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Editors: Gabbard, Glen O.; Beck, Judith S.; Holmes, Jeremy
Title: O x f o r d T e x t b o o k o f P s y c h o t h e r a p y , 1 s t E d i t i o n
Copyr ight 2005 Oxford Univers i ty Press
> Ta b l e o f Co n t en t s > Sec t i o n I I - P sych o t h e ra py i n p sych i a t r i c d i s o rde r s > 1 5 - Ea t i n g
d i s o rde r s
15
Eating disorders
Kel ly M. Vitousek *
Jennifer A. Gray
* The former name of the f i rs t author is Ke l ly Bemis.
Introduction
The k indred d isorders of anorex ia nervosa and bul imia nervosa present a
number of common problems to the psychotherapist . Both: (1) are
organized around a character is t ic set of be l ie fs about the importance of
weight as an index of personal worth; (2) lead to stereotyped behav iors
des igned to manipulate food intake and energy expenditure; and (3)
d isrupt normal phys io logy, wi th predictab le and somet imes profoundeffects on psycholog ica l and soc ia l funct ioning as wel l as phys ica l heal th.
The centra l ideas about eat ing and weight are often highly res is tant to
modi f icat ion, espec ia l ly in ind iv iduals with anorex ia nervosa; at the same
t ime, the phys ica l consequences that resul t f rom the be l ie f-cons is tent
behav iors of undereat ing, overexerc is ing, and purg ing require c lose
attent ion and somet imes prompt intervent ion on the part of c l in ic ians.
The d is t r ibut ion of these d isorders is approx imate ly para l le l , and
markedly skewed by sex, age, cul ture, and perhaps era. Females are
disproport ionate ly vulnerable to both condi t ions, wi th males se ldom
represent ing more than 5% of ident i f ied cases. (Because the great
major i ty of ind iv iduals with anorex ia nervosa and bul imia nervosa arefemale, feminine pronouns are used throughout the chapter to refer to
ind iv iduals with these d isorders. ) Anorex ia nervosa usual ly deve lops
between the prepuberta l per iod and the beginning of adul thood; onset for
bul imia nervosa is s l ight ly later, w i th symptoms commonly emerging in
late adolescence through young adul thood. Prevalence rates are low for
both d isorders, w i th anorex ia af fect ing up to 0.5% of young females and
bul imia present in 12%. These condi t ions are rare in underdeveloped
countr ies, of ten appear ing for the f i rs t t ime dur ing per iods of rap id soc ia l
change assoc iated with exposure to Western cul ture.
Controversy pers is ts regard ing the nature and degree of the re lat ionship
between these condi t ions. The two symptom c lusters often over lapconcurrent ly or sequent ia l ly . Approx imate ly hal f of low-weight anorex ic
pat ients a lso b inge and/or purge, and substant ia l proport ions cross
d iagnost ic boundar ies over the course of the ir d isorder, most often from
anorex ia to bul imia. The p ic ture is further obscured by the fact that many
indiv iduals deve lop pers is tent eat ing d is turbances that share features
with one or both of these d isorders, but fa i l to match the spec i f icat ions
for e i ther and are cons igned to the res idual category of eat ing d isorder
not otherwise spec i f ied (ED-NOS). Some experts argue that the high
percentage of unc lass i f iab le cases, the frequent migrat ion of pat ients
across categor ies, the s imi lar i ty of symptoms and d is t r ibut ion pat terns,
and the ev idence of cross-t ransmiss ion of fami l ia l r isk suggest the
operat ion of common mechanisms (Holmgren et a l . , 1983; Beumont et a l .,
1994; Pa lmer , 2000; Fa i rburn et a l . , 2003; Fa irburn and Harr ison, 2003).
To bet ter re f lect this rea l i ty , Fa i rburn et a l . (2003) have p roposed a
tr ansd ia gn os t ic app roa ch to co nc ept ua li z in g an d tr ea ti ng the ea ti ng
disorders.
On the other hand, a number of features suggest meaningful d is t inct ions
between anorex ia nervosa and bul imia nervosa. The d isorders are
di f ferent ia l ly assoc iated with a var iety of background character is t ics and
personal i ty features. In anorex ic pat ients , low weight status dominates
the present ing p ic ture and ear ly phases of intervent ion. Throughout
therapy, the d isorders are d is t inguished by the extent to which symptom
resolut ion is des i red, at tempted, achieved, and mainta ined. Anorex ic
ind iv iduals are much less l ike ly to seek t reatment, to persevere in e f forts
to change, and to obta in benef i t even i f they remain engaged. One fo l low-
up of 246 cases t reated an average of 7.5 years ear l ier found that 74% of
pat ients with bul imia nervosa achieved a ful l recovery at some point
dur ing the fo l low-up per iod, compared with 33% of those with anorex ia
nervosa (Herzog e t a l . , 1999). A prospect ive natura l is t ic s tudy of 220
eat ing-d isordered ind iv iduals found s imi lar ly high rates of symptom
remiss ion for those d iagnosed 5 years ear l ier wi th bul imia or ED-NOS,
whi le a substant ia l ly greater proport ion of anorex ic part ic ipants reta ined
eat ing d isorder and/or other psychiatr ic symptoms (Ben-Tov im et a l .,
2001) .
Another d is t inct ion that wi l l be ev ident throughout this rev iew is that the
study of these d isorders has fo l lowed markedly d i f ferent deve lopmental
sequences. Al though anorex ia nervosa has been the subject of intens ive
invest igat ion for more than hal f a century, only a handful of control led
studies of psychotherapy have been conducted. In contrast , t reatment
research was in i t iated soon after the des ignat ion of bul imia nervosa as a
psychiatr ic d isorder in 1980, and has cont inued to accumulate at an
impress ive rate.
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In the next sect ions, we wi l l out l ine three t reatment modal i t ies for
bul imia nervosa [cogni t ive-behav iora l therapy (CBT), interpersonal
psychotherapy (IPT), and pharmacotherapy] and four for anorex ia nervosa
(fami ly therapy, psychodynamic therapy, CBT, and pharmacotherapy).
These were se lected on the bas is of the ir prominence in the f ie ld and
degree of empir ica l support . Space l imitat ions prevent a more exhaust ive
rev iew of the ful l range of approaches proposed, inc lud ing behav ior
therapy (BT; e.g. , Rosen and Le i tenberg, 1982, 1985), feminist therapy
(e.g. , Orbach, 1985; Fa l lon et a l . , 1994; Kearney-Cooke and Str iege l-
Moore, 1997), nonverbal express ive approaches such as art and movement
therapy (e.g. , Hornyak and Baker, 1989; Mac lagan, 1998), narrat ive
therapy (e.g. , Madigan and Goldner, 1999), and solut ion-focused therapy
(e.g. , McFar land, 1995). We omit a number of these with regret; however,
on balance i t seems preferable to inc lude more deta i led informat ion about
severa l approaches than to of fer thumbnai l sketches of a l l .
Treatment approaches for bulimia nervosa
The centra l feature of bul imia nervosa is the presence of recurrent
episodes of b inge eat ing, def ined as uncontrol led consumpt ion of
object ive ly large amounts of food, accompanied by compensatorybehav iors intended to prevent weight gain (American Psychiatr ic
Assoc iat ion, 2000). Compensatory methods inc lude se l f- induced vomit ing,
laxat ives, d iuret ics , enemas, fast ing, and excess ive exerc ise. Bul imia
nervosa is subdiv ided into purg ing and nonpurg ing types on the bas is of
the st rateg ies employed. Ini t ia l ly , ind iv iduals with this d isorder may not
v iew the ir behav ior as problemat ic , in that the advantage of be ing able to
eat f ree ly without gaining weight overshadows
P.178
concern about the negat ive ramif icat ions of b inge eat ing and purg ing.
Over t ime, this perspect ive is l ike ly to change, as ep isodes become more
frequent and adverse consequences begin to accumulate.
As the fo l lowing case examples i l lust rate, bul imia nervosa var ies wide ly in
sever i ty and can occur in pat ients with vast ly d i f ferent leve ls of g lobal
adjustment. For some ind iv iduals , the pat tern is exper ienced as an
isolated symptom c luster in the context of re lat ive ly successful overa l l
funct ioning; in other cases, l i fe is dominated by the d isorder and
addit ional severe psychiatr ic problems may be present .
Ca s e e x a m p l e s
Sharon is a 24-year-old graphics des igner with
a 5-year his tory of bul imia nervosa. She
started d iet ing and exerc is ing r igorous ly after
gaining 12 pounds dur ing her f i rs t year in
col lege. Al though these ef forts in i t ia l ly resul ted
in the des i red weight loss, her success began
to erode as she deve loped a pat tern of eat ing
larger and larger quant i t ies of food late at
night . After reading a personal account of
bul imia in connect ion with a psychology course,
Sharon exper imented with se l f- induced
vomit ing. At f i rs t the act was d i f f icul t and
painful , and she at tempted i t only when
extremely d is t ressed by the amount she had
eaten. Over t ime, she found the ref lex eas ier
to e l ic i t , and b ingepurge episodes increased in
frequency to the ir present leve l of three to f ive
t imes per week. Al though Sharon sought
counse l ing for s t ress and mi ld depress ion whi le
in col lege, she d id not d isc lose her d isordered
eat ing behav ior to her therapist . Sharon is now
mot ivated to seek profess ional he lp for her
bul imia because she p lans to move in with her
f ianc and fears that she wi l l be unable to
conceal her pat tern once they are l iv ing
together.
