Bulimia Research: 2002-2006
     
Ther Umsch. 2006 Aug;63(8):535-8.
[Bulimia nervosa]
[Article in German]
Zeeck A, Hartmann A, Sandholz A, Joos A.
Abteilung fur Psychosomatische Medizin und Psychotherapie, Universitatsklinik Freiburg. almut.zeeck@uniklinik-freiburg.de

Bulimia nervosa is characterized by episodes of binge eating and compensatory behaviours (self-induced vomiting, laxative misuse, dietary restriction). It has a complex aetiology and is mostly found in young women. Bulimia leads to substantial physical and psychosocial morbidity. Bulimia nervosa needs specialized psychotherapeutic treatment. In most cases outpatient treatment is sufficient, but comorbidity with other psychiatric disturbances has to be taken into account. Additional psychopharmacological interventions might be helpful. After 5 to 10 years about 50% of the patients show complete remissions, 30% partial remissions and about 20% a chronic course of the illness. General practitioners, dentists and gynaecologists should be informed about typical signs of the disorder that is often hidden by the patients.

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Ther Umsch. 2006 Aug;63(8):551-4.
[Family therapy within the treatment of eating disorders]
[Article in German]
Schrauth M, Nikendei C, Kochling A, Martens U, Herzog W, Zipfel S.
Abteilung fur Psychosomatische Medizin und Psychotherapie, Universitatsklinikum Tubingen. markus.schrauth@med.uni-tuebingen.de

The families of patients suffering from eating disorders such as Anorexia nervosa (AN) und Bulimia nervosa (BN) are, owing to the illness, subject to considerable emotional strain and are furthermore often characterised by significant structures and patterns of interaction within the family. Consequently the inclusion of patients' family members, whose status can be seen as increasingly gaining in scientific approval, plays an important role within both diagnosis and therapy. Of particular importance is the medical informative discussion with both patients and their parents which takes place in a primarily medical context and aims to develop and increase therapy motivation. For this purpose the doctor should possess basic knowledge concerning dialogue management with families, as will be presented in the current article. Within further stages of the therapeutic process the spectrum of interventions at the level of the family ranges from educational and supportive measures to family therapy in a more narrow sense, which is carried out by specialist psychotherapists either as outpatient-treatment or within the framework of therapy with inpatients of a clinic.

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Int J Eat Disord. 2006 Aug 25; [Epub ahead of print]
Aftercare intervention through text messaging in the treatment of bulimia nervosa-Feasibility pilot.
Robinson S, Perkins S, Bauer S, Hammond N, Treasure J, Schmidt U.
Section of Eating Disorders, Institute of Psychiatry, London, UK.

OBJECTIVE:: Even with the best available treatment, most bulimia nervosa (BN) sufferers are not symptom free at the end of therapy and, for those who have achieved remission, risk of relapse is high. Thus, there is a need for aftercare or relapse prevention interventions after therapy. It is not yet known what type of intervention should be delivered, and how to suit patient needs while being mindful of cost and time constraints of service providers. This pilot study was conducted to explore the feasibility, acceptability, and efficacy of a text messaging (short messaging service [SMS])-based intervention in the aftercare of BN patients who had received outpatient psychotherapy. METHOD:: A total of 21 patients with BN participated in the 6-month SMS-based intervention as a step-down treatment AFTER outpatient therapy. RESULTS:: Levels of use of the program were relatively low and attrition high, indicating limited acceptance of the intervention. CONCLUSION:: This study suggests that the SMS-based intervention would benefit from further adaptation to make it a more useful tool for the aftercare of patients after outpatient treatment for bulimia nervosa. (c) 2006 by Wiley Periodicals, Inc. Int J Eat Disord 2006.

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Behav Res Ther. 2006 Aug 7; [Epub ahead of print]
Remote treatment of bulimia nervosa and binge eating disorder: A randomized trial of Internet-assisted cognitive behavioural therapy.
Ljotsson B, Lundin C, Mitsell K, Carlbring P, Ramklint M, Ghaderi A.
Department of Clinical Neuroscience, Section of Psychiatry, Karolinska Institute, SE-171 76 Stockholm, Sweden.

