Psychotherapeutic Approaches to the Treatment of Bulimia Nervosa

Joyce L. Donnini, Temple University

John P. Galla, Clifford T. Stewart, Michele Hyman-Dollar, Joseph Paola, Lawrence A. Fehr

Widener University

Abstract

Various psychotherapeutic approaches are employed in the treatment of individuals with bulimia nervosa. In this paper three broadly defined categories, representing differing approaches to the treatment of bulimia, are discussed. They are the (1) cognitive / behavioral, (2) psychoanalytic / psychodynamic, and (3) pharmacologic. The purpose is to present an overview of these approaches with regard to their contributions to the treatment and understanding of individuals with bulimia.

Copyright © 1995 John P. Galla

Paper presented on Thursday, April 6, 1995, at the National Social Science Association Conference, San Diego, CA.

Bulimia Nervosa (Bulimia) is an eating disorder which is most often manifested by recurrent episodes of binge eating followed by inappropriate compensatory behaviors such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise. According to the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., to be clinically diagnosed as bulimic these behaviors must occur, on average, at least twice a week for 3 months and there must be a persistent over-concern with body shape (American Psychiatric Association, 1994, p. 539, p. 549). Obsessive thoughts concerning food, eating, purging, and preoccupation with weight (i.e., fear of becoming overweight and misperceiving themselves as overweight when they are not) are major characteristics of the bulimic psychopathology.

In 1987, Pope and Hudson estimated that at least one million American women and tens of thousands of American men suffer from bulimia. The incidence of bulimia as described in the DSM-IV is estimated to be between 1% and 3% in adolescent and young adult women (DSM-IV, 1994; Fahy, Eisler, & Russell, 1993), whereas the incidence of bulimic behaviors that do not meet the DSM-IV criteria may be between 10% and 20% of adolescent and young adult women (Cesari, 1986; Connors, & Johnson, 1987; Wells & Logan, 1987).

The rate of occurrence of bulimia in males is approximately one-tenth that of females. At greatest risk for developing bulimia among males are athletes and homosexuals (American Psychiatric Association, 1993; Andersen, 1986; Carlat & Carmargo, 1991; DSM-IV, 1994; Pope & Hudson, 1986; Robinson & Holden, 1986; Schneider & Agras, 1987; Yager, Kurtzman, Landsverk, & Wiesmeier, 1988). Unless otherwise specified, the articles reviewed in this paper deal with individuals (female and male) who are clinically diagnosed as bulimic.

At least 90% of all bulimics are female (DSM-IV, 1994). The typical female bulimic is a white woman in her early to mid twenties. Mean onset of bingeing is 18 years of age with purging beginning approximately one year later (usually by vomiting). Weight may range from underweight to overweight although many bulimics exhibit normal weight for their age. Familial history of obesity is common (Osvold & Sodowsky, 1993; Strober & Humphrey, 1987).

There is evidence that depression, anxiety, personality disorders and substance abuse exhibit positive relationships with bulimia (Jacobs, 1995; Katz, 1990; Kennedy, & Garfinkel, 1992; Mitchell, Specker, & de Zwaan, 1991; Rothenberg, 1990; Schlesier-Stroop, 1984). In patients with bulimia, comorbid major depression or dysthymia has been reported in 70%, anxiety disorders in 43%, chemical dependency disorders in 34%, personality disorders, (or at least substantial personality trait disturbances) in 62% to 75%, and sexual abuse in 34% (American Psychiatric Association, 1993; Fairburn, 1991; Mitchell, Soll, Eckert, & Pyle, 1989; Rand & Kuldau, 1992; Schlesier-Stroop, 1984; Yager, 1992).

According to Yager (1992) dysfunctional families are common, with reported prevalence of 37% for substance abuse and 32% for affective disorders in family members. In a comparison of 50 bulimic and a comparable group of 40 non-eating disordered women, Dolan, Evans, and Lacey (1989), found no significant differences in social class, family size, birth position, or sibling sex ratio, although parents of bulimics were found to be significantly older than for non-bulimics.

