Psychotherapy for Bulimia Nervosa and Binge-Eating Disorder Study Notes

CBT is the leading treatment for bulimia nervosa (BN) and has shown good outcomes in most patients (Fairburn, 2005; Hail & LaGrange, 2018; Linardon et al., 2017).
Central to CBT for BN is the understanding that extreme concerns about shape and weight are core features of the disorder (Fairburn et al., 2008).
- The therapist encourages clients to monitor their thoughts and feelings surrounding eating behaviors, particularly during binge and purge episodes.
- Clients learn to confront irrational cognitions and to develop healthier attitudes towards their body and eating habits.

Therapist: What were you thinking just before you began to binge?
Client: I was upset and sad about my social life. I wanted to eat to feel better.
Therapist: And as you were eating, what were you thinking?
Client: The ice cream tasted good, but I also thought I shouldn't be eating this. My life is such a wreck, so I deserve to eat what I want.
Therapist: After the binge, what were you thinking?
Client: That I was a failure, that I have no control, and that the therapy isn't working.
Therapist: Did bingeing ultimately help you feel better?
Client: No, I felt terrible afterward.

The therapy introduces forbidden foods back into the client's diet (e.g., bread) while challenging irrational beliefs about these foods, like "If I have just one doughnut, I will inevitably binge."
Encourages regular meal patterns (three healthy meals a day) while addressing anxiety surrounding weight gain.
CBT typically lasts about 3 to 6 months, consisting of 10 to 20 sessions.

Studies find that approximately half of CBT clients completely cease the binge/purge cycle (Fairburn, 2005; Shapiro et al., 2007).
Clients often experience:
- Decreased depression and anxiety
- Improved social functioning
- Reduced preoccupation with dieting and weight
CBT has been found to be more effective than pharmacological treatments in achieving long-term cessation of binge eating and purging (Fairburn, 2005; Linardon et al., 2017).
Expanded forms of CBT that address emotional regulation are particularly effective for individuals with combined eating disorders and depression (Fairburn et al., 2009).

Other psychotherapeutic approaches mentioned:
- Interpersonal Therapy (IPT): Focuses on interpersonal issues related to the eating disorder. Therapist works with the client to develop coping strategies.
- Supportive-Expressive Psychodynamic Therapy: Encourages discussion about eating disorder-related problems in a nondirective manner.
- Behavioral Therapy: Focuses on tracking food intake, reinforcing exposure to avoided foods, and teaching coping techniques.
All approaches lead to significant improvements in eating behaviors and emotional well-being, yet CBT and IPT show the most enduring positive outcomes (Linardon et al., 2017).
Research indicates that CBT works faster than IPT, with noticeable improvements within 3 to 6 weeks (Agras et al., 2000; Fairburn et al., 2015).

CBT is reported to be more effective for BED compared to other therapeutic methods or antidepressants (Brownley et al., 2016; Linardon et al., 2017).
Benefits of CBT in BED include reductions in binge frequency and concerns with weight, shape, and eating.

Despite CBT's effectiveness, access to quality treatment remains challenging (Kazdin et al., 2017).
Innovations include online therapy and mobile applications to enhance accessibility (Agras et al., 2017).
Prevention programs targeting risk factors like media exposure and thinness ideal internalization have shown promise (Becker & Stice, 2017; Le et al., 2017).

Current approved medications for eating disorders are primarily selective serotonin reuptake inhibitors (SSRIs) like fluoxetine (Prozac) for BN and lisdexamfetamine (Vyvanse) for BED (Lutter, 2017).
Vyvanse, used in ADHD treatment, was approved FDA for moderate to severe BED in 2015. It reduces binge episode frequency but is not prescribed for weight loss.
- Concerns include potential abuse, dependence, and serious cardiovascular risks (Hornberger & Lane, 2021).
SSRIs like fluoxetine can reduce binge-eating and purging but typically do not restore normal eating patterns.
There are currently no approved medications for anorexia nervosa (AN); however, olanzapine and dronabinol are under study (Flament et al., 2012; Himmerich et al., 2020; Linardon et al., 2017).
Research indicates that combining CBT with antidepressant treatment can improve recovery rates (Fairburn, 2005).

Atypical antipsychotics like olanzapine have shown weight gain in individuals with AN (Flament et al., 2012).
Meta-analyses suggest several drugs (SSRIs, antiepileptic medications like topiramate, obesity medications like orlistat) outperform placebo in reducing binge eating but do not significantly diminish worries about body shape or weight (Brownley et al., 2016; Flament et al., 2012; Reas & Grilo, 2008).

Experts agree that a combination of biological, psychological, and social factors contribute to the development of eating disorders (Brownell & Walsh, 2017; Culbert et al., 2015).
Societal pressures, especially the promotion of an unrealistic thin ideal, heavily influence unhealthy eating behaviors among women.
- This creates a negative body image, leading to excessive dieting and impulsive binge-eating cycles.
Research indicates that increased use of social media correlates with lower self-esteem and increased depression, alongside image-focused platforms exacerbating body image concerns.

Certain individuals may have genetic predispositions or hormonal/neurotransmitter dysregulations that make them more susceptible to eating disorders.
- Factors like anxiety or mild depression can also predict tendencies toward dieting and thinness desires.

Personality traits such as perfectionism, all-or-nothing thinking, and low self-esteem are associated with disordered eating behaviors.
- These traits often stem from familial environments characterized by a lack of affection and high demands for perfection.

Once established, disordered eating behaviors tend to be reinforced by societal pressures and personal achievements in dieting, leading to difficulties in recovery.
The interplay of personal control and compensatory behaviors in bulimia nervosa and binge-eating disorder can prolong the cycle of disordered eating.

Rachel's behaviors, characteristic of many college women, reflect dietary recommendations but have led to unhealthy weight loss and obsessive exercise.
Prior to DSM-5-TR, Rachel might not qualify for a diagnosis due to the absence of amenorrhea. However, the criteria have evolved, and now her symptoms may meet the diagnosis of anorexia nervosa without the cessation of menses.
Rachel’s case raises questions about whether current diagnostic criteria are overly strict or if applying a psychiatric diagnosis to common behaviors is appropriate.