Psychoanalytic Psychotherapy vs. CBT for Bulimia Nervosa

Joel Yager, MD

Twenty-two sessions of cognitive-behavioral therapy provided in 5 months substantially outperformed 2 years of weekly psychoanalytic psychotherapy.

Practice guidelines favor cognitive-behavioral therapy (CBT) for treating bulimia nervosa. However, many clinicians treat the condition with psychodynamically oriented psychotherapy, which has not been compared head to head with CBT. Investigators in Denmark randomly assigned 70 patients with bulimia nervosa (99% women) to either 21 sessions of CBT-enhanced (focusing on engagement, body image concerns, and coping skills) delivered over 6 weeks, plus one session 20 weeks later, or to 2 years of weekly manual-guided psychoanalytic psychotherapy (PPT) for bulimia nervosa. Randomization was stratified by diagnosis of personality disorder (37%) and pharmacological treatment (14%). One author receives royalties for CBT-enhanced.

Therapists' psychotherapy experience averaged 8 years for CBT-enhanced and 17 years for PPT. Mostly in their mid-twenties, patients had bulimia nervosa for a mean of 12 years; a third had anorexia nervosa previously, and more than half received prior eating-disorders treatment. Treatment was completed by 78% and 71% of the CBT and PPT groups, respectively. PPT nondropouts averaged 72 sessions.

Significantly more CBT patients than PPT patients ceased binge eating and purging, both at 5 months (end of CBT; 42% vs. 6%) and at 2 years (end of PPT; 44% vs. 15%). Improvements in overall eating-disorder psychopathology occurred more rapidly with CBT, although after 2 years the level did not differ between therapies.

Citation(s):

Poulson S et al. A randomized controlled trial of psychoanalytic psychotherapy or cognitive-behavioral therapy for bulimia nervosa Am J Psychiatry 2013 Nov 26; [e-pub ahead of print].