Get Alert
Please Wait... Processing your request... Please Wait.
You must sign in to sign-up for alerts.

Please confirm that your email address is correct, so you can successfully receive this alert.

Articles   |    
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
View Author and Article Information

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.


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.

Abstract Teaser
Figures in this Article

Your Session has timed out. Please sign back in to continue.
Sign In Your Session has timed out. Please sign back in to continue.
Sign In to Access Full Content
Sign in via Athens (What is this?)
Athens is a service for single sign-on which enables access to all of an institution's subscriptions on- or off-site.
Not a subscriber?

Subscribe Now/Learn More

PsychiatryOnline subscription options offer access to the DSM-5 library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.

Need more help? PsychiatryOnline Customer Service may be reached by emailing PsychiatryOnline@psych.org or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).

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.

Anchor for Jump
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.

Anchor for Jump
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.

Anchor for Jump
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.



National Collaborating Centre for Mental Health:  Eating Disorders: Core Interventions in the Treatment and Management of Anorexia Nervosa, Bulimia Nervosa and Related Eating Disorders .  London,  The British Psychological Society and The Royal College of Psychiatrists, 2004
Shapiro  JR;  Berkman  ND;  Brownley  KA;  Sedway  JA;  Lohr  KN;  Bulik  CM:  Bulimia nervosa treatment: a systematic review of randomized controlled trials.  Int J Eat Disord 2007; 40:321–336
[CrossRef] | [PubMed]
Hay  PPJ;  Bacaltchuk  J;  Stefano  S;  Kashyap  P:  Psychological treatments for bulimia nervosa and binging.  Cochrane Database Syst Rev 2009; 4:CD000562
Wilson  GT;  Grilo  CM;  Vitousek  KM:  Psychological treatment of eating disorders.  Am Psychol 2007; 62:199–216
[CrossRef] | [PubMed]
Clinton  D:  Affect regulation, object relations and the central symptoms of eating disorders.  Eur Eat Disord Rev 2006; 14:203–211
Heatherton  TF;  Baumeister  RF:  Binge eating as escape from self-awareness.  Psychol Bull 1991; 110:86–108
[CrossRef] | [PubMed]
Safer  DL;  Telch  CF;  Chen  EY:  Dialectical Behavior Therapy for Binge Eating and Bulimia .  New York,  Guilford Press, 2009
McWilliams  N:  Psychoanalytic Psychotherapy: A Practitioner’s Guide .  New York,  Guilford Press, 2004
Lunn  S;  Poulsen  S:  Psychoanalytic psychotherapy for bulimia nervosa: a manualized approach.  Psychoanal Psychother 2012; 26:48–64
Fairburn  CG:  Cognitive Behavior Therapy and Eating Disorders .  New York,  Guilford Press, 2008
Fairburn  CG;  Jones  R;  Peveler  RC;  Carr  SJ;  Solomon  RA;  O’Connor  ME;  Burton  J;  Hope  RA:  Three psychological treatments for bulimia nervosa: a comparative trial.  Arch Gen Psychiatry 1991; 48:463–469
[CrossRef] | [PubMed]
Fairburn  CG;  Jones  R;  Peveler  RC;  Hope  RA;  O’Connor  M:  Psychotherapy and bulimia nervosa: longer-term effects of interpersonal psychotherapy, behavior therapy, and cognitive behavior therapy.  Arch Gen Psychiatry 1993; 50:419–428
[CrossRef] | [PubMed]
Agras  WS;  Walsh  T;  Fairburn  CG;  Wilson  GT;  Kraemer  HC:  A multicenter comparison of cognitive-behavioral therapy and interpersonal psychotherapy for bulimia nervosa.  Arch Gen Psychiatry 2000; 57:459–466
[CrossRef] | [PubMed]
Garner  DM;  Rockert  W;  Davis  R;  Garner  MV;  Olmsted  MP;  Eagle  M:  Comparison of cognitive-behavioral and supportive-expressive therapy for bulimia nervosa.  Am J Psychiatry 1993; 150:37–46
Bachar  E;  Latzer  Y;  Kreitler  S;  Berry  EM:  Empirical comparison of two psychological therapies: self psychology and cognitive orientation in the treatment of anorexia and bulimia.  J Psychother Pract Res 1999; 8:115–128
Fairburn  CG;  Cooper  Z;  Doll  HA;  O’Connor  ME;  Bohn  K;  Hawker  DM;  Wales  JA;  Palmer  RL:  Transdiagnostic cognitive-behavioral therapy for patients with eating disorders: a two-site trial with 60-week follow-up.  Am J Psychiatry 2009; 166:311–319
[CrossRef] | [PubMed]
Byrne  SM;  Fursland  A;  Allen  KL;  Watson  H:  The effectiveness of enhanced cognitive behavioral therapy for eating disorders: an open trial.  Behav Res Ther 2011; 49:219–226
[CrossRef] | [PubMed]