Emi ly is a 38-year-old woman with severe,
unremit t ing bul imia nervosa dat ing back to
mid-adolescence. I t is probable that Emi ly
br ie f ly met cr i ter ia for anorex ia when she was
15; however, she rece ived no t reatment for her
eat ing d isorder at that t ime, and soon shi f ted
into a pat tern of bul imic behav ior. She has
been hospi ta l ized twice for t reatment of her
bul imia, excess ive dr ink ing, se l f- injury, and
suic ida l ideat ion. At present , her l i fe is
dominated by near ly cont inuous cyc les of b inge
eat ing and purg ing, wi th vomit ing induced f ive
to 10 t imes dai ly . Emi ly is separated from her
abus ive husband and estranged from her
d ivorced parents and two s is ters . She is
current ly subs is t ing on d isabi l i ty payments and
occas ional temporary work as a data entry
c lerk. Emi ly has seen severa l therapists on an
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outpat ient bas is , but f requent ly fa i ls to at tend
scheduled sess ions and has never remained
engaged in t reatment for more than severa l
months. Her present weight is at the low end of
the normal range, and she is re luctant to gain
for fear of becoming overweight , as she was
dur ing chi ldhood and ear ly adolescence;
however, she be l ieves that the pr inc ipa l
determinant of her bul imic behav ior is the need
to b lunt the pain of her empty ex is tence.
Co g n i t i v e - b e h a v i o r a l t h e r a p y
Theoretical base
Fairburn's cogni t ive-behav iora l model of bul imia nervosa proposes that
the d isorder ar ises f rom excess ive re l iance on weight and shape as bases
for se l f-evaluat ion (Fairburn, 1981, 1997a; Fa irburn et a l . , 1986, 1993b).
Extreme concerns about the s ize and shape of the body, in combinat ion
with low se l f-esteem, lead to increas ing ly determined at tempts to l imit
the quant i ty and type of foods consumed. These pers is tent e f forts create
phys io log ica l and psycholog ica l vulnerabi l i ty to ep isodes of b inge eat ing.
Indiv iduals t ry to undo these lapses in restra int by vomit ing, tak ing
laxat ives, and impos ing st i l l more st r ingent exerc ise reg imens and d ietary
rules; however, resort to these behav iors re inforces the bul imic cyc le by
tr igger ing d is t ress, d iminishing se l f-esteem, renewing concern about
weight and shape, and increas ing depr ivat ion. CBT is des igned to address
each of the pr inc ipa l e lements in the model .
Support for the cogni t ive-behav iora l analys is of bul imia nervosa comes
from a number of sources, inc lud ing r isk factor research, corre lat ional
studies, and some exper imental invest igat ions (Vi tousek, 1996; Cooper,
1997; Fa irburn, 1997a; Byrne and McLean, 2002; Fa irburn et a l . , 2003) .
In addi t ion, pat terns of t reatment response are cons is tent with this model
of symptom maintenance. Across therapeut ic modal i t ies , the reduct ion of
d ietary restra int mediates decreases in b inge ing and purg ing (Wi lson et
a l. , 2002). The centra l ro le ass igned to cogni t ive factors is af f i rmed by
two f ind ings: d ismant led vers ions of CBT that reta in i ts behav iora l
components but omit d i rect work on be l ie fs are less ef fect ive than the ful l
t reatment package (Fairburn et a l . , 1991, 1993a; Thackwray et a l . , 1993;
Cooper and Steere, 1995), and the pers is tence of d is torted at t i tudes at
post t reatment predicts re lapse (Fairburn et a l . , 1993a) .
Description
The standard intervent ion is a st ructured, manual-based approach that
inc ludes 19 ind iv idual sess ions spanning 5 months (Fairburn et a l .,
1993b; W i l son et a l . , 1997). Treatment is d iv ided into three stages, which
are character ized by d is t inct therapeut ic goals .
The f i rs t phase begins by establ ishing a therapeut ic re lat ionship and
present ing the CBT model and t reatment rat ionale. The c l in ic ian
emphas izes that therapy wi l l address a l l facets of the eat ing d isorder,
with part icular s t ress in the beginning on the importance of reduc ing
dietary restra int . Many ind iv iduals with bul imia nervosa hope that therapy
wi l l he lp them exc ise the unwanted behav iors of b inge ing and purg ing so
that they can d iet more ef fect ive ly and achieve a lower preferred weight .
The message de l ivered at the incept ion of CBT conta ins both good news
and bad news from these pat ients perspect ive. They have not become
trapped in the ir current pat tern of behav ior because they are greedy or
crazy or lack se l f-control , but because they are at tempt ing to impose
unreasonable and counterproduct ive standards of d ietary restra int .
Overeat ing is the normal response to food depr ivat ion in humans and
animals a l ike; indeed, i t should not be construed as overeat ing at a l l ,
but as a lawful react ion to condi t ions of def ic i t or i r regular supply . The
unwelcome corol lary is that the two goals of e l iminat ing bul imic behav ior
and achiev ing a higher leve l of d ietary restra int are incompat ib le . In
order to gain f reedom from binge-eat ing, bul imic ind iv iduals must adopt a
pattern of regular eat ing.
Accord ing ly , the intervent ion begins with a st rong emphas is on consuming
(and reta ining) the regular, spaced meals and snacks that reduce
suscept ib i l i ty to bul imic ep isodes. A number of behav iora l techniques are
introduced dur ing the f i rs t s tage, inc lud ing se l f-monitor ing and the
schedul ing of a l ternat ive act iv i t ies to rep lace b inge-eat ing and purg ing
(see sect ion on Attent ion to eat ing and weight). Pat ients are a lso
prov ided with psychoeducat ional mater ia l about d ietary restra int ,
nutr i t ion, weight regulat ion, and the consequences of bul imia. Some of
this informat ion is intended to correct erroneous be l ie fs about spec i f ic
bul imic behav iors . For example, laxat ive abuse is usual ly based on the
assumpt ion that cathart ics prevent weight gain by shoot ing food so
rapid ly through the intest ina l t ract that ca lor ies cannot be absorbed. In
fact , even mass ive doses of laxat ives e l iminate only a smal l f ract ion of
the ca lor ies consumed dur ing b inges (Bo-Linn et a l . , 1983). Other
psychoeducat ional mater ia l is he lpful in underscor ing the CBT model or
decreas ing concern about the consequences of g iv ing up bul imic behav ior.
For example, whi le most pat ients fear that the lessening of d ietary
restra int wi l l cause substant ia l weight gain, the ev idence shows that the
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great major i ty of pat ients gain l i t t le or no weight af ter a successful
course of CBT (Fairburn, 1993, 1995; Fa irburn et a l . , 1993a).
In the second stage, the emphas is on regular eat ing pat terns cont inues;
in addi t ion, pat ients are asked to start re introduc ing exc luded foods into
the ir d iets and to resume eat ing in set t ings (such as restaurants) and
soc ia l s i tuat ions that they may have been avoid ing. Cognit ive
restructur ing techniques are used to analyze think ing pat terns that he lp
susta in symptoms, inc lud ing d ichotomous judgments about eat ing, weight ,
and personal performance. Pat ients are encouraged to rev iew the ev idence
for and against the ir be l ie fs in order to reach reasoned conc lus ions that
can be used to guide the ir behav ior.
The f ina l s tage focuses on re lapse prevent ion st rateg ies. The pat ient
rev iews the tact ics that she has found espec ia l ly he lpful dur ing t reatment,
ant ic ipates high-r isk s i tuat ions, and out l ines an ind iv idual ized
m ai nt en an ce p la n .
Cons is tent with general CBT pr inc ip les, therapists combine a d i rect ive,
problem-solv ing focus with a col laborat ive sty le throughout therapy.
P.179
Cl ients must take an act ive role in achiev ing symptom control through
col lect ing data, generat ing solut ions, and pract ic ing new behav iors . An
important goal is for pat ients to deve lop the sk i l l s and se l f-conf idence
that a l low them to become the ir own therapists dur ing and after the
t ime-l imited course of CBT (Wi lson et a l . , 1997) .
Empirical evidence, indications for use, and
unresolved questions
The empir ica l examinat ion of CBT for bul imia nervosa has fo l lowed a
thought ful and systemat ic sequence of invest igat ion. The approach was
developed through c l in ica l exper imentat ion with some of the f i rs t bul imic
cases reported in the l i terature, and was guided by a c lear, conc ise model
of symptom maintenance. I t was t rans lated into a manual ized intervent ion
and tested in more than 25 control led t r ia ls in a var iety of set t ings
against a number of wel l -chosen a l ternat ive modal i t ies . Within 15 years of
the t ime the approach was proposed (Fairburn, 1981), research had begun
to examine therapeut ic mechanisms, combined and sequent ia l t reatment
approaches, general i ty of e f fects across d i f ferent pat ient populat ions and
prov iders, and d isseminat ion st rateg ies. On the bas is of this impress ive
body of ev idence, CBT has earned the status of t reatment of choice for
bul imia nervosa (Wi lson, 1996; Agras, 1997; Compas et a l . , 1998; Wi lson
and Fairburn, 1998; American Psychiatr ic Assoc iat ion, 2000; Cochrane
Depress ion Anx iety and Neuros is Group, 2000; Fa irburn and Harr ison,
2003) .
In the reduct ion of both core and assoc iated symptoms, CBT is c lear ly
super ior to wai t - l i s t control condi t ions, and matches or exceeds a l l other
examined psycholog ica l intervent ions, inc lud ing psychodynamic therapy,
support ive t reatment, IPT, BT, s t ress management, exposure and
response prevent ion, and nutr i t ional counse l ing. Rev iews ind icate that
CBT resul ts in mean reduct ions of 7393% for b inge eat ing and 7794%
for purg ing; tota l remiss ion of symptoms is at ta ined by one-thi rd to one-
hal f of CBT-treated pat ients when resul ts are analyzed on an intent-to-
t reat bas is (Cra ighead and Agras, 1991; Wi lson et a l . , 1997; Wi lson and
Fa i rburn , 1998; Fa i rburn and Har r i son , 2003; Thompson-Brenner et a l .,
2003). Cons is tent with the theoret ica l model that informs the t reatment
approach, CBT has a lso been shown to reduce d ietary restra int , decrease
depress ion, enhance se l f-esteem, and produce pos i t ive changes on g lobal
measures of adjustment and soc ia l funct ioning (Fairburn et a l . , 1991;
Garne r et a l . , 1993; Wi lson et a l . , 1997; Wi lson and Fairburn, 1998).