The present study investigated the efficacy of self-help based on cognitive behaviour therapy in combination with Internet support in the treatment of bulimia nervosa and binge eating disorder. After confirming the diagnosis with an in-person interview, 73 patients were randomly allocated to treatment or a waiting list control group. Treated individuals showed marked improvement after 12 weeks of self-help compared to the control group on both primary and secondary outcome measures. Intent-to-treat analyses revealed that 37% (46% among completers) had no binge eating or purging at the end of the treatment and a considerable number of patients achieved clinically significant improvement on most of the other measures as well. The results were maintained at the 6-month follow-up, and provide evidence to support the continued use and development of self-help programmes.

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Z Kinder Jugendpsychiatr Psychother. 2006 Jul;34(4):267-74.
[Family-oriented group therapy in the treatment of female patients with anorexia and bulimia nervosa--a pilot study]
[Article in German]
Salbach H, Bohnekamp I, Lehmkuhl U, Pfeiffer E, Korte A.
Klinik fur Psychiatrie, Psychosomatik und Psychotherapie des Kindes- und Jugendalters, Charite, Universitatsmedizin Berlin. harriet.salbach@charite.de

OBJECTIVES: Family therapy has proven effective in the treatment of anorexia nervosa (AN) and bulimia nervosa (BN) in adolescence. While cognitive-behavioural treatment has been shown to be effective in adult patients suffering from BN, there have been few studies on the effectiveness of psychotherapy in the treatment of adolescents. Since in the majority of AN patients their illness starts in mid-adolescence, and in late adolescence in BN patients, it is crucial to develop and evaluate treatment programmes for these disorders and age groups. In view of these arguments, a programme of group psychotherapy was set up for eating-disordered patients and their parents, combining disorder-specific psychoeducational components with a family group psychotherapy approach that is more open with regard to individual treatment goals. Patients participated together with their parents in the same group. METHODS: The treatment programme was evaluated within the framework of a naturalistic single-group study design. Pre-post changes were assessed. RESULTS: 32 female patients (29 with AN, 3 with BN) and their parents took part in the treatment programme. All of the families completed the programme, which was interpreted as a high rate of acceptance. Pre-post analysis revealed a decrease in the degree of eating-disorder symptoms. CONCLUSIONS: The advantages and disadvantages of this treatment programme, as well as the limitations of the pilot study are critically discussed.

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Adv Ther. 2006 May-Jun;23(3):481-94.
Citalopram versus fluoxetine for the treatment of patients with bulimia nervosa: a single-blind randomized controlled trial.
Leombruni P, Amianto F, Delsedime N, Gramaglia C, Abbate-Daga G, Fassino S.
Department of Neurosciences, Section of Psychiatry-University of Turin, S. Giovanni Battista Hospital, Turin, Italy.

The most studied and most frequently used pharmacologic treatments in bulimia nervosa are the selective serotonin reuptake inhibitors (SSRIs), in particular, fluoxetine. Less is known about the efficacy of the other SSRIs. To compare fluoxetine with citalopram in the treatment of bulimic patients, 37 bulimic patients were randomized to receive fluoxetine (n=18) or citalopram (n=19); these patients were assessed with regard to clinical (ie, body mass index, pathologic behaviors), psychopathologic (Eating Disorder Inventory-2, Body Shape Questionnaire, Binge-Eating Scale, Beck Depression Inventory), personality (Temperament and Character Inventory), and clinical global impression measures. These measures were compared between the 2 treatment groups at baseline and at the end of treatment. Dropout rates were similar in the 2 groups. Both groups showed significant improvement in eating psychopathology, angry feelings, and clinical global impression. Patients in the fluoxetine group displayed a greater reduction in introjected anger, whereas those in the citalopram group displayed a greater reduction in depressive feelings. Both treatments showed some effect on outcome measures, but efficacy profiles did not overlap. Citalopram may be useful in depressed patients with bulimia, whereas fluoxetine is more specific for those with introjected anger and bulimia.