Based on a review of the literature, Strober and Humphrey (1987) summarized familial influences in bulimia. They found that a wide variety of family-oriented facts shape the phenomenology of eating disorders, particularly bulimia. For example, they found that bulimia was strongly associated with a lack of parental affection; overly negative, hostile, and disengaged patterns of family interaction; parental impulsivity, and family alcoholism and obesity. These factors seem to exert their influence through a number of constitutional and experiential pathways -- poor self-regulation of affect and behavior, tendencies towards alcoholism and obesity, and family wide discord and emotional deprivation. They also found evidence that eating disorders aggregate in families, but note that the genetic and environmental contributions to transmission have not yet been elucidated. Moreover, although certain familial patterns are associated with eating disorders, there does not seem to be a single mechanism or pathway of influence. They suggest that certain personality factors, which may be genetically determined, predispose the individual to greater sensitivity and vulnerability to powerful familial and social experiences that impinge adversely on self- esteem and self-efficacy. They conclude that the family environment to which bulimic patients are exposed may hamper the development of a stable identity, of autonomy, and of self-efficacy through a cluster of disturbed patterns of relating and interacting that are characterized by enmeshment, poor conflict resolution, emotional over involvement or detachment and a lack of affection and empathy.

Treatment Considerations. Bulimia does not have a single etiology. Given the many and varied antecedents of the condition, and the myriad behavioral courses that it can take, it is not surprising to find that no single strategy is used exclusively in its treatment. In fact, the Practice Guideline for Eating Disorders indicates that approaches to the treatment of bulimia currently include nutritional counseling, cognitive-behavioral, behavioral, psychoanalytic, and psychodynamic therapies, family interventions; individual and group approaches to therapy, and medication (American Psychiatric Association, 1993). In this paper three broadly defined categories, representing differing approaches to the treatment of bulimia, are discussed. They are the (1) cognitive / behavioral, (2) psychoanalytic / psychodynamic, and (3) pharmacologic. The purpose is to present an overview of these approaches with regard to their contributions to the treatment and understanding of individuals with bulimia.

Cognitive / Behavioral Approach

Cognitive-behavioral therapy Cognitive-behavioral therapy (CBT) and behavior therapy (BT) conducted from an individual, group or family approach, represent the first category. These therapies reflect a clinical treatment orientation which is based on the experimental scientific study of human behavior and are thus derived from empirically based theoretical frameworks (Goldfried & Davidson, 1976).

The theoretical structure of cognitive-behavioral therapy (CBT) is related to cognitive psychology, information-processing theory and social psychology and is based on the notion that psychological disturbances frequently stem from specific, habitual errors in thinking (Beck in Kaplan & Sadock, 1985, p. 1432). With regard to the treatment of bulimia, CBT focuses on reducing the bulimic's dominant dysfunctional beliefs while supporting those which are adaptive. At the same time behavior modification techniques are employed to help them structure their days and weeks in ways that maximize the impact of the therapy (Beck in Kaplan & Sadock, 1985, p. 1432).

CBT was first proposed for bulimia nervosa by Fairburn (1981). The objectives of the treatment are (1) to help the patient establish behavioral control over her eating, (2) to help her modify her abnormal attitudes to food, eating, and body weight and shape and (3) to focus on problem-solving skills, and on maintaining progress after therapy (Fairburn, 1981; Garfinkel & Goldbloom, 1993). Thus, the cognitive view of bulimia predicts that for there to be complete and lasting recovery, there should be change not just in these patients' behavior but also in their attitudes towards their shape and weight (Fairburn, 1988).