One c lear advantage is that CBT works quick ly in compar ison with other
psychotherapies (Wi lson and Fairburn, 1998). For example, Wi lson et a l .
(1999) determined that CBT had a l ready produced most of the
improvement ev ident at post test by the thi rd week of t reatment. The
rapid gains assoc iated with CBT are a lso endur ing. Reduct ions in b inge
eat ing and purg ing are character is t ica l ly mainta ined at 612-month
fol low-up assessments (Wi lson et a l . , 1997). In the longest fo l low-up
reported to date, 71% of the part ic ipants who had achieved ful l symptom
remiss ion by the end of the act ive t reatment per iod remained symptom-
free an average of 5.8 years later (Fa irburn et a l . , 1995) .
Al though the pos i t ive ef fects of CBT are robust and stab le, i t i s a lso wel l -
estab l ished that no more than 50% of pat ients recover complete ly , whi le a
substant ia l minor i ty obta in minimal symptom re l ie f f rom part ic ipat ion in
this mode of therapy. Across studies, the hal f or more of pat ients who do
not at ta in ful l recovery through CBT cont inue to b inge an average of 2.6
t imes per week and to purge 3.3 t imes per week at t reatment terminat ion
(Thompson-Brenner et a l . , 2003). L i t t le is known about the factors that
inf luence response to CBT, as the few var iab les that appear to be
assoc iated with outcome in ind iv idual s tudies are se ldom repl icated across
them (Wi lson and Fairburn, 1998). The most cons is tent predictors of poor
response are comorbid personal i ty d isorder and high base l ine frequency of
b inge ing and purg ing. In addi t ion, the st rong re lat ionship between
symptom reduct ion dur ing the f i rs t few weeks of CBT and eventual
outcome prov ides some rat ional bas is for cont inuing the standard
approach or cons ider ing modi f ied, supplementary, or a l ternat ive
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intervent ions (Wi lson et a l . , 1999; Agras et a l . , 2000). Unfortunate ly ,
there is scant empir ica l bas is for ant ic ipat ing that pat ients who fa i l to
respond to CBT wi l l der ive greater benef i t f rom a d i f ferent t reatment
approach (Wi lson et a l . , 2000).
C l in ica l lore holds that CBT is appropr iate only for re lat ive ly s imple
cases of bul imia nervosa such as that represented by Sharon, but
contra ind icated for complex, severe, and/or comorbid symptom pictures,
exempl i f ied by the descr ipt ion of Emi ly . Certa inly , Sharon is far more
l ike ly than Emi ly to be symptom-free after 19 sess ions of CBT; however,
i t is a fa l lacy to conc lude that CBT is therefore the wrong t reatment for a
pat ient with Emi ly 's symptom prof i le . Such reasoning holds only i f an
al ternat ive approach is known to support super ior outcomes in comparable
pat ients (Hol lon and Kr iss , 1984; Wi lson, 1995, 1996). No such ev idence
ex ists in the t reatment of bul imia. A reasonable course for Emi ly 's case
might be c l in ica l exper imentat ion with modi fy ing CBT by increas ing i ts
intens i ty and/or durat ion, and by inc lud ing addi t ional components to
address d i f f icul t ies with af fect regulat ion (e.g. , Segal et a l . , 2002), se l f-
harm (e.g. , L inehan, 1993), and substance abuse (e.g. , A. T . Beck et a l .,
2001; Pa rks et a l . , 2001) (see d iscuss ions in Wi lson, 1996; Wi lson et a l .,
1997 and Fa i rburn et a l . , 2003) .
More general ly , commentators f rom both within and outs ide the CBT
or ientat ion have suggested that modi f icat ions to the bas ic approach might
prov ide greater benef i t to a broader range of pat ients . Cr i t iques of CBT
for bul imia nervosa usual ly highl ight three over lapping l imitat ions. F i rs t ,
the standard intervent ion is narrowly focused on spec i f ic eat ing d isorder
symptoms, pay ing minimal at tent ion to interpersonal issues or gener ic
concerns about se l f-worth (Hol lon and Beck, 1994; Vi tousek, 1996; Garner
e t a l . , 1997). CBT for other d isorders character is t ica l ly extends to a wider
range of top ics as re levant to ind iv idual cases, and there is no obv ious
c l in ica l just i f i cat ion for restr ic t ing the scope of CBT for bul imic pat ients .
Second, the manual-based approach re l ies predominant ly on behav iora l
tact ics , w i th fa i r ly cursory at tent ion paid to the explorat ion of be l ie fs and
less to the role of af fect (Hol lon and Beck, 1994; Meyer et a l . , 1998;
Ainsworth et a l . , 2002). A thi rd and re lated concern is that CBT appears
less ef fect ive in reduc ing pat ients focus on weight and shape than in
e l iminat ing the behav iora l symptoms of b inge ing and purg ing (Wi lson,
1999). Greater change might be obta ined through more emphas is on
cognit ive work; in addi t ion, c loser focus on body image issues through
therapist-ass is ted exposure and other targeted CBT techniques could be
benef ic ia l (Tuschen and Bent , 1995; Rosen, 1996; Fa irburn, 1997a; Wi lson
e t a l . , 1997; Wi lson, 1999; Fa irburn et a l . , 2003).
On the bas is of these observat ions, Fa i rburn et a l . (2003) recent ly
proposed a rev ised model of the maintenance of bul imia nervosa and
out l ined a broader approach to i ts t reatment. The new formulat ion is
intended to supplement rather than rep lace the or ig inal model , pr inc ipa l ly
through the inc lus ion of four addi t ional foc i , i f ind icated for ind iv idual
pat ients: perfect ionism, low se l f-esteem, mood intolerance, and
interpersonal d i f f icul t ies .
I f the standard course of manual-based CBT is not suf f ic ient for a l l
pat ients , the ful l t reatment may be unnecessary for some (Wi lson, 1995;
Wi lson et a l . , 1997). The pressures of cost conta inment and the scarc i ty
of t ra ined spec ia l is ts have st imulated ef forts to f ind economical , readi ly
d isseminable t reatments for bul imic pat ients . Severa l s t reaml ined
intervent ions cons is tent with the CBT approach have been evaluated. One
of these involves se l f-he lp manuals (Schmidt and Treasure, 1993; Cooper,
1995; Fairburn, 1995) des igned for d i rect use by bul imic ind iv iduals with
or without guidance by a profess ional or paraprofess ional (Fa irburn and
Carter, 1997; Birchal l and Palmer, 2002; Carter, 2002). Another
poss ib i l i ty is an abbrev iated CBT intervent ion that can be appl ied in
pr imary care set t ings (Wal ler et a l . , 1996). Addi t ional a l ternat ives are
group CBT that inc ludes a l l components of the standard model but can be
del ivered economical ly to mult ip le pat ients (Agras, 2003; Chen et a l .,
2003) or a shorter group ser ies that presents the psychoeducat ional
content covered in the ful l approach (Olmsted and Kaplan, 1995).
Each of these approaches has been examined, and the same general
conc lus ion appears to apply across a l l : t runcated and/or group-
administered var iants of CBT prov ide substant ia l benef i t to a subgroup of
pat ients , but typ ica l ly y ie ld lower rates of improvement and remiss ion
than the complete
P.180
indiv idual approach (e.g. , Olmsted et a l . , 1991; T reasure et a l . , 1994,
1996; Th ie l s et a l . , 1998; Mitche l l et a l . , 2001; Palmer et a l . , 2002; Chen
et a l . , 2003). The appropr iate use of se l f-he lp and/or group
psychoeducat ion may be as in i t ia l intervent ions in a stepped-care model ,
wi th ind iv iduals who fa i l to respond of fered a subsequent course of the
ful l t reatment; conc lus ions about br ie f CBT and a group vers ion of
standard CBT are more tentat ive pending the accumulat ion of addi t ional
data.
I n t e r p e r s o n a l p s y c h o t h e r a p y
Theoretical base
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In contrast to CBT, the use of IPT in the t reatment of bul imia nervosa is
not predicated on an e legant , d isorder-spec i f ic model of symptom
maintenance. The approach was f i rs t appl ied to this populat ion because i t
sui ted the purposes of c l in ica l researchers who needed a short-term, wel l -
spec i f ied modal i ty that had minimal conceptual or procedural over lap with
CBT. IPT ful f i l led these spec i f icat ions admirably , and was in i t ia l ly se lected
for compar ison with CBT and BT in a t r ia l conducted by Fairburn et a l .
(1991) .
Al though IPT was in some senses chosen as a fo i l , i t would be unjust to
both the researchers and IPT i tse l f to assume that i t was meant to be a
st raw tr eat me nt th at wo u ld ma ke the re su lt s o f CBT ap pe ar mo re
impress ive by contrast . IPT was a l ready establ ished as an ef fect ive
therapy for depressed outpat ients (Weissman et a l . , 1979; E l k in et a l .,
1989), and would have been a poor bet for invest igators seek ing an
attent ion-p lacebo condi t ion. Moreover, i f there is no e laborated
in te rp e rs ona l th eo ry of bu li mi a ner vo sa , th er e is su bst ant ia l evi de nce
that interpersonal issues are impl icated in the d isorder. Fami ly problems,
sens i t iv i ty to cr i t ic ism, conf l ic t avoidance, and concern about soc ia l
presentat ion are a l l prominent in bul imic pat ients , and b inge episodes are
often prec ip i tated by interpersonal s t ress. Therefore, IPT of fered a
credib le a l ternat ive t reatment that was manual based and approx imate ly
matched to CBT in format, yet focused on d i f ferent issues, employed
di f ferent techniques, and presumably worked through d i f ferent
mechanisms.
