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.Dysfunctional dieting is decreased and patients attitudes abouttheir body shape and weight are improved.In addition, there is usually areduction in the level of general psychiatric symptoms and an improvementin self-esteem and social functioning.Therapeutic improvement is typicallywell maintained at 1 year following treatment.Cognitive Behavioural Therapy versus PharmacologicalTreatmentBeyond CBT, the most intensively researched treatment for bulimia nervosahas been antidepressant medication.Both tricyclics and fluoxetine havebeen shown to be significantly more effective than pill placebo in the shortterm [4].Consequently, antidepressant medication provides a stringentstandard of comparison for the effects of CBT.Studies comparing the relative and combined efficacy of CBT andantidepressant medication have been the subject of meta-analyses and otherreviews [4 6].The results can be summarized as follows: a) CBT is moreeffective than treatment with a single antidepressant drug and is especiallysuperior to medication in producing complete remission of binge eatingand purging; b) CBT appears to be more acceptable to patients and thedrop-out rate is typically lower than in pharmacological treatment; c) thecombination of CBT with antidepressant medication is significantly moreeffective than medication alone; d) the combination has not been shown yetto improve reliably on the outcome of CBT alone a possible problem hereis that the statistical power in some of the studies might have beeninsufficient to demonstrate a combined effect, e.g.although Walsh et al.[7]found no statistically significant effect of the combined CBT plusmedication condition, this combination was associated with a higherPSYCHOLOGICAL INTERVENTIONS: A REVIEW ______________________________________ 317remission rate for binge eating and vomiting (50%) than placebo plus CBT(24%); e) the combination of CBT and antidepressant medication may bemore effective than CBT alone in reducing anxiety and depressivesymptoms; f) CBT results in superior long-term maintenance, e.g.Mitchellet al.[8] showed poor maintenance of improvement in patients who hadreceived medication, in contrast to those who had received psychologicaltreatment [9].Fluoxetine has been shown to be significantly more effectivethan pill placebo in the treatment of non-responders to CBT andinterpersonal psychotherapy (IPT) [10].The relative durability of the effect of CBT must be underscored.Thedearth of evidence of the long-term effects is a major limitation of treatmentwith antidepressant medication.In the only controlled study of its kind todate, Romano et al.[11] conducted a 52-week double-blind relapseprevention trial of fluoxetine versus pill placebo after acute response tothe drug.Although fluoxetine was superior to pill placebo in delaying timeto relapse, patients in both conditions deteriorated over the course offollow-up.Moreover, of the 76 patients assigned to the fluoxetine condition,63 (83%) dropped out.The corresponding figure for placebo was 92%.Cognitive Behavioural Therapy versus AlternativePsychotherapiesCBT has proved superior to other psychological treatments with which ithas been compared [5,6].The exception to this finding is the outcome of twostudies comparing CBT with IPT, which was originally developed byKlerman et al.as a short-term treatment for depression.The primary focusof IPT is to help patients to identify and modify current interpersonalproblems; IPT is non-interpretive and non-directive.As adapted for bulimianervosa [13], IPT focuses exclusively on interpersonal issues, with little orno attention directed to the modification of binge eating, purging, disturbedeating or overconcern with body shape and weight.Specific eatingproblems are viewed as a means of understanding the interpersonalcontext that is assumed to be their cause.Fairburn et al.[14] compared CBT with both IPT and a narrowbehavioural treatment that was essentially a stripped down version ofCBT.At post-treatment, IPT was as effective as CBT at reducing thefrequency of binge eating, but it was clearly inferior with respect tovomiting, dietary restraint and attitudes toward body shape and weight.During the 1-year follow-up, however, patients who received IPT showedcontinuing improvement to the point where their outcome was comparableto that of those who received CBT [ Pobierz całość w formacie PDF ]