In a relatively recent clinical report, Browers and Wiggum (1993) explain how they employed individual CBT to help patients deal with "unrealistic expectations, identify and express fears underlying perfectionism, and develop the courage to accept their own imperfections" (p.141). They defined two characteristics of perfectionism inherent in the bulimic psychopathology. The first, the unrealistic expectation, was described as the striving for unattainable goals motivated by fear of failure and which repeatedly results in frustration due to the inability to attain the goal. The second, dichotomous thinking, was described as all-or-nothing thinking. An example given of classic all-or-nothing thinking in bulimia is the binge-purge, where the individual tells herself she can binge (eat all of the food) because she can always get rid of what she eats through vomiting (nothing).

The objectives of the therapy were to help the patient understand that her perfectionism is a sustaining factor in her disorder, and that she needs to learn to express her fears, challenge these fears, and view the world in a more balanced, as opposed to all-or-none, manner. It was found that perfectionist patients with bulimia responded positively to the use of cognitive methods of insight, restructuring, relaxation, and imagery (Browers and Wiggum, 1993).

Since 1980, several comparative studies have been done employing individual and group administered CBT. Most of these have been critically evaluated elsewhere (Fairburn, 1988; Hudson & Pope, 1986; Garfinkel & Goldbloom, 1993; Yager, 1988,1992) and the general conclusion is that CBT treatments do seem to be reasonably effective. In one review of CBT studies Fairburn (1988) concluded that CBT was found to consistently "benefit most patients with substantial improvements being obtained both in eating habits and attitudes and in associated psychopathology" (p. 636). In a more recent review, Garfinkel and Goldbloom (1993) concluded that in all CBT studies which use a wait-list design (a no-treatment or waiting list comparison group) was used, "patients do not improve without active treatment, and cognitive-behavioral techniques show statistically significant improvements over the no-treatment comparison" (p. 43).

Some have suggested that CBT is superior to other approaches with the exception of interpersonal psychotherapy (IPT ), a psychodynamic form of psychotherapy (Fairburn, 1991; Fairburn, 1992; Fairburn et al., 1991). Others suggest that most psychotherapeutic treatments for bulimia work to some degree, and that none has been found to be superior for all patients (Yager, 1992). Whether CBT is superior or not, both behavioral and cognitive-behavioral therapies have been subjected to better designed and evaluated studies than the psychodynamic approaches leading to a greater confidence in their general efficacy (Yager, 1992).

Two recent studies have compared the efficacy of individual and group CBT to other approaches. In a randomized controlled study involving three psychological treatments, Fairburn, Jones, Peveler, Hope, & O'Connor (1993) compared individually administered BT and IPT with CBT. Seventy five patients diagnosed as bulimic (but without concurrent anorexia) were randomly assigned to the CBT, IPT or BT groups.

The CBT focused on cognitive procedures to change patients' behavior, their attitudes toward shape and weight, and other cognitive distortions such as low self-esteem and extreme perfectionism.

The BT was a "dismantled" version of the cognitive-behavioral approach, consisting of the behavioral treatments from CBT, without attending to attitudes of shape and weight. The focus was exclusively on normalizing eating habits through establishing regular eating patterns and ceasing to diet.

The IPT was described as a form of short term focal psychotherapy, which was originally designed for the treatment of depressed patients. It employed techniques derived from psychodynamically oriented therapies, but with a focus on the patient's current interpersonal functioning. No attention was paid to patients' eating habits or attitudes about eating or body shape and no "behavioral" procedures were used.

Treatment lasted 18 weeks, with follow up over the succeeding 12 months. The main outcome measure was frequency of binge eating and purging. Assessments of outcome were made by trained assessors who had no involvement in the treatment of the patients and were not aware of which subjects received which treatments. Assessment interviews were carried out following assignment to groups, after final treatment, and then 4, 8 and 12 months thereafter.