In i ts or ig ina l formulat ion for depressed pat ients , IPT was a lso des igned
as a research t reatment that gave st ructure to the emphas is many
c l in ic ians p lace on the ir c l ients re lat ionships (K lerman et a l . , 1984) .
Drawing on Sul l ivan's (1953) interpersonal approach, IPT makes few
assumpt ions about the var iab les that produce spec i f ic symptom patterns.
The rat ionale for i ts use across d iagnost ic categor ies and c l ients is that
a l l psychiatr ic d isorders deve lop and pers is t in a soc ia l context , and are
often amel iorated by resolv ing interpersonal problems. IPT focuses on
pat ients current soc ia l re lat ionships rather than at tempt ing to address
chi ldhood issues or endur ing personal i ty character is t ics (Weissman and
Markowitz, 1994).
Description
The adaptat ion of IPT for bul imia is out l ined in severa l descr ipt ive art ic les
(Fairburn, 1993, 1997b, 2002b; Apple, 1999; Wi l f ley et a l . , 2003) .
Therapy is de l ivered in 19 sess ions over 1820 weeks, scheduled twice
week ly in the f i rs t month, week ly for the subsequent 2 months, then in
a l ternate weeks. This represents a s l ight reduct ion and rearrangement of
the sess ions spec i f ied for work with depressed pat ients , in order to a l ign
the format more prec ise ly with CBT and BT. With a few except ions, the
intervent ion for bul imia is otherwise ident ica l to the approach deta i led in
the IPT manual for depress ion (K lerman et a l . , 1984; Weissman et a l .,
2000). Two changes in content are prescr ibed: the in i t ia l sess ions involve
an analys is of the chronology and context of eat ing d isorder symptoms;
thereafter, d iscuss ion of d isorder-spec i f ic mater ia l is act ive ly d iscouraged
to mainta in the focus on interpersonal issues. The f i rs t of these
modi f icat ions is ent i re ly cons is tent with the pr inc ip les of IPT for
depress ion; however, the second represents a departure that was
intended to sharpen the d is t inct ion between IPT and CBT/BT (Palmer,
2000). In other appl icat ions, IPT does not exc lude d i rect work on current
symptoms. As reformulated for bul imia, IPT avoids any reference to eat ing
patterns, compensatory behav iors , and weight concern between the f i rs t
and last few sess ions of the t reatment course. I f these top ics are ra ised
by pat ients , therapists are inst ructed to t ry to l imit pat ients d iscuss ion
of the ir d isordered eat ing behav iors to 10 seconds or less (Apple, 1999,
p. 717).
The f i rs t phase of IPT is completed in three or four sess ions, which are
devoted to a thorough assessment of the interpersonal context
surrounding bul imic symptoms. Therapist and pat ient t race the his tor ica l
assoc iat ion between s igni f icant events, re lat ionships, mood, se l f-esteem,
and changes in eat ing pat terns and weight . This rev iew is used to create a
li fe ch art th at il lu st rat es th e co nnec ti on be tw een ex pe r ie nce s an d
symptoms. The assessment a lso inc ludes ident i f icat ion of interpersonal
t r iggers for ep isodes of b inge-eat ing (Fairburn, 2002b).
On the bas is of the informat ion col lected and organized dur ing this in i t ia l
phase, therapist and pat ient ident i fy one or more problem areas that wi l l
become the focus of the next s tage of t reatment. Para l le l ing IPT for
depress ion, these are drawn from four categor ies: gr ie f react ions,
interpersonal ro le d isputes, d i f f icul t ies ar is ing from role t rans i t ions (such
as moving out of the parenta l home or start ing work), and interpersonal
def ic i ts . For bul imic pat ients , the most common targets are role d isputes
(re levant for 64% of c l ients) and role t rans i t ions ( ident i f ied in 36%);
issues re lated to gr ie f (12%) or interpersonal def ic i ts (16%) are less
often impl icated for this populat ion (Fairburn, 1997b).
With reference to the case examples out l ined ear l ier , a natura l focus of
IPT for Sharon might be her impending t rans i t ion from l iv ing a lone to
forming a new household with her f ianc. In v iew of Emi ly 's profound
soc ia l iso lat ion, therapy might focus on her interpersonal def ic i ts or
unresolved issues in her conf l ic ted re lat ionships with her estranged
husband and fami ly . Unfortunate ly , just as the standard CBT intervent ion
may not be ef fect ive in Emi ly 's case, pat ients present ing with
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longstanding interpersonal def ic i ts are d i f f icul t to he lp through IPT as wel l
(Fa i rburn, 1997b).
In the f ina l phase of t reatment, the pat ient and therapist rev iew progress
to date, d iscuss remaining d i f f icul t ies , and ant ic ipate and p lan for
poss ib le future problems. At this point , pat ients are encouraged to
ident i fy any changes in eat ing-d isordered symptoms over the course of
therapy, and to note the ir l inkage to improvements in re lat ionship
patterns (Apple, 1999).
Empirical evidence, indications for use, and
unresolved questions
In the study that prompted the adaptat ion of IPT for bul imia nervosa, the
approach appeared moderate ly e f fect ive when status was assessed at the
end of the t reatment per iod (Fairburn et a l . , 1991). IPT and CBT were
assoc iated with comparable reduct ions in b inge frequency and depress ion,
as wel l as equivalent improvements in soc ia l funct ioning; however, CBT
was more ef fect ive than IPT (or BT) in modi fy ing at t i tudes about weight
and shape, and produced greater reduct ions in d ietary restra int and
vomit ing frequency. Data col lected after a 1-year c losed fo l low-up per iod
revealed some surpr is ing t rends (Fairburn et a l . , 1993a). Whi le
part ic ipants in the BT condi t ion were doing qui te poor ly , those who had
rece ived IPT had caught up to the CBT-treated pat ients so that the groups
had become stat is t ica l ly ind is t inguishable across a l l ind ices of outcome. A
s imi lar pat tern of resul ts was obta ined in a subsequent mult is i te s tudy
(Agras et a l . , 2000). CBT again outperformed IPT at post t reatment
assessment; once more, no d i f ferences were d iscernib le by fo l low-up as a
funct ion of cont inuing improvement in part ic ipants prev ious ly t reated with
IPT.
The unant ic ipated ef f icacy of IPT at fo l low-up seemed to ra ise important
quest ions for models of bul imia nervosa. C lear ly , some ind iv iduals were
able to accompl ish s igni f icant ( i f s l ight ly de layed) changes in the ir eat ing-
d isordered behav ior even when therapy paid l i t t le or no at tent ion to the
spec i f ic symptoms that prompted them to seek t reatment. The d i f ferent
temporal pat tern of change a lso supported the v iew that these modal i t ies
worked through a l ternat ive mechanisms. Fa irburn speculated that IPT
might fac i l i tate change by increas ing pat ients fee l ings of se l f-worth,
ind irect ly lessening the ir tendency to evaluate themselves on the bas is of
body shape and weight (Fa irburn, 1988, 1997b; Fa irburn et a l . , 1991) .
This hypothes is appeared cons is tent with the lag between the act ive
treatment phase and the achievement of symptom controlperhaps i t
s imply took more t ime for ind iv iduals to t rans late improvements in se l f-
esteem into modi f icat ions of the ir eat ing behav ior.
P.181
The int r iguing int imat ion of a de layed t reatment response or s leeper
ef fect , however, was d isconf i rmed by further analyses of data f rom the
second study (Wi lson et a l . , 2002). In fact , the same proport ion of
pat ients who remained symptomat ic af ter IPT or CBT cont inued to improve
dur ing the fo l low-up per iod; thus, IPT appeared to catch up to CBT
s imply because there were more symptomat ic pat ients le f t at the end of
IPT who were st i l l e l ig ib le for a late shi f t toward recovery. The conjecture
that the two t reatments work through d i f ferent mechanisms was
contradicted as wel l . The mediators be l ieved to account for improvement
in IPTimproved se l f-esteem and interpersonal funct ioningshowed no
re lat ionship to symptom changes in e i ther IPT or CBT. Instead, both
treatments decreased b inge ing and purg ing through reduct ions in d ietary
restra int , w i th CBT appear ing more ef fect ive than IPT at post test because
i t accompl ished this object ive more rap id ly .
Al though i t remains unc lear how IPT works, the equivalence of IPT and
CBT by fo l low-up supports the conc lus ion that these modal i t ies are
comparably ef fect ive (Fairburn, 1993). On that bas is , e i ther t reatment is
a defens ib le f i rs t -choice a l ternat ive for bul imia nervosa, wi th the
se lect ion between them inf luenced by pat ient and therapist preference,
avai lab i l i ty of expert ise, and the importance of prompt symptom control .
Another poss ib i l i ty is that IPT might be reserved as a second- l ine
treatment for pat ients who do not achieve sat is factory resul ts through
CBT. The sole study that has invest igated the mer i ts of such sequent ia l
t reatment, however, was not support ive (Mitche l l et a l . , 2002).
P h a r m a c o t h e r a p y
An ec lect ic assortment of drugs has been proposed and tested for the
treatment of bul imia nervosa, of ten on the bas is of short- l ived theor iesabout the nature of the d isorder. I t was reasoned var ious ly that op iate
antagonists might work i f pat ients are addicted to bul imic behav ior,
ant iconvulsants i f the i r t rance- l ike s tate dur ing b inges ref lects se izure
act iv i ty , and appet i te suppressants i f they are responding to faul ty
s ignals of hunger and sat iety . Whatever the mer i ts of these models , the
medicat ions they recommended proved unhelpful . Only one group of
agents, the ant idepressant drugs, out lasted the abandoned model that
f i rs t suggested i ts use. Al though the v iew that bul imia nervosa represents
a var iant form of af fect ive d isorder (Pope and Hudson, 1984) is no longer
tenable, ant idepressants make a moderate contr ibut ion to i ts t reatment.