Fairburn  CG;  Cooper  Z;  Doll  HA;  O’Connor  ME;  Palmer  RL;  Dalle Grave  R:  Enhanced cognitive behavior therapy for adults with anorexia nervosa: a UK-Italy study.  Behav Res Ther 2013; 51:R2–R8
[CrossRef] | [PubMed]
Dalle Grave  R;  Calugi  S;  Doll  HA;  Fairburn  CG:  Enhanced cognitive behavior therapy for adolescents with anorexia nervosa: an alternative to family therapy? Behav Res Ther 2013; 51:R9–R12
[CrossRef] | [PubMed]
Fonagy  P;  Gergely  G;  Jurist  EL;  Target  M:  Affect Regulation, Mentalization, and the Development of the Self .  New York,  Other Press, 2002
Goodsitt  A:  Eating disorders: a self-psychological perspective, in  Handbook of Treatment for Eating Disorders , 2nd ed. Edited by Garner  DM;  Garfinkel  PE.  New York,  Guilford Press, 1997, pp 205–228
Fairburn  CG;  Cooper  Z;  Shafran  R:  Cognitive behavior therapy for eating disorders: a “transdiagnostic” theory and treatment.  Behav Res Ther 2003; 41:509–528
[CrossRef] | [PubMed]
Fairburn  CG;  Cooper  Z:  The Eating Disorder Examination,12th ed, in  Binge Eating: Nature, Assessment, and Treatment . Edited by Fairburn  CG;  Wilson  GT.  New York,  Guilford Press, 1993, pp 317–360
The SCAN Advisory Group:  Present State Examination (Short Version for Clinical Use, Version 2) .  Washington, DC,  American Psychiatric Press, 1994
Derogatis  LR:  SCL-R-90: Symptom Checklist-90-R (SCL-90-R) Administration, Scoring, and Procedures Manual .  Minneapolis,  National Computer Systems, 1994
Beck  AT;  Steer  RA;  Brown  GK:  Manual for the Beck Depression Inventory–II .  San Antonio, Tex,  Psychological Corp, 1996
Spielberger  CD:  State-Trait Anxiety Inventory (Form Y) .  Palo Alto, Calif,  Mind Garden, 1983
First  MB;  Gibbon  M;  Spitzer  RL;  Williams  JBW;  Benjamin  LS:   Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II) .   Washington, DC,  American Psychiatric Press, 1997
Horowitz  LM;  Alden  LE;  Wiggins  JS;  Pincus  AL:  IIP: Inventory of Interpersonal Problems–Manual .  San Antonio, Tex,  Psychological Corp, 2000
Loeb  KL;  Wilson  GT;  Labouvie  E;  Pratt  EM;  Hayaki  J;  Walsh  BT;  Agras  WS;  Fairburn  CG:  Therapeutic alliance and treatment adherence in two interventions for bulimia nervosa: a study of process and outcome.  J Consult Clin Psychol 2005; 73:1097–1107
[CrossRef] | [PubMed]
Wampold  BE;  Ollendick  TH;  King  NJ:  Do therapies designated as empirically supported treatments for specific disorders produce outcomes superior to non-empirically supported treatment therapies? in  Evidence-Based Practices in Mental Health: Debate and Dialogue on the Fundamental Questions . Edited by Norcross  JC;  Beutler  LE;  Levant  RF.  Washington, DC,  American Psychological Association, 2006, pp 299–328
Fairburn  CG;  Agras  WS;  Walsh  BT;  Wilson  GT;  Stice  E:  Prediction of outcome in bulimia nervosa by early change in treatment.  Am J Psychiatry 2004; 161:2322–2324
[CrossRef] | [PubMed]
Tobin  DL;  Johnson  CL:  The integration of psychodynamic and behaviour therapy in the treatment of eating disorders: clinical issues versus theoretical mystique, in  Psychodynamic Treatment of Anorexia Nervosa and Bulimia . Edited by Johnson  CL.  New York,  Guilford Press, 1991, pp 374–397
Murphy  S;  Russell  L;  Waller  G:  Integrated psychodynamic therapy for bulimia nervosa and binge eating disorder: theory, practice and preliminary findings.  Eur Eat Disord Rev 2005; 13:383–391
Stice  E;  Fairburn  CG:  Dietary and dietary-depressive subtypes of bulimia nervosa show differential symptom presentation, social impairment, comorbidity, and course of illness.  J Consult Clin Psychol 2003; 71:1090–1094
[CrossRef] | [PubMed]
Lunn  S;  Poulsen  S;  Daniel  SIF:  Subtypes in bulimia nervosa: the role of eating disorder symptomatology, negative affect, and interpersonal functioning.  Compr Psychiatry 2012; 53:1078–1087
[CrossRef] | [PubMed]
References Container

CME Activity

There is currently no quiz available for this resource. Please click here to go to the CME page to find another.
Submit a Comments
Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discertion of APA editorial staff.

* = Required Field
(if multiple authors, separate names by comma)
Example: John Doe

Related Content
See Also...
Gabbard's Treatments of Psychiatric Disorders, 4th Edition > Chapter 48.  >
Dulcan's Textbook of Child and Adolescent Psychiatry > Chapter 26.  >
The American Psychiatric Publishing Textbook of Psychopharmacology, 4th Edition > Chapter 59.  >
Dulcan's Textbook of Child and Adolescent Psychiatry > Chapter 26.  >
Gabbard's Treatments of Psychiatric Disorders, 4th Edition > Chapter 48.  >
Topic Collections
Psychiatric News
APA Guidelines
PubMed Articles