Twenty five (33%) of the originally 75 patients either dropped out at some stage of the study or were withdrawn by the researchers: five (20%) from the CBT group, eight (32%) from the IPT group and 12 (48%) from the BT group. The dropout rate for BT was significantly different from CBT and comparisons of CBT and BT on outcome measures were not made. It was concluded, however, that patients from the BT group showed substantial reduction in binge-purge behavior. Patients in the CBT and IPT groups made equivalent, substantial, and lasting changes across all areas of symptoms, although IPT took longer to achieve those results and was less effective in reducing dieting and vomiting behavior and in changing attitudes about shape and weight.

Fairburn, et al. (1993) concluded from their results that bulimia can be treated successfully using a CBT or a IPT approach, even though their mediating mechanisms are different, but that BT by itself is not particularly effective.

Wilfley et al. (1992) assessed the efficacy of group CBT and group IPT for nonpurging bulimics in a controlled comparison. Fifty-six women with non-purging bulimia were randomly assigned to a CBT, IPT or wait-list (WL) control group. Treatment was administered in group session for 16 weeks. At the conclusion of treatment both the CBT and the IPT groups showed significant reduction in binge eating compared to the WL group. In both a six month and one year follow up binge eating episodes for both treatment groups remained significantly below baseline levels.

Behavior Therapy The basic approach of behavior therapy (BT) is to use the methodology of experimental and social psychology, with an emphasis placed on observable behaviors of the patient rather than inferred mental states (Brady, 1985). Critical to this approach is the behavioral analysis. This consists of describing in as "...objective, explicit, and quantitative terms as possible the maladaptive responses that constitute the patients' disorder" (Brady, 1985, p. 1365). Thus abstractions such as anxiety or depression are operationalized in specific terms, such as a particular score on a behavioral assessment device, or a concrete description of behavior. With regard to bulimia, the basic assumption is that bulimic behaviors are lawful and the function of specifiable antecedents (Goldfried & Davison, 1976).

Reviews of the literature have found that BTs are generally successful, and the individual BT is generally more successful than group BT, when compared to no

treatment at all (Garfinkel & Goldbloom, 1993; Yager, 1992). Although BT has been demonstrated to significantly change attitudes about eating, weight, self-esteem, and depression (Agras, Schneider, Arnow, Raeburn, & Telch, 1989; Freeman, Sinclair, Turnbull, & Annandale 1985; Freeman, Barry, Dunkeld-Turnbull, & Henderson, 1988), it is not seen as effective as CBT, perhaps because BT generally lacks the cognitive restructuring dimension and procedures which specifically address concerns about body shape and weight (Fairburn et al., 1993).

Psychoanalytic / Psychodynamic Approach

Psychoanalysis Psychoanalysis, as well as derivative and related psychodynamic forms of psychotherapy, such as self-psychology and interpersonal psychotherapy, represent the second approach. These perspectives attempt to modify behavior by such psychological methods as confrontation, clarification, and interpretation. They require introspection from the patient and empathy from the therapist and pay attention to Freudian notions of transference and countertransference (Stewart, 1985).

Herron & Herron (1989) describe three psychoanalytic treatment applications for normal weight female bulimics. The first is a drive model, the second an object - relations model and the third a masochism model. Although different in focus, all aim at the patient developing true separation and individuation as well as eliminating the bulimic syndrome.

The drive model sees change in the bulimic cycle following interpretations of the regressive oedipal fantasy. The relational model sees the development of more appropriate object relations as modes of interpersonal interaction which would integrate drives and affects in an effective way. The masochistic model sees analysis as providing the patient with a different relationship than she has with her mother, including the recognition by the analyst that this will be ambivalently reacted to by the patient. In all three models there is danger of overemphasis on a particular aspect of a patient's personality. One model is no more correct than another. Regardless of model, the psychoanalytic approach is seen as a viable treatment method for bulimia (Herron & Herron, 1989).