Most c lasses of ant idepressant medicat ion have been examined, inc lud ing
tr icyc l ics , monoamine ox idase inhib i tors , SSRIs, and atypica l
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ant idepressants (Walsh, 2002a). In v i r tual ly a l l t r ia ls , these medicat ions
have been super ior to p lacebo, y ie ld ing cons is tent and approx imate ly
equivalent reduct ions in symptom frequency and assoc iated features ( for
rev iews, see Cra ighead and Agras, 1991; Mitche l l and de Zwaan, 1993;
Compas et a l . , 1998; Mayer and Walsh, 1998; Wi lson and Fairburn, 1998;
Peterson and Mitche l l , 1999; Walsh, 2002a). In the short-term, b inge
purge episodes are reduced by an average of approx imate ly 60% and
suppressed complete ly in about one-thi rd of pat ients (Compas et a l .,
1998; Wi lson and Fairburn, 1998); however, re lapse rates appear to be
substant ia l i f drugs are administered on a long-term bas is , and
astronomical i f they are d iscont inued (Pope et a l . , 1985; Py le et a l .,
1990; Wa l sh et a l . , 1991). Al though a l l tested ant idepressants of fer
comparable benef i ts , f luoxet ine is general ly favored for i ts low s ide-ef fect
prof i le (Wi lson and Fairburn, 1998; Walsh, 2002a).
Interest ing ly , i t has been establ ished that ant idepressants do not
decrease bul imic behav ior through the a l lev iat ion of depressed mood.
Nei ther the presence nor the sever i ty of mood d is turbance predicts
response to medicat ion, and pos i t ive ef fects on b inge ing and purg ing
often precede changes in depress ive symptoms (Johnson et a l . , 1996;
Walsh, 2002a). Moreover, higher doses of f luoxet ine (60 mg/day) are
required for the control of bul imic behav ior than the leve ls typ ica l ly
ind icated (20 mg/day) for the management of depress ion (F luoxet ine
Bul imia Nervosa Col laborat ive Study Group, 1992).
Direct compar isons of ant idepressants and CBT cons is tent ly favor the
lat ter. A meta-analys is ind icated that CBT is s igni f icant ly more ef fect ive
in reduc ing b ingepurge frequency, modi fy ing at t i tudes toward shape and
weight , and decreas ing depress ion (Whit ta l et a l . , 1999). CBT is a lso
assoc iated with lower rates of at t r i t ion, greater reduct ion of d ietary
restra int , and bet ter preservat ion of t reatment gains. Only one
invest igat ion has suggested modest incremental benef i t for s imultaneous
treatment with CBT and ant idepressants (Walsh et a l . , 1997). Leading
researchers in pharmacotherapy for eat ing d isorders conc lude that in most
cases ant idepressants should be used as a second- l ine t reatment for
pat ients who fa i l to respond to an adequate t r ia l of CBT (Mitche l l et a l .,
2001; Walsh, 2002a). The only two studies that have examined the use of
medicat ion as a fo l low-up t reatment reached d i f fer ing conc lus ions about
i ts incremental advantage (Walsh e t a l . , 2000; Mitche l l et a l . , 2002) .
Treatment approaches for anorexia nervosa
Anorex ia nervosa is def ined by the ass iduous pursui t of thinness through
dietary restr ic t ion and other weight-control measures, resul t ing in a body
mass index (BMI) substant ia l ly be low the normal range. As pat ients weights dec l ine, the ir fear of ga ining weight paradox ica l ly increases, so
that the prospect of going from 89 to 90 pounds may seem almost as
intolerable as reaching 150 pounds. The ir at t i tudes toward the ir current
d imens ions are complex. On the one hand, many descr ibe fee l ing
overweight even whi le emaciated; s imultaneous ly , most take pr ide in the ir
exemplary thinness and may be of fended i f i t i s not recognized by others
(Bruch, 1978; Vi tousek, 2005). The card inal features of the d isorder are
ego-syntonicindeed, they are often f ierce ly and assert ive ly so. Low
weight and restr ic t ive eat ing are not mere ly accepted as cons is tent with
the rea l se l f , but va lued as accompl ishments of the best se l f . Many
pat ients keep this dynamic to themselves; those who d iscuss i t use
str ik ing imagery to descr ibe the appeal of semistarvat ion:
When I eventual ly weighed under 80 pounds
and looked at myse l f in the mirror I saw
someone beaut i fu l: I saw mysel f. The c learer
the out l ine of my ske leton became, the more I
fe l t my t rue se l f to be emerging. I was,
l i tera l ly and metaphor ica l ly , in perfect shape
I was so super ior that I cons idered mysel f to
be v i r tual ly beyond cr i t ic ism.
MacLeod (1982, pp. 6970)
For methis is rea l ly s ickit 's l ike winning the
Nobel Pr ize or something. I t ' s l ike you get a
k ingdom or become a goddess I fe l t i t was to
be someone, l ike I was becoming a unique
person, creat ing my own ident i ty . You fee l that
you are nobody before, and when you starve,
you' re get t ing yourse l f down to the bones:
T h is is rea ll y me . Th is is wha t I am.
--Pat ient quoted in Way (1993, p. 69)
The ego-syntonic qual i ty of symptoms seems to account for much of the
var iance in expla ining why anorex ia nervosa is so d is t inct ive ly d i f f icul t to
t reat . In most d isorders, lack of mot ivat ion is cons idered a spec ia l
problem in psychotherapy. In anorex ia nervosa, however, at tachment to
symptoms and re luctance to change are not spec ia l problems but expected
features that af fect a lmost every aspect of t reatment with v i r tual ly a l l
pat ients . Without some understanding of this centra l issue, i t i s d i f f i cul t
to apprec iate why control led t r ia ls of psychotherapy are so rare, at t r i t ion
rates so high, and resul ts so unsat is factory. Awareness of the
phenomenon a lso prov ides essent ia l context for the t reatment modal i t ies
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out l ined be low, i l luminat ing why fami ly therapy favors external control by
parents, why dynamic therapy is usual ly supplemented with symptom-
focused t reatment, why CBT expects l i t t le at t i tude change from cogni t ive
restructur ing techniques, and why pharmacotherapy has fa i led to ident i fy
any medicat ions (at least to date) that inf luence the core psychopathology
of this d isorder.
The achievement of restra int and thinness, however, comes at substant ia l
cost . Pat ients are haunted by anx iety about the r isk of los ing control and
increas ing ly constra ined by se l f- imposed rules about what , when, where,
and how to eat . These d is t ress ing concerns are accompanied by other
character is t ic symptoms, inc lud ing depress ion, i r r i tab i l i ty , soc ia l
w i thdrawal , and sexual d is interest , as wel l as a host of major and minor
phys io log ica l d is turbances. Most of these symptoms are secondary to
semistarvat ion; a l l are exacerbated by undereat ing and weight loss. The
pattern that most cons is tent ly precedes anorex ia nervosa and surv ives i ts
resolut ion is a c luster
P.182
of obsess ional and perfect ionis t ic t ra i ts (Vi tousek and Manke, 1994;
Fairburn et a l . , 1999a; Serpe l l et a l . , 2002; Sha f ran et a l . , 2002;
Ander luh et a l . , 2003). There is ev idence that these features have a
genet ic bas is (L i lenfe ld e t a l . , 1998), and some experts be l ieve that they
help to account for both the appeal of a narrowed focus on weight control
and the capac i ty to persevere in the demanding rout ines required.
Data on the course of anorex ia nervosa ind icate that i t can be a
pers is tent , d isabl ing, and somet imes lethal condi t ion. Rapid weight gain
can be accompl ished in the hospi ta l through operant programs or sk i l led
nurs ing care, wi thout resort to nasogastr ic feeding; however, pat ients
often begin los ing weight immediate ly after d ischarge. When outcomes are
averaged across fo l low-up studies of vary ing lengths, i t i s typ ica l ly
reported that somewhat fewer than hal f of anorex ic pat ients have
recovered, whi le a thi rd are improved but st i l l mani fest s igni f icant eat ing
disorder symptoms and a fourth remain severe ly i l l or have d ied of the
disorder (P ike, 1998; Ste inhausen, 2002; Sul l ivan, 2002).
These aggregate stat is t ics , however, obscure cons iderable heterogenei ty
in the odds for recovery in the ind iv idual case (Fairburn and Harr ison,
2003). One var iab le that contr ibutes to the predict ion of outcome in
anorex ia (but less cons is tent ly in bul imia) is the durat ion of i l lness at
intake (Ste inhausen, 2002; Keel et a l . , 2003). In some young pat ients
with a short symptom history, the d isorder appears to be e i ther se l f-
l imit ing or respons ive to br ie f , low-intens i ty intervent ions; after the
disorder is wel l -estab l ished, i t i s of ten highly res is tant to change ef forts
(Wi lson and Fairburn, 1998; Fa irburn and Harr ison, 2003). Compar isons of
outcome f igures across t reatment t r ia ls are uninformat ive without
reference to the age and durat ion of i l lness of the samples t reatedeven
i f the current sever i ty of symptoms appears approx imate ly equivalent , as
in the two cases out l ined be low.
