The following is an analysis of all patients who presented for treatment with a primary diagnosis of Bulimia Nervosa between the start of my private practice in 2009 and spring 2017. Given that this is an analysis of end of treatment outcomes, patients who were currently in treatment with me as of spring 2017 or later were not included in this sample. Patients and families whom I saw only for evaluations or consultations rather than treatment were not included in this sample.
Description of the Sample
This sample includes 13 individuals, all female, who were between the ages of 14 -27 at the time of their initial evaluation (mean age = 19). Duration of eating disorder prior to starting treatment with me ranged from 1 month to 11 years, with a mean duration of 3.5 years. Nearly half of the sample (46%) had a prior history of anorexia nervosa prior to beginning treatment for bulimia with me. More than ¾ of the sample (77%) had a secondary diagnosis, with the most common being Major Depressive Disorder, followed by ADHD and Anxiety Disorder Not Elsewhere Classified.
Description of the Treatment
Number of sessions attended ranged from 2 to 35, with a mean of 15 sessions. Duration of treatment ranged from 1 month to 28 months, with a mean duration of 8.8 months. Over half of the sample (54%) took psychotropic medication during their treatment.
All patients under the age of 18 had moderate or high levels of family involvement in their treatment. For patients over the age of 18, the degree of family involvement was determined by the patient’s living situation, family circumstances, and preferences. Among adults, 57% had no family involvement and the remaining 43% had some degree of family involvement, ranging from low (participation in at least one session and/or some phone contact with me outside of sessions) to high (participation in most or all sessions).
Sixty percent of patients under the age of 18 received Family-Based Treatment for Bulimia Nervosa (FBT-BN). The remaining 40% of patients under 18 received Cognitive-Behavioral Therapy (CBT) with a moderate to high level of family involvement, meaning that a parent or guardian participated in many or most of the sessions. Patients over age 18 received CBT, with an integration of Dialectical Behavior Therapy (DBT) skills for mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness.
Approximately 62% of the sample paid full rate for services. The remaining 38% received a reduced rate based on financial need.
Status at End of Treatment with Me
Twenty-three percent of patients completed a full course of treatment with me. Of those who completed a full course of treatment, 100% achieved full remission. A full course of treatment resulting in full remission required an average of 13 sessions over the course of 5 months.
The rate of attrition (treatment dropout) in this sample was very high. Over half of patients in this sample (54%) discontinued treatment prematurely after making significant progress, but prior to achieving full remission. Fifteen percent of patients were referred to other treatment providers or types of treatment that could better meet their needs, after making little or no progress in treatment with me. Eight percent of patients moved to other geographic locations and were thus referred to providers near their new homes.
For complete definitions of terms such as “full remission” and “significant progress,” see this blog post from 2013.
Predictors of Positive Treatment Outcome
- Completion of a full course of treatment was the strongest predictor of positive outcome. 100% of individuals who completed a full course of treatment achieved full remission.
- Patients who took Prozac during treatment were more likely to achieve full remission than those who did not take medication.
- Shorter duration of illness prior to beginning treatment with me was associated with greater likelihood of full remission. Patients who achieved full remission had been suffering from an eating disorder for an average of 3.3 years, whereas those who did not achieve full remission had been suffering for an average of 5.3 years.
- A prior history of Anorexia Nervosa was associated with lower likelihood of achieving full remission from Bulimia Nervosa.
- Presence of a comorbid diagnosis was not related to likelihood of remission.
- There was no significant difference in treatment completion or remission rates between patients who paid full rate for services vs. those who paid a reduced rate based on financial need.
- Degree of family involvement was not related to likelihood of treatment completion or full remission. Individuals were able to achieve full remission with varying levels of family involvement, from no involvement to involvement in every session. Likewise, individuals dropped out of treatment at similar rates regardless of degree of family involvement. In contrast, among my patients with Anorexia Nervosa, family involvement was strongly related to likelihood of treatment completion and full remission.