Professionally Assisted Self Help Treatment for Bulimia Nervosa

A number of studies evaluated professionally assisted self-help treatments for BN. The earliest study of combined bibliotherapy and support intervention for women with BN was completed by Huon in 1985. This study evaluated three versions of a self-administered intervention that included seven monthly readings containing information and specific suggestions about food, body image, self-concept and emotional support. The first version received information alone, the second received support from a woman with BN who was "improved," and the final version received support from a woman with BN who was "cured." Women were randomly assigned to one of the three interventions and an additional 30 women agreed to be in a comparison group. For the entire sample, 19% of subjects were abstinent at the end of the 7-month treatment, and an additional 68% were improved; at 6-month follow-up, abstinence rates increased to 32%. Those who received both the mailing and either form of contact were most successful.

Using a similar approach, Cooper and colleagues (Cooper, Coker, & Fleming; 1994) conducted an uncontrolled study to evaluate the effectiveness of a supervised CBT-based self-help manual for women with BN. For 4-6 months, participants completed the CBT manual, Bulimia Nervosa and Binge Eating: A Guide to Recovery (Cooper, 1993) and received guidance from a social worker with no previous specialist training in the treatment of eating disorders. Guidance included 20- to 30-minute sessions for support and encouragement to continue applying the strategies in the self-help manual. At post-assessment, half of the participants had discontinued binge eating and self-induced vomiting. On average, the frequency of binge eating decreased by 85% and self-induced vomiting was reduced by 88%. Improvement on other key features including body shape and weight dissatisfaction and dietary restraint were also noted.

In 1996, Cooper, Coker, and Fleming reported similar results using their structured CBT-based self-help manual in an open clinical trial with individuals with BN. The authors reported an 80% decrease in binge eating episodes and a 79% decrease in self-induced vomiting. Poor treatment responders or dropouts were more likely to have had a previous diagnosis of anorexia and were somewhat more likely to meet diagnosis for a personality disorder. After one year, almost two thirds of those who completed the follow-up assessment reported complete cessation of both binge eating and self-induced vomiting.

Treasure and colleagues (1994) compared a CBT-based self-help manual against standard individual CBT for BN with participants who were randomly assigned to one of three conditions: (a) self-help; (b) individual CBT; or (c) wait-list control. Participants in the self-help condition received the manual and were instructed to complete the exercises and practice the strategies in the manual during the following 8 weeks. CBT participants were assigned to a therapist for 16 sessions of psychotherapy. Participants in both treatment conditions showed significant improvements in eating disorder symptoms compared to WL. Participants in both interventions showed significant reductions in the frequency of binge eating and other weight control behaviors. Twenty-four percent of CBT participants, 22% of self-help participants, and 11% of WL participants reported full remission of symptoms.

In Italy, Dalle Grave (1997) evaluated a translated version of Fairburn's Overcoming Binge Eating (1995) in an uncontrolled study. In addition to reading the book, participants completed eight 20-minute sessions with a therapist spaced 2 weeks apart. Overall, 59% of participants improved and 35% discontinued binge eating and self-induced vomiting. In Germany, Thiels, Schmidt, Treasure, Garthe, and Troop (1998) evaluated a guided self-help program against standard individual CBT for BN. Participants were randomly assigned to one of two treatment conditions: guided self-help (GSH) or individual CBT. The GSH participants received the treatment manual and eight 50- to 60-minute, face-to-face sessions with a therapist every other week. The primary role of the therapist was to encourage use of the manual and manage acute crises. Participants in the CBT condition received weekly 50- to 60-minute sessions of standard CBT-based individual psychotherapy. Significant improvements were observed for both treatment groups in overeating, self-induced vomiting, dietary restraint, and shape and weight concerns. Improvements were maintained at follow-up.