C a se e x a m p l e s
Chloe is a 16-year-old high school sophomore
who began d iet ing after her t rack coach
suggested that her performance might be
enhanced i f she lost 5 or 10 pounds. She
immediate ly reduced her food intake dur ing the
day to a s ing le carton of yogurt and an apple,
and d id her best to avoid eat ing fat tening
foods dur ing fami ly d inners. In addi t ion to her
t rack pract ice, she a lso began running for an
hour each morning before school and doing
cal is thenics in her room at night . Within
severa l months, she had lost 20 pounds. Chloe
was e lated by her weight loss (as wel l as her
improved race t imes), and fe l t confused and
angry when her coach suspended her f rom the
team and contacted her parents after she
fa inted dur ing pract ice. On the adv ice of the
fami ly phys ic ian, Chloe was in i t ia l ly seen by a
counse lor who worked with adolescent (but
rare ly eat ing-d isordered) c l ients . When Chloe 's
weight cont inued to dec l ine, her phys ic ian
prescr ibed an ant idepressant and referred her
to a d iet i t ian for nutr i t ional counse l ing, to noapparent e f fect . At that point , she was br ie f ly
hospi ta l ized on a pediatr ic uni t for medica l
s tab i l i zat ion and an at tempt at weight
restorat ion. By the t ime her increas ing ly
desperate parents brought Chloe ( f igurat ive ly
k ick ing and screaming) to a spec ia l ty eat ing
disorder program, she had reached a BMI of
14.5, just over 1 year after the onset of her
anorex ia nervosa.
Amanda is a 29-year-old Engl ish inst ructor in a
community col lege who has a long his tory ofrestr ic t ing anorex ia nervosa. She was
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hospi ta l ized for 6 months when she was 20, but
lost weight soon after d ischarge. Amanda
mainta ined a BMI between 15 and 17 for the
remainder of her years in col lege and graduate
school . She was in therapy on and of f dur ing
this per iod, but s tudious ly avoided any form of
t reatment in which she would be expected to
gain weight . At present , Amanda fo l lows a
highly restr ic t ive vegetar ian d iet , and exerc ises
2 hours per day. Her l i fe centers around her
d isorder and her teaching. She l ives a lone but
remains c lose to her parents, who are res igned
to the ir inabi l i ty to af fect her eat ing behav ior.
She has few soc ia l contacts outs ide of work,
and rare ly dates. After Amanda's weight
recent ly dr i f ted down an addi t ional 7 pounds,
her co-workers and phys ic ian began urg ing her
to seek he lp.
F am i l y t h e r a p y
Theoretical base
Dominant schools of fami ly therapy have taken a keen interest in anorex ia
nervosa and had cons iderable impact on the f ie ld (e.g. , Minuchin et a l .,
1978; Se lv ini-Palazzol i , 1978; Dare, 1985; Dare and Eis ler , 1992).
Minuchin's s t ructura l model ident i f ied anorex ia as the prototype
ps yc ho so ma t ic di so rde r , in wh ic h fa mi l y dy sf unct io n (i ncl udi ng
enmeshment, overprotect iveness, r ig id i ty , and conf l ic t avoidance) is
expressed by the symptom-bear ing chi ld . The t reatment approach featured
fa m il y lu nch se ss io n s, du r in g wh ic h th e the ra pi st ob ser ve d fa mi ly
dynamics and carr ied out on-the-spot intervent ions. Parents were urged
to uni te and force the ir anorex ic chi ld to eatin some instances by
hold ing her down and pushing food into her mouth with the therapist ' s
encouragement and support . The method was wide ly publ ic ized through
the d is t r ibut ion of f i lmed sess ions, which for a t ime were shown rout ine ly
in abnormal psychology c lasses throughout the Uni ted States. Many
undergraduates found these d is turb ing to v iewas d id most eat ing
disorder spec ia l is ts . The resul ts Minuchin c la imed to have achieved,
however, were every b i t as dramat ic as the sample sess ions: near ly 90%
of pat ients were sa id to be doing wel l at fo l low-up (Rosman et a l . , 1978) .
Cr i t ics have quest ioned the r igor, representat iveness, and even the
verac i ty of these data; many experts a lso d ispute the assumpt ion that
fami ly dynamics are uni form or causal in anorex ia nervosa (e.g. , Yager,
1982; Rakoff , 1983; Vandereycken, 1987).
The most inf luent ia l contemporary form of fami ly therapy for anorex ia
nervosa is the Mauds ley model , which combines e lements f rom both
structura l and st rateg ic approaches (Dare and Eis ler , 1995, 1997; Lock et
a l. , 2001). Fol lowing Minuchin, therapists d i rect parents to assume
control over the anorex ic chi ld 's eat ing behav ior and orchestrate cr ises
dur ing meal sess ions to empower them in this ro le . The Mauds ley
approach is more c lose ly a l igned with st rateg ic fami ly therapy, however,
in favor ing an agnost ic v iew of et io logy. Fami ly members are charged
with respons ib i l i ty for the anorex ic ind iv idual ' s recovery, but expl ic i t ly
exonerated from blame for her d isorder.
Description
As appl ied to adolescent pat ients , the Mauds ley approach involves 1020
fami ly sess ions spaced over 612 months. The conjoint format spec i f ies
that a l l fami ly memberssib l ings as wel l as parents and the anorex ic
chi ldshould be seen together. A recent ly publ ished manual (Lock et a l .,
2001) descr ibes the implementat ion of conjoint fami ly therapy (CFT) in
deta i l . As d iscussed be low, a form of separated fami ly therapy has a lsobeen dev ised and tested.
CFT is d iv ided into three phases, wi th t rans i t ion from one to the next
dependent on the achievement of spec i f ic object ives. The approach is
highly st ructuredindeed, a lmost scr ipted, part icular ly in the ear ly
sess ions. The key therapeut ic maneuver in Phase I is to reestabl ish
parenta l author i ty in the fami ly system, with part icular re ference to
assert ing control over the anorex ic chi ld 's eat ing and weight . Severa l
tact ics are adopted to further this goal . Us ing a sympathet ic but
author i tat ive sty le , the therapist works to he ighten the parents leve l of
anx iety by underscor ing the sever i ty of the ir daughter 's condi t ion. In an
al mo st r it ual i st ic fa sh io n (La sk, 19 92), c li n ic ia ns ar e ad v is ed to a ss umea portentous, brooding, and grave manner (Lock et a l . , 2001, p. 208)
when they greet parents; in the f i rs t sess ion, they should concentrate on
the horror of this l i fe-threatening i l lness, (p. 52) warning parents that
so me th in g ve ry dr ast ic has to hap pe n fo r yo u to sa ve [y ou r ch il d' s] l if e
(p. 47).
Another recommended technique is the external izat ion of anorex ic
symptoms. The d isorder is construed as an a l ien force that has overtaken
the pat ient so complete ly that she is incapable of control l ing her own
behav iorand therefore cr i t ica l ly in need of her parents forceful
intervent ion. This benevolent d issoc iat ion is intended to assuage
parents gui l t about us ing st rong measures to combat the i l lness, as wel l
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as to convey support for the pat ient as an ind iv idual d is t inct f rom her
d isorder (Lock et a l . , 2001; Russe l l , 2001).
Parents are asked to br ing food to the second t reatment sess ion, and
coached by the therapist to f ind ways of compel l ing the ir daughter to eat .
Outs ide of therapy, they are adv ised to keep her under parenta l
superv is ion 24 hours a day dur ing the f i rs t few weeks, temporar i ly
arranging leaves of absence from school and work to accompl ish the task
of re feeding. External
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control tact ics are a lso appl ied to other eat ing-d isordered behav iors; for
example, parents are to ld to lock the refr igerator and cupboard doors i f
necessary to prevent b inge-eat ing, and to inform neighborhood
pharmacies that the ir daughter must not be a l lowed to purchase laxat ives.
Phase I I begins when the pat ient is surrender ing re lat ive ly cons is tent ly to
the demand to increase her intake and weight , typ ica l ly af ter 35 months
of week ly fami ly sess ions (Lock et a l . , 2001). Dur ing this s tage, the
therapist encourages a gradual fad ing of c lose superv is ion and re inforces
the pat ient 's return to age-appropr iate act iv i t ies and leve ls of autonomy.
The message is that anorex ia nervosa depr ived her of the r ight to make
her own choices, as she had funct ional ly regressed to a chi ld- l ike
incompetence and dependency; now that she is beginning to improve, she
is ent i t led to rec la im more control over her l i fe in this and other domains.
Parents are asked to focus the ir at tent ion on st rengthening the mar i ta l
re lat ionship; a l l members of the fami ly are enl is ted in reestabl ishing
in te rg ener at io nal bou nda r ie s be twe en th e pa re nt al dya d an d th e
chi ldren.
Phase I I I is in i t iated after the pat ient demonstrates her capac i ty to
mainta in a stab le weight without high leve ls of external control . This
stage involves severa l sess ions spaced 46 weeks apart . Parents are
prov ided with informat ion about normal adolescent deve lopment, and the
emphas is on foster ing independence cont inues; however, the therapist
a lso works to inst i l l fear about the poss ib i l i ty that symptoms could
resurface, in order to ensure cont inued parenta l v ig i lance to the r isk of
re lapse.
A modi f ied form of fami ly therapy is recommended for adul t pat ients . I t is
inappropr iate (as wel l as imposs ib le) for the fami ly or partner of an adul t
pat ient to se ize control of her eat ing behav iorclear ly , the 29-year-old
Amanda's parents cannot be adv ised to hold her down and push food into
her mouth. Instead, CFT for o lder pat ients focuses on restructur ing fami ly
re lat ionships so that the eat ing d isorder no longer dominates the p ic ture.
This appl icat ion has not been descr ibed in the same deta i l as fami ly
therapy for adolescents and, as d iscussed be low, appears to be much less
ef fect ive. I t should a lso be noted that in the case of adul t pat ients , a
dec is ion to implement CFT does imply certa in assumpt ions about the
s igni f icance of fami ly dynamics in the maintenance of symptoms. I t may
wel l be poss ib le to take an agnost ic v iew of et io logy when us ing the
approach with adolescents, as the tact ic of enl is t ing parents as t reatment
agents can be just i f ied on pure ly pragmat ic grounds. Because adul ts
necessar i ly reta in pr inc ipa l respons ib i l i ty for the management of the ir own
symptoms, however, a preference for work ing with such ind iv iduals
through a fami ly uni t that may no longer res ide together requires a
theory-based explanat ion. Many ind iv idual therapists might schedule a few
sess ions with the spouse, parents, or f r iends of an older anorex ic pat ient
(general ly because she requests i t ); however, a therapist who e lects to
see her pr imar i ly or exc lus ive ly with her fami ly members present is
making a much st ronger statement about wh y she became or remains i l l .
