A randomized controlled trial recently published in the American Journal of Psychiatry found that Enhanced Cognitive Behavioral Therapy (CBT-E) was far more effective than psychoanalytic therapy in the treatment of Bulimia Nervosa (BN).
In this study, 70 adults with BN were randomly assigned to either the CBT-E group or the psychoanalytic therapy group. Those in the CBT-E group received 20 sessions over the course of 5 months, whereas those in the psychoanalytic therapy group received weekly sessions for 2 years.
CBT-E for bulimia nervosa directly targets bulimic symptoms of dietary restriction, binge eating, and purging by modifying self-defeating behaviors, identifying and challenging distorted thoughts and beliefs about food, body shape, and weight, and learning skills to regulate moods and deal with setbacks. For example, patients learn to moderate their food intake by consuming regular, satisfying meals and snacks throughout the day rather than fasting, which often leads to nighttime binges.
In contrast, psychoanalytic therapy helps patients work through emotions and resolve inner conflicts which are believed to be at the root of their eating disorder.
After five months of treatment, 42% of patients receiving CBT-E had stopped bingeing and purging, compared to only 6% of patients in the psychoanalytic therapy group. After two years, 44% of patients in the CBT-E group had remained abstinent from bingeing and purging, compared to 15% of patients in the psychoanalytic group. It is important to note that the 2-year assessment represents a 19-month post-treatment follow-up for patients in the CBT-E group, but an end-of-treatment assessment for the psychoanalytic therapy group. Thus, patients in the CBT-E group had maintained their remission 19 months after treatment ended.
I draw the following conclusions from this study:
1.) Treatments which directly target bulimic symptoms are likely to be much more effective than treatments that deal with underlying emotions and psychic conflicts.
2.) Bulimic patients who receive CBT-E experience symptom relief much more quickly than those who receive psychoanalytic therapy.
3.) CBT-E is more efficient and cost-effective. If a psychologist charges $150 per hour, twenty sessions of CBT-E over the course of 5 months would cost a total of $3000. Weekly psychoanalytic sessions for two years would cost a total of $15,600.
4.) The benefits of CBT-E are long-lasting for those who recover
5.) Psychoanalytic therapy can be effective for a small fraction of bulimic patients
6.) CBT-E should be a front-line treatment for bulimia nervosa because, statistically, patients are much more likely to benefit from it than from other treatment approaches.
Bulimia nervosa wreaks havoc on the brain as well as the rest of the body. Insufficient or erratic nutrition caused by restrictive dieting, fasting, bingeing, laxative abuse, purging, and dehydration have a direct and immediate impact on brain function. I suspect that a primary reason for the superiority of CBT-E is that it targets the symptoms of dieting, bingeing, and purging immediately, thereby helping patients achieve medical stability and brain healing. When a person is receiving consistent balanced nutrition and keeping it down, he or she is better able to process emotions, refrain from impulsive behaviors, and do the hard work that is necessary for full recovery.
Perhaps patients in the psychoanalytic therapy group did not have the tools necessary to recover. It is one thing to gain insight into one’s emotions and beliefs; it is another thing entirely to halt a destructive and addictive cycle of restricting, bingeing, and purging.
The authors of this study conclude that it “provides one of the clearest examples of the superiority of one well-implemented psychological treatment over another.” However, CBT-E is not a magic bullet: more than half of the patients who received CBT-E did not recover. Therefore, we need to improve existing treatments for BN and develop new, more effective treatments for this devastating illness.