatments produced significant improvement in levels of depression, but this effect was most pronounced in the cognitive therapy treatment (see Fig. 1).
A STUDYOFPSYCHOTHERAPY FORBULIMIA TABLE3. SELFRATING
417
SCALES (IDA)
Cognitive therapy
Significant reduction
in in in
Depression Anxiety Outward irritability
Behaviour therapy
Significant reduction
in in in in
Depression Anxiety Outward irritability Inward irritability
Group therapy
Significant reduction
in
Inward irritability only
The I.D.A. self-rating scale for anxiety, depression and inward and outward irritability showed that cognitive and behaviour therapy produced greater improvement than did group therapy (see Table 3). Waiting list control For technical reasons, this group was started later than the three active treatments. This was so that the therapists could be fully employed from the start of the study. So far this group numbers ten subjects and there is little evidence of any change in bulimic behaviour over the 15 week waiting period.
DISCUSSION
These results are preliminary, and the study is still in progress. We plan to continue until there are at least 35 subjects in each group. Initial analysis suggests that all three treatments are effective at reducing the frequency of bulimic behaviour, implying that the most economical way of doing this would be in a group setting. There are already some definite indications that cognitive therapy appears to be most effective at altering depressive thoughts, self-esteem and feelings of control. The high drop-out rate for group treatment has not been reported by other authors. Final confirmation and explication of these findings will be available when the main part of the study is concluded. The crucial test of the treatments however will be the rates of relapse when treatment is finished. Accordingly we intend to follow up subjects for at least a year, and longer if possible. REFERENCES CAINE, T. M., FOULDS,B. A. and HOPE, K. (1967) Monuol of the Hostiiity and Direction of Hostility Question-
noire (HDHQ). University of London Press, London. Diagnostic ond Stotisticol Monuol of Mentol Disorders (1980), 3rd Edn. American Psychiatric Association, Washington, D.C. FREEMAN,C. P. L. and HENDERSON,M. (1985) The Bulimic Investigatory Test. Edinburgh (B.I.T.E.), in press. GARNER, D. M., OLMS~ED,M. P. and POLIVY,J. (1983) The development and validation of a multi-dimensional eating disorder inventory for anorexia nervosa and bulimia. Int. J. Eoting Disord. 2.15-34. GARNER,D. M., OLMSTED,M. P., BOHR, Y. and GARFINKEL,P. E. (1982) The Eating Attitudes Test; psychometric features and clinical correlates. Psychof. Med. 12.871-878. GARNER,D. M. and GARFINKEL,P. E. (1979) The Eating Attitudes Test: an index of the symptoms of anorexia nervosa. Psycho/. Med. 9,273-279.
478
CHRISTOPHERFREEMAN et al.
HEWAN, C. P. and POLIVY.J. (1975) Anxiety, restraint and eating behavior. J. abnorm. Psycho/. 84.666-672. MONTOOM~RY, S. A. and ASBERG, M. A new depression scale designed to be sensitive to change. Br. J. Pry&at. 134,382-389. Russa~~, G. F. M. (1979) Bulimia nervosa: an ominous variant of anorexia nervosa. Psyc/tol. Med. 9,429-448. SNNTH, R. P.. CONSTANTOPO~ILOS, A. A., JARD~N~,M. Y. and McGt.nnn~. P. 1978) A clinical scale for the self-assessment of irritability. Br. J. Psychiat. 132, 164-171. SPIELBKROHR,C. D. GXt.WCH, R. L. and LUSHENB,R. (1969) The State-Trait Anxiety Inventory Form X-I. The Consulting Psychologists Press, Palo Alto. California. ZUCKE~WAN,M.. KOLIN, E. A., PRICE, L. and Zooa. I. (1964) Development of a Sensation Seeking Scale. J. Consult. Psychol. t8(b), 477-482.