Empirical evidence, indications for use, and
unresolved questions
Fami ly therapy is the most extens ive ly researched t reatment for anorex ia
nervosa, contr ibut ing at least one ce l l to hal f of a l l control led t r ia ls of
psychotherapy. Only one of these studies found fami ly therapy c lear ly
super ior to a compar ison t reatment, and the ef fect was restr ic ted to
pat ients who carr ied part icular ly favorable prognoses by v i r tue of the ir
young age and br ie f durat ion of i l lness. At least for this subgroup,
however, no a l ternat ive t reatments have been demonstrated to work
better than some vers ion of fami ly therapy. On the bas is of the
accumulated ev idence, fami ly therapy is the sole intervent ion that
current ly meets the standard of an empir ica l ly supported t reatment for
adolescent anorex ia nervosa.
The st rong assoc iat ion between recency of onset and the l ike l ihood of
pos i t ive response to fami ly therapy was ev ident in the f i rs t t r ia l
conducted by the or ig inators of the Mauds ley approach (Russe l l et a l .,
1987). In that s tudy, CFT was much more ef fect ive than a support ive,
dynamical ly or iented ind iv idual therapy with a subset of pat ients who had
become anorex ic before the age of 19 and been symptomat ic for less than
3 years. The ef fects of in i t ia l t reatment were st i l l d iscernib le at 5-year
fol low-up: 90% of those who had rece ived CFT were c lass i f ied as
re co ve red , wh il e 45% o f t he pa ti ents or ig in a l ly a l lo ca te d t o in d iv id ua l
therapy remained anorex ic or bul imic (Eis ler et a l . , 1997). In contrast ,
fami ly therapy was ne i ther e f fect ive nor d i f ferent ia l ly e f fect ive for other
subsets of pat ients who had a longer his tory or a later onset; in fact ,
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there was a tendency for the lat ter group to do bet ter in ind iv idual
therapy, a l though few pat ients responded wel l to e i ther t reatment.
Subsequent research has conf i rmed the importance of short durat ion as a
predictor of response to CFT. Indeed, the data suggest that the window
for successful intervent ion is even narrower than the 3-year per iod used
to form subgroups in the Russe l l et a l . (1987) study. In a project carr ied
out by the same invest igators, a l l part ic ipants had been anorex ic for just
236 months, wi th an average durat ion of 12.9 months and a mean age of
15.5 years (Eis ler et a l . , 2000). Even within this extremely restr ic ted
range, there was a s igni f icant corre lat ion between how very recent onset
had been and t reatment outcome in e i ther of two forms of fami ly therapy.
Pat ients who were doing wel l at 1 year had been anorex ic for a mean of 8
months at the incept ion of t reatment, compared with 16 months for those
with intermediate or poor outcomes. Another his tor ica l var iab le was a lso
l inked to t reatment response. When pat ients who had rece ived repeated
pr ior t reatment on an inpat ient or outpat ient bas is were compared with
those obta ining therapy for the f i rs t t ime, the contrast was again sharp:
73% of the t reatment veterans d id poor ly in fami ly therapy, whi le only
19% of the nov ices fa i led to improve.
The s igni f icance of these data is underscored when we cons ider the ir
impl icat ions for the sample cases of Chloe and Amanda. There is no
reason to ant ic ipate that 29-year-old Amanda would respond to fami ly
therapy; indeed, she fa l ls into the category of adul t pat ients for whom
indiv idual therapy appeared s l ight lyif rare lymore ef fect ive in the
ini t ia l s tudy. Chloe, however, seems to match a l l spec i f icat ions for the
empir ica l ly supported t reatment of CFT: the onset of her d isorder was
square ly in the middle of adolescence, she has been anorex ic for just over
a year, and she is s t i l l l iv ing at home in an intact (and concerned) fami ly .
I f we t ry to extrapolate her prognos is f rom the f igures prov ided by Eis ler
et a l . (2000), however, Chloe 's out look appears less sanguine. At a
durat ion of 13 months, she fa l ls r ight in between the group of pat ients for
whom fami ly therapy was found to be ef fect ive and those for whom i t was
not . The fact that she has a l ready been a t reatment fa i lure e lsewhere is
ominous as wel l . Even though the nonspec i f ic therapy, nutr i t ional
counse l ing, drug t reatment, and br ie f hospi ta l izat ion to which she has
been exposed may not represent part icular ly promis ing intervent ions for
her d isorder, the ir presence on her t reatment record cons igns her to the
category from which only one-fourth of pat ients wi l l emerge as successful
responders to fami ly therapy.
This pat tern could have a number of p laus ib le explanat ions, and the
al ternat ive poss ib i l i t ies hold d i f ferent impl icat ions for how we should v iew
the resul ts of fami ly therapy. In the ear ly stages of anorex ia nervosa,
pat ients may not yet have crysta l l i zed the ir ident i t ies around the
disorder, and i t is conce ivable that i t i s eas ier and more ef f icac ious to
exerc ise external control over the express ion of symptoms in such cases.
I t is a lso poss ib le that ear ly intervent ion appears to work bet ter in part
because we end up count ing among our t reatment successes the subset
of pat ients whose d isorders would be se l f- l imit ing with or without
profess ional (or parenta l) intervent ion.
Al though i t is c lear that fami ly therapy is e f fect ive pr inc ipa l ly for br ie f ly
i l l anorex ic pat ients , i t has not been establ ished that i t d i f fers f rom other
forms of t reatment in this regard. I t may wel l be that a l ternat ive
approaches are comparably constra ined. Certa inly , the general pat tern of
corre lat ion between durat ion and outcome obta ins across most of the
treatment t r ia ls and uncontrol led fo l low-up studies reported in this f ie ld;
however, few have analyzed data with suf f ic ient prec is ion to conf i rm or
d isconf i rm the stark assoc iat ion between months of symptom pers is tence
and t reatment response ev ident in Eis ler et a l . (2000) .
The v iew that fami ly therapy is pr e fe ren ti al l y ind icated for the t reatment
of recent-onset anorex ia nervosa depends on the demonstrat ion that i t
resolves such cases faster or more complete ly or in a higher proport ion of
pat ients than a l ternat ive therapies. The answers to those quest ions are
less c lear than the wide d ispar i ty found by Russe l l et a l . (1987)
suggested. The
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pronounced super ior i ty of fami ly over ind iv idual t reatment in that in i t ia l
s tudyevident even with samples of 10 and 11 pat ients per ce l lcerta inly
of fered a compel l ing bas is for further invest igat ion. Commendably ,
proponents of fami ly therapy d id cont inue to examine the method they
advocate; inexpl icab ly , however, they stopped compar ing i t w i th anything
e lse. The Mauds ley group never t r ied to rep l icate the ir remarkable f ind ing
with larger samples or a l ternat ive forms of ind iv idual therapy. Instead,
they embarked on a ser ies of int ramural s tudies compar ing d i f ferent
formats and intens i t ies of fami ly therapy ( le Grange e t a l . , 1992; Lock,
1999; E i s l e r et a l . , 2000), as i f the case for i ts super ior i ty over other
modal i t ies were a l ready amply documented.
Three d i f ferent teams of invest igators d id take up some of the bas ic
quest ions bypassed by the Mauds ley group, with mixed resul ts . Two
studies rev is i ted the quest ion of fami ly versus ind iv idual t reatment. When
indiv idual therapy was operat ional ized in the form of an ego-or iented
approach in one t r ia l , fami ly therapy (combined with some CBT e lements)
appeared s l ight ly but not durably more ef fect ive with a sample of
adolescent pat ients who had been i l l for less than a year (Robin et a l .,
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1994, 1995). When the ind iv idual t reatment condi t ion was CBT, both
modal i t ies y ie lded equivalent and fa i r ly pos i t ive resul ts wi th adolescent
and young adul t pat ients , w i th no t rends favor ing e i ther approach for any
subgroup (Bal l , 1999). A thi rd study found no d i f ferences between e ight
sess ions of fami ly therapy and e ight sess ions of group fami ly
psychoeducat ion when these were prov ided adjunct ive ly in connect ion
with inpat ient t reatment for adolescents (Geist et a l . , 2000) .
Interest ing ly , the int ramural research to which the Mauds ley invest igators
turned d id ident i fy one mode of t reatment that appears super ior to CFT:
an a l ternat ive format for de l iver ing the same Mauds ley message. In two
studies, the standard conjoint approach was compared with separated
fami ly therapy (SFT), in which parents and the anorex ic chi ld were
counse led in d i f ferent sess ions ( le Grange et a l . , 1992; E i s l e r et a l .,
2000). In parent meet ings, the therapist prov ided adv ice cons is tent with
the parenta l control s t rateg ies of CFT, whi le anorex ic pat ients rece ived
support ive ind iv idual therapy that could inc lude d iscuss ion of both fami ly
and eat ing/ weight issues. On theoret ica l and c l in ica l grounds, SFT was
c lear ly expected to prove weaker than CFT, as i t of fered no d i rect
opportuni t ies to observe and intervene in fami ly dynamics, d id not inc lude
meal sess ions, and d id not involve s ib l ings.