Rozen (1993) attempts to understand the bulimic symptom of bingeing and self-induced vomiting from a psychoanalytic perspective. Based on clinical observation she suggests that bulimia represents a disturbance in "whole-object relations." Whole object relations remain limited and superficial, whereas part-object relations, due to excessive splitting and projective identification dominate. She believes that for the bulimic patient there was a severe disturbance in early childhood when splitting and projective identification predominate. Rozen suggests that one must look at the split-off fantasies of the individual in order to understand why she maintains one symptom over another.

Psychodynamic Psychotherapies The psychodynamic therapies have evolved from the psychosexual formulations of psychoanalysis to "object relations and disturbances in self and identity,"(Swift and Letven, 1984). In most psychodynamic psychotherapies, key activities include uncovering of abreaction to traumatic events; emotional responses to real, imagined, and anticipated losses; realizations regarding the existence of conflictual attitudes and self-deceptions; analysis of typical maladaptive emotional reactions and defensive styles; examination of negative transference reactions when they present clear resistance's to therapeutic advance; and the development of new perspectives in relation to these discoveries (Yager, 1992).

According to Herzog, Franko and Brotman (1989) current psychodynamic therapies look at bulimia in "the context of tension regulation,"(p. 143), with treatment models focusing on developmental issues relating to dependency and separation-individuation. "Determining the underlying meaning of the bulimic symptoms and the functions they serve for the patient are the primary goals of psychodynamic therapy," (p. 143).

It appears, then, that psychodynamically oriented psychotherapies for bulimia have been based on pathogenic models that view this disorder as in part representing developmental struggles for autonomy, competence, self-esteem, and self-control. These themes provide the focus of discussion during therapy sessions. The symptoms are seen both as expressions of attempts to control and regulate anxiety and other tension states, and as failing defenses. The specific defensive constellations seen in bulimia are attributed to both constitutional and developmental processes (Yager, 1992).

While the bulimic is often accepting of treatment initially, she may have a low tolerance for frustration and quickly terminate treatment when it does not provide immediate symptomatic relief (Herzog et al., 1989). Most psychodynamically oriented clinicians have found the empathic stance currently espoused by self-psychologists to be more useful and effective with these patients than the more neutral and distancing stances of classic psychoanalysis. Specific techniques depend on the personality and cognitive style of the patient and on the details of her history (Yager, 1992).

Although, psychodynamic psychotherapies are often used in conjunction BT or CBT and have been evaluated in this regard (Fairburn et al., 1993; Wilfley et al. 1992), most evidence for the efficacy of psychodynamic approaches comes from clinical reports rather than controlled research studies. Lacey (1986), for example, employed individual BT and general counseling to deal with symptoms of bulimia, individual and group insight-directed therapy to deal with emotional conflicts relating to the disorder and group insight-directed therapy and individual counseling to deal with social problems relating to the disorder. Based on 200 patients receiving this treatment, Lacey reports that in initial concentrated sessions, BT can effectively interrupt a disordered eating pattern. Once the patient is no longer "hindered by food manipulation," individual and group psychodynamic psychotherapy (short term focal insight-directed therapy) can be an effective forum for dealing with underlying emotional issues and conflicts. He concludes that bulimia can be controlled with simple behavioral techniques but that underlying emotional conflicts and social problems respond best to psychodynamic therapy.

MacKenzie, Livesley, Coleman, Harper and Park (1986) agree with published research reports that behavioral, cognitive-behavioral, and dynamic psychotherapy all produce significant change with the use of brief techniques but conclude, based on clinical observation, that short term group psychotherapy is the preferred modality for treating bulimia.

Steiger (1989) presents a rationale for integrating brief dynamic and CBT techniques. In this approach, unlike traditional psychotherapy, regression is limited rather than fostered, through the confrontation of dependency or passivity. The therapist "speaks" to the patient's highest level of functioning rather than accepting regression. In this fashion, maladaptive relationship patterns are presumably understood rather than repeated. The therapist emphasizes limit-setting and confrontation, in balance (according to patients' tolerances) with ego-supportive and structuring work.

