best treatment for bulimia nervosa

best treatment for bulimia nervosa Considerable evidence supports the eff ectiveness of CBT for bulimia and indicates
good maintenance of symptom reduction at 6-month and 1-year followups
(Wilson, Fairburn, & Agras, 1997). Although interpersonal therapy has also
produced good results, improvement occurs more slowly, and fewer outcome
studies have been conducted (American Psychiatric Association, 2000).
A CBT manual (Fairburn, 1985; Fairburn, Marcus, & Wilson, 1993) based
on Christopher Fairburn’s formulation of the disorder is widely used, strictly
applied in research studies and more loosely followed in clinical settings. Th is approach aims to correct the inaccurate cognitions and destructive behaviors
that perpetuate the disorder.
According to Fairburn, unrealistic pursuit of an ideal body is at the root
of bulimia. Females with low self-esteem assume this pursuit in an attempt
to boost feelings of self-worth. Th ey restrict their intake in the hopes of
approaching an ideal, but in actuality prime themselves both psychologically
and physiologically to lose control by overeating. Although purging is used
to compensate for bingeing, it actually perpetuates bingeing by alleviating
anxiety about weight gain and by confusing signals of fullness, both of which
ordinarily regulate intake. Bingeing and purging further damage self-esteem
and, in so doing, worsen the vulnerability that gives rise to and perpetuates
the disorder.
Treatment begins with an explanation of the model and an overview of
general treatment strategies. Common misconceptions held by most bulimics
about the weight-regulating eff ects of laxatives and vomiting are dispelled,
and the detriments of over- and undereating are detailed. Self-monitoring
is introduced by having clients record everything they eat, times of eating,
associated thoughts and feelings, and antecedents to bingeing and purging.
Clients are also asked to weigh themselves only once a week and to begin
implementing a normal eating pattern.
Weekly weigh-ins are a powerful tool in addressing bulimia. If you have a
bathroom for the exclusive use of the counseling center, you can place a scale
there for students to weigh themselves before their sessions. If clients have
eaten feared foods, like a piece of cake or a cookie, and are positive that their
weight has ballooned, getting on the scale and discovering that this has not
happened will astonish them. And if their weight has in fact increased, the
therapist can work with them immediately on possible reasons—water retention,
menstrual bloating, etc., cognitively challenging them to identify other
possible explanations besides the piece of cake. Th e scale brings their weight
fears and false beliefs immediately into the consulting room.
CBT makes clients anxious. Th ey are eating foods they normally avoid,
eating and digesting foods they usually purge, and feeling unnerved by sensations
of fullness and fears of immediate weight gain. Th ey are urged to
abide the discomfort. Doing so allows them to test out their weight fears
and discover that their anxiety doesn’t spiral endlessly but reliably wanes
with time.
Self-monitoring reveals the triggers to starving, bingeing, and purging.
Common triggers include fl are-ups of low self-esteem and strong emotion.
Once these triggers are identifi ed, adaptive means of coping can be generated,
such as regulating emotion by journaling or taking a walk instead of
resorting to bulimic symptoms. For example, one student discovered through
self-monitoring that she oft en binged and purged in the evenings, when she
became fl ooded with the feelings she had put “on hold” all day. Journaling throughout the day helped her to label and discharge emotions periodically,
and so avoid an overwhelming buildup of feeling. Self-monitoring also helps
to reveal the many food- and weight-related cognitive distortions that characterize
bulimia—for example, that eating a forbidden food will inevitably
lead to bingeing and a noticeable change in appearance. Clients are asked
to be aware of distorted thoughts and to immediately counter them with
realistic ones.
Th e fi nal phase of treatment reviews progress and remaining vulnerabilities.
Depending on what has worked well, strategies are put into place to maintain
recovery and prevent relapse.
Th e course of treatment depicted in the Fairburn manual spans 19 sessions.
Although most college counseling centers cannot provide that many sessions,
an abbreviated version may be helpful for those whose motivation is high and
symptom severity low. For students with higher levels of pathology, an introduction
to the model and some experience with behavior change may strengthen
their motivation and willingness to continue with treatment off -campus.
Fairburn (1995) has provided a self-help manual which explains the selfmaintaining
cycle of restricting/bingeing/purging and off ers strategies to
break out of the cycle and to establish normal eating. Th e book familiarizes
the reader with CBT principles and can be used alone or in conjunction with
individual and group therapy. It is recommended for students with either
bulimia or BED.