Across both t r ia ls , however, there was a t rend favor ing SFT over CFT. In
the second and larger project (Eis ler et a l . , 2000), near ly twice as many
pat ients achieved a good outcome through SFT (48% versus 26%), whi le
fewer than hal f as many pat ients d id poor ly (24% versus 53%). This
ef fect was accounted for by the subset of fami l ies in which parents
frequent ly d i rected cr i t ica l remarks toward the anorex ic chi ld . When
subgroups of cases high and low in expressed emot ion (EE) were
compared, SFT was s igni f icant ly and st r ik ing ly more ef fect ive than CFT
with high EE fami l ies , benef i t ing 80% versus 29% of the pat ients t reated;
for low EE fami l ies , no t rend favored e i ther format.
I t is commendable that the Mauds ley invest igators put themselves in a
pos i t ion to learn that the ir assumpt ions about what works best for
anorex ia nervosa were mistaken. To date, however, the ir response to
these unusual ly dec is ive resul ts has been d isappoint ingboth for this
spec ia l ty area and the ev idence-based t reatment movement as a whole.
The ir own f ind ings ind icate that SFT is a s l ight ly bet ter t reatment opt ion
overa l l and a dramat ica l ly bet ter one for pat ients with the mis fortune to
come from content ious fami l ies . Yet the Mauds ley group recent ly
publ ished a manual that s t rongly advocates the less ef fect ive conjoint
format (Lock et a l . , 2001), and is us ing that approach rather than SFT in
ongoing research (Lock, 1999). At present , then, a cur ious anomaly
at taches to the empir ica l s tanding of fami ly therapy for anorex ia nervosa.
CFT is at once the best-supported t reatment for recent-onset adolescent
pat ientsand one of the very few act ive modal i t ies in the f ie ld that has
been found infer ior to an a l ternat ive approach. A therapist who was
commit ted to pract ic ing val idated t reatments should indeed adopt the
Mauds ley model for cases matching the prof i le of Chloe; i ronica l ly ,
however, he or she should not adhere to the manual wr i t ten to
d isseminate the approach, as i t descr ibes a vers ion of fami ly therapy that
has been shown to d isadvantage a s izeable subgroup of the pat ients to
whom i t is appl ied.
More broadly , i t should be noted that no study has yet examined the
meri ts of the spec i f ic type of fami ly intervent ion espoused in the
Mauds ley model . Across or ientat ions, most spec ia l is ts advocate work ing
with parents when t reat ing ind iv iduals in the young-to-mid-adolescent age
group, somet imes us ing pr inc ip les and techniques qui te d i f ferent f rom
those assoc iated with the Mauds ley model . Only d i rect compar isons can
i l luminate which of these should be preferred. At present , a l l that can be
stated with some conf idence is that see ing fami ly members together does
not contr ibute to pos i t ive outcomes, and is contra ind icated for a subgroup
of part icular ly vulnerable pat ients .
P s y c h o d y n a m i c t h e r a p y
Theoretical bases and treatment descriptions
Psychodynamic approaches do not f i t comfortab ly into the format used to
prof i le other modal i t ies in this chapter. The d i f f icul ty is that there are too
many a l ternat ives to cover, none of which is dominant in the eat ing
disorder f ie ld. They d i f fer so markedly that there would be mult ip le
th eo r ie s an d t rea tm en t de sc r ip t io ns to su mm ar iz e unde r th e se ct io n
subheadings, whi le the empir ica l ev idence that has been col lected bears
only on the spec i f ic var iants tested.
In this spec ia l ty area, the des ignat ion of a t reatment approach as
ps yc hody nam ic co nve ys li tt le in fo rma t io n ab out th e co nce pt ual mo de l
that guides i t or the techniques i t subsumes. Dr ive-conf l ic t , object
re lat ions, and se l f-psycholog ica l models d isagree about why people
become anorex ic and how they should be he lped to recover (Goods i t t ,
1997). Accord ing to d i f ferent accounts, se l f-s tarvat ion is a defense
against ora l impregnat ion or aggress ive fantas ies (Wal ler et a l .,
1940/1964; Masserman, 1941; Freud, 1958; Szyrynsk i , 1973), a react ion
to maternal impingement and/or host i l i ty (Masterson, 1977; Se lv ini-
Palazzol i , 1978), or a desperate at tempt to organize and empower the se l f
(Bruch, 1973; Caspe r , 1982; Goods i t t , 1985, 1997; Ge i s t , 1989; St robe r ,
1991). Therapists may be adv ised to interpret the meaning of the
pat ient 's symptoms (Thoma, 1967; Sours, 1974, 1980; Cr isp, 1980, 1997)
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or to of fer her a heal ing re lat ionship with a car ing adul t (Goods i t t , 1997);
a l ternat ive ly , both of these prescr ipt ions may be misguided and perhaps
downr ight dangerous (Bruch, 1988). Depending on the source consul ted,
eat ing and weight issues should be addressed, ignored, or de legated to
someone other than the therapist . Some treatment proposals spec i fy a 25-
sess ion course of outpat ient psychotherapy (Treasure and Ward, 1997a),
whi le others advocate 624 months of res ident ia l care (Story, 1982;
Strober and Yager, 1985). C lear ly , any at tempt to general ize across such
diverse models , methods, and formats would be uninformat ive.
Only a few character is t ics he lp to d is t inguish psychodynamic approaches
from al ternat ive methods (a l though none is universa l across or exc lus ive
to this group of therapies). Psychodynamic therapists are more l ike ly to
endorse the v iew that i t ' s not about eat ing and weight , to explore the
or ig in of symptoms, to focus on longstanding conf l ic ts or def ic i ts , to
encourage the express ion of emot ion, and to highl ight the therapeut ic
re lat ionship. They are, in general , less l ike ly to emphas ize the prov is ion
of facts about the d isorder, to g ive adv ice about the management of
eat ing and weight , to examine d isorder-spec i f ic be l ie fs , to suggest extra-
therapy act iv i t ies , or to use an act ive, d i rect ive sty le dur ing sess ions.
Another factor compl icat ing the rev iew of psychodynamic models is that
they are rout ine ly combined with other approaches in the t reatment of
anorex ia nervosa. Vi r tual ly a l l therapists f ind the ir accustomed modes of
pract ice chal lenged by the d is t inct ive features of this d isorder, and many
venture outs ide fami l iar f rameworks in search of bet ter a l ternat ives
(Garner and Bemis, 1982; Casper, 1987; Tobin and Johnson, 1991;
Palmer, 2000). The ident i ty cr is is seems espec ia l ly acute, however, for
those who pract ice nondirect ive forms of therapy. To a greater extent
than fami ly therapists or CBT therapists , c l in ic ians whose pr imary
af f i l iat ion is psychodynamic tend to favor a hyphenated approach when
work ing with anorex ic pat ients ,
P.185
borrowing e lements f rom fami ly systems, CBT, interpersonal , exper ient ia l ,
and medica l models . Most are (commendably) re luctant to over look
pat ients current heal th, weight , eat ing behav ior, and patent ly fa lse
be l ie fs , whi le t rac ing the or ig ins of the ir d i f f i cul t ies to ear ly
developmental def ic i ts . In response, some adopt a pragmat ic ec lect ic
approach, import ing symptom management st rateg ies f rom other
or ientat ions to put a longs ide the techniques they prefer. Others modi fy
psychodynamic therapy i tse l f to sui t the d is t inct ive features of pat ients
with this d isorder.
For example, the inf luent ia l theor is t and therapist Hi lde Bruch (1973,
1978, 1988) out l ined a causal model of anorex ia nervosa consonant with
her psychoanalyt ic t ra ining, yet caut ioned that t rad i t ional psychodynamic
therapy was s ingular ly inef fect ive and potent ia l ly harmful , even fata l
when appl ied to these pat ients . She recommended us ing a more d i rect
fa ct - f in d in g t re at me nt th a t en li st ed th e pa t ie nt as a tr ue co ll ab or at or in
the ef fort to ident i fy and chal lenge spec i f ic fa lse assumpt ions or i l log ica l
deduct ions (Bruch, 1962, 1978, 1985). The therapeut ic s ty le that Bruch
descr ibed as more ef fect ive with this populat ion bears a st r ik ing
resemblance to Aaron Beck 's cogni t ive therapy (A. T . Beck, 1976; A. T .
Beck et a l . , 1979; J. S. Beck, 1995; Greenberger and Padesky, 1995) and
adapted vers ions des igned for use with anorex ic pat ients (Garner and
Bemis, 1982, 1985; see subsequent sect ion on CBT).
Only a few psychodynamic intervent ions for anorex ia nervosa have been
out l ined in deta i l , inc lud ing the hybr id approaches labe led feminist
psychoanalyt ic therapy (which a lso incorporates e lements of CBT; Bloom
et a l . , 1994) and cogni t ive analyt ica l therapy (CAT; Treasure and Ward,
1997a). St i l l fewer have been both spec i f ied and examined in control led
tr ia ls , inc lud ing CAT and focal psychoanalyt ic psychotherapy (FPP; Dare
and Crowther, 1995).
CAT is a t ime-l imited dynamic therapy (Ry le, 1990) that is descr ibed as
uni qu el y po si ti on ed be tw e en [t he] ex tr eme s o f sy mp to m fo cu s and
ins ight or ientat ion (Be l l , 1999, p. 36). As appl ied to anorex ic pat ients ,
the format involves 20 week ly sess ions fo l lowed by 35 monthly fo l low-up
v is i ts (Treasure and Ward, 1997a; Dare et a l . , 2001; Tanner and Connan,
2003). Work ing col laborat ive ly , the therapist and pat ient ident i fy target
problems and analyze the t raps, snags, and d i lemmas through which
these are mainta ined. Therapy a lso examines interpersonal pat terns,
termed rec iprocal ro les, which are t raceable to ear ly re lat ionships and
form the background for the pat ient 's present exper ience. This
informat ion is mapped on to a v isual schemat ic ca l led the sequent ia l
d iagrammat ic re formulat ion that depicts conne
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