The therapist also directly challenges patients' irrational thinking patterns around eating (and other issues) that underlie unpleasant affects and maladaptive behavioral patterns (i.e. the belief that if I gain weight I risk becoming fat or if a relationship fails then I must be inadequate or undesirable as a person), and is directive in encouraging the patient to consider alternative, less aversive conceptualizations.

Cognitive-behavioral strategies are integrated in several ways. One is the interruption of maladaptive behaviors that feed back into the cognitive domain (e.g., excessive dieting resulting in thought disjunction due to malnutrition) or patterns that can become quite autonomous from psychological causes (e.g., the cycle of dieting, bingeing and purging). Another involves encouraging the patient to behave in ways that put beliefs to reality tests (i.e., discovering whether in fact by eating she loses control and gains weight exponentially; Steiger, 1989).

Like others who come from the psychodynamic approach, Steiger suggests that bulimia nervosa involves object-relations disturbances and problems around separation-individuation, specifically around the stage of transitional object use resulting in a narcissistic fixation on one's own body, at the expense of the utilization of external objects. Externalizing defenses (projection, idealization/devaluation) and self-sacrifice are often prominent. Similarly, the bulimic symptoms are conceived of as an attempt to fill, in a clandestine fashion, ungratified needs. This pattern is presumed to account for the narcissistic, "false self-type personalities often seen among bingeing patients" (Steiger, 1989).

Pharmacologic Approach Pharmacologic intervention, usually involving the prescription of antidepressant drugs, represents the third category for discussion. Initially the antidepressants of choice were the tricyclics, such as imipramine (Tofranil) or desipramine (Norpramin), or the monoamine oxidase inhibitors, such as phenelzine (Nadil) or isocarboxazid (Marplan). Since their introduction in the late 1980s, however, the selective serotonin reuptake inhibitors such as fluoxetine (Prozac) or fluvoxamine (Luvox) have become the drugs of choice in the treatment of bulimia. They have fewer side effects and selectively block the reuptake of serotonin, a central nervous system (CNS) neurotransmitter whose dysfunction is believed to play a major role in the perpetuation, and possibly the initiation of, bulimia and related disorders such as depression. Prozac is the only drug currently marketed in the U.S. as a bulimia treatment.

The objective of pharmacological therapy is to reduce the symptoms of bulimia. Although they reportedly work well in this regard, evidence suggests that treating bulimia with antidepressants alone, without the use of psychotherapeutic intervention, is not effective in the long run (Agras & McCann, 1987; Fichter et al., 1991; Kettlewell, Mizes & Wasylyshyn, 1992; Lewis & Brisman, 1992; Mitchell & Groat, 1984; Rossiter, Agras, Losch & Telch, 1988; Tiller, Ulrike & Treasure, 1993; Wells & Logan, 1987). After reviewing drug and group treatments (cognitive-behavioral and psychodynamic), Freeman and Munro (1988) concluded that neither drugs nor group treatments are as effective as individual psychotherapy but that group treatments seemed, in general, to be more effective than drug treatments alone. For a more complete review of the literature on pharmacological therapy see Galla et al., 1995.

Discussion The three broad treatment categories described above are neither mutually exclusive nor collectively exhaustive. Yager (1988, 1989, 1992) suggests that before determining which approach to use with a given patient a multidimensional assessment should be done. Due to the possibility of comorbidity, the assessment should look at the individual's biological and psychosocial vulnerabilities, including maladaptive learning experiences, history of dieting, exercise, eating habits, body image, and family history and patterns of interaction. Given the results of the assessment, treatment should be based on the needs of the patients rather than adherence to a particular theoretical model.

