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A Randomized Controlled Trial of Psychoanalytic Psychotherapy or Cognitive-Behavioral Therapy for Bulimia Nervosa
Stig Poulsen, Ph.D.; Susanne Lunn, M.Sc.; Sarah I. F. Daniel, Ph.D.; Sofie Folke, M.Sc.; Birgit Bork Mathiesen, Ph.D.; Hannah Katznelson, M.Sc.; Christopher G. Fairburn, F.Med.Sci., F.R.C.Psych.
Am J Psychiatry 2014;171:109-116. doi:10.1176/appi.ajp.2013.12121511
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Supported in part by grant 9901684/25-01-0011 from the Danish Council for Independent Research/Humanities, grant 41470 from the Egmont Foundation and grant 07018005 from the Ivan Nielsen Foundation. C.G.F. is supported by a Principal Research Fellowship from the Wellcome Trust (046386).

Dr. Fairburn has received royalties from the sales of the CBT-E Treatment Manual. The other authors report no financial relationships with commercial interests.

From the Department of Psychology, University of Copenhagen, Denmark, and the Department of Psychiatry, Oxford University, England.

Presented in part at the 2011 International Conference on Eating Disorders, April 28-30, 2011, Miami, and at the Society for Psychotherapy Research, 42nd International Meeting, June 29–July 2, 2011, Bern, Switzerland.

Address correspondence to Dr. Poulsen (stig.poulsen@psy.ku.dk).

Copyright © 2014 by the American Psychiatric Association

Received December 04, 2012; Revised April 17, 2013; Revised June 15, 2013; Revised July 24, 2013; Revised August 15, 2013; Accepted August 19, 2013.

Abstract

Objective  The authors compared psychoanalytic psychotherapy and cognitive-behavioral therapy (CBT) in the treatment of bulimia nervosa.

Method  A randomized controlled trial was conducted in which 70 patients with bulimia nervosa received either 2 years of weekly psychoanalytic psychotherapy or 20 sessions of CBT over 5 months. The main outcome measure was the Eating Disorder Examination interview, which was administered blind to treatment condition at baseline, after 5 months, and after 2 years. The primary outcome analyses were conducted using logistic regression analysis.

Results  Both treatments resulted in improvement, but a marked difference was observed between CBT and psychoanalytic psychotherapy. After 5 months, 42% of patients in CBT (N=36) and 6% of patients in psychoanalytic psychotherapy (N=34) had stopped binge eating and purging (odds ratio=13.40, 95% confidence interval [CI]=2.45–73.42; p<0.01). At 2 years, 44% in the CBT group and 15% in the psychoanalytic psychotherapy group had stopped binge eating and purging (odds ratio=4.34, 95% CI=1.33–14.21; p=0.02). By the end of both treatments, substantial improvements in eating disorder features and general psychopathology were observed, but in general these changes took place more rapidly in CBT.

Conclusions  Despite the marked disparity in the number of treatment sessions and the duration of treatment, CBT was more effective in relieving binging and purging than psychoanalytic psychotherapy and was generally faster in alleviating eating disorder features and general psychopathology. The findings indicate the need to develop and test a more structured and symptom-focused version of psychoanalytic psychotherapy for bulimia nervosa.

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FIGURE 1. CONSORT Flow Diagram of Participants in a Study of Psychoanalytic Psychotherapy or CBT for Bulimia Nervosa

FIGURE 2. Percentage of Patients Reporting No Binge Eating or Purging Over the Previous 28 Days and Mean Eating Disorder Examination (EDE) Global Scoresa

a N=70; missing values replaced by last observation carried forward.

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TABLE 1.Baseline Characteristics of the Sample in a Study of Psychoanalytic Psychotherapy or CBT for Bulimia Nervosaa
Table Footer Note

a IQR=interquartile range; EDE=Eating Disorder Examination; SCL-90-R=Symptom Checklist-90-Revised; GSI=Global Severity Index; BDI=Beck Depression Inventory; STAI-S=State-Trait Anxiety Inventory-State; STAI-T=State-Trait Anxiety Inventory-Trait; IIP=Inventory of Personality Problems.

Table Footer Note

b Sum of vomiting, laxative, diuretic misuse episodes.

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TABLE 2.Secondary Outcome Measures by Treatment 5 And 24 Months After Beginning Treatmenta
Table Footer Note

a EMM=estimated marginal means; EDE=Eating Disorder Examination; SCL-90-R=Symptom Checklist–90-Revised; GSI=Global Severity Index; BDI=Beck Depression Inventory; STAI-S=State-Trait Anxiety Inventory-State; STAI-T=State-Trait Anxiety Inventory-Trait; IIP=Inventory of Personality Problems.

Table Footer Note

b Estimated marginal means and confidence intervals for objective binges and purging episodes are squared to correct for initial square root transformation.

Table Footer Note

c Sum of vomiting, laxative, diuretic misuse episodes.

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TABLE 3.Global Eating Disorder Examination (EDE) Score Within the Community Range in a Study of Psychoanalytic Psychotherapy or CBT for Bulimia Nervosaa
Table Footer Note

a Below 1.74 for adult female participants.

Table Footer Note

b In the calculation of proportions, missing data were replaced by last observation carried forward.

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