15 - Alimentación

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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

5


6/47

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

6


7/47

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).



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

9


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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

10


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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

P.183

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 .



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 ,

11


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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

P.184

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

15 - Alimentación

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