In fact, due to the heterogeneous nature of the bulimic patient population and to the multidetermined nature of bulimia, many therapists have seen a need to employ more than one general approach with their patients. Johnson, Connors, and Tobin (1987) report, for example, integrating behavioral and psychodynamic treatment principles in order to manage bulimic symptoms in the same patient. According to Herzog et al. (1989) bulimia is an "admixture or thoughts, behaviors, and affects. There are behavioral components (binge eating, vomiting, fasting), cognitive aberrations (irrational beliefs concerning weight, food, and body image), and psychodynamic underpinnings (deficits at various developmental levels)" (p. 142). For these reasons they see the need for "an integrative approach to psychotherapy" and advocate an "integrated multimodal treatment approach" (p. 142), including pharmacologic intervention. Thus, one, two, and sometimes all three approaches are employed combinationally, simultaneously or successively, in treating an individual with bulimia.

Regardless of whether one employs a "pure" therapeutic approach, based on a specific theoretical model, or a mixed approach, combining aspects of different models, assessment of efficacy is made with reference to outcome measures. Although a variety of measures are used, depending on the therapist, the therapy and the specific patient, most studies done to assess the efficacy of a particular therapeutic approach do so in terms of reduction in binge-purge behavior and concomitant changes in attitudes toward eating and body image (Garfinkel & Goldbloom, 1993; Johnson, Conners, & Tobin, 1987; Fairburn, 1988; Herzog et al. 1989; Yager 1988, 1989, 1992). These outcomes are often measured with a combination of therapist direct assessment techniques such as the Eating Disorder Examination (EDE), a semi-structured interview technique for the assessment of eating psychopathologies (Cooper & Fairburn, 1987) and the use of a variety of self-report measures, such as the Eating Disorders Inventory (EDI; Garner, Olmsted, & Polivy, 1983; Garner & Olmsted, 1984), the Eating Attitudes Test (EAT; Garner & Garfinkel, 1979), the Bulimic Investigatory Test (BITE) (Henderson & Freeman, 1987), and the Bulimia Test (BULIT; Smith & Thelen, 1984).

These inventories and questionnaires are most often used in research studies which purport to measure the efficacy of a given approach to the treatment of bulimia. Many clinical reports, as compared with research reports, provide clinical observation as the primary "measure" of efficacy of an approach. Given the variability associated with self-report inventories, a general lack of agreement on what constitutes a binge-purge episode and reduction in binge-purge behavior, and the difficulty in assessing attitude change in general, it is fair to say that outcome measures are not without problems in terms of both reliability and validity. Nevertheless, the attempt to "standardize" outcome measures has made it easier to make comparisons of the efficacy of different treatment approaches.

Summary The purpose of this paper was to present an general overview of the various psychotherapeutic approaches to the treatment of bulimia and to draw some conclusions as to their efficacy in this endeavor. Three broadly defined approaches to the treatment of bulimia were presented (1) cognitive / behavioral, (2) psychoanalytic / psychodynamic, and (3) pharmacologic. Generally speaking the cognitive / behavioral and the pharmacologic approaches have been subjected to better designed and evaluated studies than the psychodynamic approaches. Nevertheless, when considering the cognitive / behavioral and the psychoanalytic / psychodynamic approaches, the preponderance of evidence, based on both controlled research and clinical report, fails to provide a clear winner between them in terms of unqualified superiority in the treatment of bulimia. On the other hand, the well controlled studies on pharmacological therapy suggest that by itself, the treatment of bulimia with drugs is not as effective as either cognitive / behavioral or psychoanalytic / psychodynamic psychotherapy.

Thus, the results of the studies reported in the literature, and reviewed herein, allow us to end with some general statements, which we currently employ as working assumptions. These are that (1) individuals who undergo some form of systematic therapeutic treatment seem to improve, compared to those who do not, at least in the short run, (2) assessment of improvement is highly variable and outcome measures of improvement are not standardized; (3) few studies have been conducted on the long term efficacy of therapy; and 4) various medications employed in treatment appear to be more effective when used as adjuncts to, rather than in place of, psychotherapy.

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