Individuals with bulimia nervosa regularly engage in binge eating and some type of compensatory behavior, like vomiting or laxative use. These behaviors are often very distressing and can cause serious medical issues. In order for a type of psychotherapy or medication to be considered an effective treatment for bulimia nervosa, it needs to help eliminate or significantly reduce these harmful behaviors. Cognitive Behavioral Therapy, or CBT for short, is a present-focused psychotherapy that has been found to be highly effective at treating bulimia nervosa. This approach encourages individuals to stop the binge-purge cycle by instituting a regular eating pattern that is not restrictive or chaotic, and by challenging distressing thoughts about weight and shape that fuel the eating disorder.
A standard course of CBT is time-limited, usually 20 sessions long over about 5 months. It eliminates binge eating and purging in approximately 40-50% of patients and greatly reduces symptoms in other individuals. But this means that even though CBT is effective for a lot of people, some do continue to struggle with bingeing and purging even after trying CBT. Researchers have therefore developed alternatives to CBT to see if they can increase the number of people who recover. Recently, a team in Denmark developed a type of psychoanalytic psychotherapy for bulimia nervosa that they wanted to test. They thought that people with bulimia nervosa might be bingeing and purging as a way to avoid or lessen painful emotions, like anxiety, sadness, or anger. The psychoanalytic psychotherapy they developed was therefore designed to help patients become more aware of the emotions they are having and be more tolerant of these emotions. To test whether this treatment was effective, they compared this psychoanalytic therapy to CBT in a randomized controlled trial.
CBT: 36 patients with bulimia nervosa were randomized to this treatment, where they could receive 20 50-minute sessions of CBT over the course of 5 months. The therapists received special training in CBT and were supervised by an expert in this type of treatment.
Psychoanalytic psychotherapy: 34 patients were randomized to this treatment and could receive weekly 50-minute sessions for two years. These therapists received special training in this type of treatment and were supervised by the creators of this treatment. Unlike CBT, which directs the topic of conversation to tackling the eating disorder, in psychoanalytic psychotherapy patients were free to talk about whatever they wanted to during the sessions. Therapists attempted to help patients gain insight into their emotions hoping that this would eventually lead to the discontinuation of binge-purge behaviors.
1) At the end of treatment, 44% of CBT patients had completely stopped binging and purging, but only 15% of those receiving psychoanalytic psychotherapy were abstinent from these behaviors. This is notable because even though CBT was much shorter in duration than psychoanalytic psychotherapy (5 months vs. 2 years), it was much more effective in eliminating bingeing and purging.
2) At the end of treatment, all participants were less depressed and had fewer concerns about their shape, weight, and eating. However, these improvements occurred much more quickly in the CBT group compared to the psychoanalytic psychotherapy group.
What does it all mean?
The results of this study are important for several reasons. These researchers demonstrated that CBT was more effective than psychoanalytic psychotherapy in treating bulimia nervosa. Significantly more people in the CBT group stopped bingeing and purging even though they could only receive a maximum of 20 therapy sessions over the course of 5 months and the psychoanalytic psychotherapy group had an average of 72 sessions over the course of 2 years. More therapy did not translate into better results.
While both treatments helped improve mood and reduce maladaptive thoughts about weight, shape, and eating, CBT was able to do this more quickly than psychoanalytic psychotherapy. This is useful information because it demonstrates that CBT is more cost-effective than psychoanalytic treatment.
Even though psychoanalytic psychotherapy did not have a large impact on eating disordered behaviors (binging & purging), it did have a significant impact on eating disordered thoughts, albeit not as quickly as CBT. Therefore, the creators of the psychoanalytic psychotherapy may be right in thinking that individuals with bulimia nervosa could benefit from gaining more insight into their emotions and learning ways to deal with these emotions in an effective and healthy manner.
Finally, while CBT was significantly more effective than psychoanalytic psychotherapy in treating bulimia nervosa, over 50% of CBT patients were still bingeing and purging to some degree at the end of the study. While this study was an important contribution to the literature on eating disorders treatment, the results reinforce the need for continued treatment refinement and development to help more people more fully recover.
To read more about this study, check out:
Poulsen, S., Lunn, S., Daniel, S…, Fairburn, C. (2014). A randomized controlled trial of psychoanalytic psychotherapy or cognitive-behavioral therapy for bulimia nervosa. American Journal of Psychiatry, 171, 109-116.
Written by Loren Gianini, Ph.D.