Upon further examination of outcome predictor variables (Thiels, Schmidt, Troop, Treasure, & Garthe, 2000), the investigators found that, in the GSH condition, lower pretreatment frequency of binge eating predicted better outcome. In the CBT condition, the absence of pretreatment depression and baseline psychiatric comorbidity and a positive history of psychiatric illness predicted good outcome. In a 4-year follow-up, Thiels and colleagues (Thiels, Schmidt, Treasure, & Garthe, 2003) assessed 45% of the original study participants. The authors reported that significant improvements for both groups were attained or preserved on eating disorder symptom measures including overeating, self-induced vomiting, dietary restraint, and shape and weight concerns.

In an innovative study, Mitchell and colleagues (2001) compared fluoxetine (Prozac) and a CBT-based self-help manual for the treatment of BN. Participants were randomly assigned to one of four conditions: (a) placebo only; (b) fluoxetine only; (c) placebo plus CBT self-help manual only; and (d) fluoxetine plus CBT self-help manual. Participants were seen by a research assistant weekly for the first 4 weeks and every other week for the remaining 12 weeks of the study. Participants also were seen every other week by a study investigator. The self-help manual was comprised of standard CBT for BN. Participants were instructed to spend approximately one hour each evening completing readings and assignments. Participants who received the self-help or medication improved significantly compared to the WL. Participants in the fluoxetine plus self-help manual group reported the greatest improvement in self-induced vomiting and binge eating episodes. However, abstinence rates in the active treatment conditions were not found to be significantly different (i.e., fluoxetine, 16%; manual plus placebo, 24%; and manual plus fluoxetine, 26%).

In a randomized controlled trial, Durand and King (2003) assigned participants diagnosed by their general medical practitioner and referred for specialist eating disorder treatment to one of two conditions: (a) self-help plus regular general medical practitioner contact for support; and (b) standard individual CBT. General medical practitioners received a training manual to assist participants with the self-help treatment. Participants in the self-help condition received a CBT-based self-help manual. Participants in both groups decreased their bulimic symptoms and no significant differences were observed between the groups. Approximately 20% of participants in both treatment arms prefered a self-help treatment and 38% (self-help) and 27% (CBT) had no treatment preference.

Embracing the potential for computer software programs to provide cost-effective self-help interventions, Bara-Carril and colleagues (2004), in an uncontrolled study, evaluated an eight-module CD-ROM-based CBT intervention for BN. Participants reported significant decreases in binge eating and self-induced vomiting. The percent of participants vomiting and binge eating at least once per week decreased from 78 to 54% and from 93 to 87%, respectively. Bara-Carril et al. (2004) reported that approximately 4 in 5 patients accepted the offer to complete the CD-ROM intervention, a rate similar to the acceptance rate received for therapist-aided treatment. However, patients with more severe eating disorder symptoms were less likely to accept the self-help treatment.

Lastly, Bailer and colleagues (2004) compared guided self-help (GSH) to CBT-based group therapy (CBT) with an Austrian sample. Participants diagnosed with BN were randomly assigned to either GSH or CBT group. The GSH group received a self-help manual and a maximum of 18 brief weekly visits. The CBT group met for 18 weekly 1.5-hour sessions. Bailer et al. (2004) found significant decreases in the frequency of binge eating episodes and self-induced vomiting in both treatment groups. These improvements were maintained after one year. Analysis of treatment completers at follow-up showed that remission rates in the GSH condition (74%) were superior to the CBT group condition (44%).

In summary, studies from North America and Europe found assisted self-help interventions for the treatment of BN to be effective. The interventions used structured CBT-based manuals that unfold over time (range 8-20 weeks). Although improvement rates vary widely (ranging from 22 to 88%), all studies report that self-help is helpful. Differences may result from different measures and criteria used to define improvement, the amount of outside "assistance," and the frequency of contact with the researchers. Durand and King (2003) confirm that many women with eating disorders prefer a self-help treatment approach and Bara-Carril and colleagues (2004) found that 80% of patients accepted a referral to self-help computer-delivered treatment.

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