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Int J Eat Disord. 2006 Apr;39(3):252-5.
Cognitive-behavioral therapy for adolescents with binge eating syndromes: a case series.
Schapman-Williams AM, Lock J, Couturier J.
Department of Psychology and Sociology, Notre Dame de Namur University, Belmont, California 94002, USA. awilliams@ndnu.edu

OBJECTIVE: Published empirically based studies of psychotherapies for bulimia nervosa (BN) have been conducted solely with adult populations. The current study extends the extant literature by piloting a version of cognitive-behavioral therapy (CBT) for BN adapted for an adolescent population. METHOD: The participants were referred for treatment for binge eating and purging behaviors at a university clinic. Patients received pretreatment and posttreatment interviews assessing the frequency of their binge eating and purge behaviors, and they also completed pretreatment and posttreatment assessments with the Eating Disorders Examination (EDE). RESULTS: Results indicated significant reductions in the frequency of binge eating from pretreatment to posttreatment. Furthermore, all subscale scores of the EDE showed significant declines from pretreatment to posttreatment. CONCLUSION: The authors concluded that CBT adapted for adolescents with bulimic symptoms appears to be a promising intervention worthy of further study in adolescents. 2006 by Wiley Periodicals, Inc.

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Psychol Addict Behav. 2006 Mar;20(1):44-52.
Motivational enhancement therapy and self-help treatment for binge eaters.
Dunn EC, Neighbors C, Larimer ME.
Department of Psychology, University of Washington, WA, USA. edunn@providencehealth.bc.ca

OBJECTIVE: The aims of this study were to evaluate whether a single session of motivational enhancement therapy (MET) would increase participant readiness to change, improve the efficacy of self-help treatment for binge eaters, and improve participant compliance with the self-help manual. METHOD: Participants with bulimia nervosa or binge eating disorder were randomly assigned either to attend a 1-hr MET session prior to receiving the self-help manual (n = 45) or to receive the self-help manual only (n = 45). Participants were followed for 4 months for assessment of self-reported eating disorder outcome and compliance. RESULTS: The MET intervention resulted in increased readiness to change for binge eating compared with the self-help-only (SH) condition. Few differences were found between the MET condition and the SH condition for changes in eating attitudes and frequency of binge eating and compensatory behaviors. No significant effects were found for compliance. DISCUSSION: This research adds to the literature regarding the use of brief motivational interventions to enhance readiness for change in populations with eating disorders.

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Int J Eat Disord. 2006 Mar 9; [Epub ahead of print]
Residential treatment for eating disorders.
Frisch MJ, Herzog DB, Franko DL.
University of Minnesota, Minneapolis, Minnesota.

OBJECTIVE:: The current study describes residential treatment for eating disorders in the United States. METHOD:: A national study involving 22 residential eating disorder treatment programs was conducted using a survey to determine treatment program descriptions and trends. Data from 19 respondents, representing 86% of all residential treatment programs in the United States, were examined. RESULTS:: Residential treatment options for individuals with anorexia nervosa and bulimia nervosa are becoming increasingly more common. A wide variety of techniques and methods are employed in the treatment of individuals with eating disorders in residential treatment programs. The average length of stay in treatment was 83 days, with an average cost per day of $956 U.S. dollars. CONCLUSION:: The residential treatment of individuals with eating disorders is a growing, variable, and largely unregulated enterprise. Future research is needed to focus on quantifying treatment program effectiveness in the residential treatment of individuals with eating disorders. (c) 2006 by Wiley Periodicals, Inc. Int J Eat Disord 2006.

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J Esthet Restor Dent. 2006;18(2):114.
Eating disorders and oral health.
Ritter AV.

WHAT IS IT? Bulimia nervosa and anorexia nervosa are eating disorders that affect the person's ability to adequately manage his or her eating habits. Although most people believe that people with eating disorders are obsessively concerned with their body image and losing weight, psychological issues almost always underlie the etiology of the condition. According to the National Eating Disorders Association, it is estimated that more than 10 million Americans suffer with either bulimia nervosa or anorexia nervosa,1 two of the most common eating disorders. Bulimia nervosa is characterized by compulsive overeating followed by self-induced vomiting, whereas anorexia nervosa is marked by extreme weight loss usually achieved through a severely restricted diet.

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Br J Clin Psychol. 2006 Mar;45(Pt 1):111-21.
Does personalized feedback improve the outcome of cognitive-behavioural guided self-care in bulimia nervosa? A preliminary randomized controlled trial.
Schmidt U, Landau S, Pombo-Carril MG, Bara-Carril N, Reid Y, Murray K, Treasure J, Katzman M.
Section of Eating Disorders, Institute of Psychiatry, PO Box 59, De Crespigny Park, London SE5 8AF, UK. u.schmidt@iop.kcl.ac.uk

OBJECTIVES: Feedback has long been a part of psychosocial and health behaviour interventions and with the advent of computerised assessment and treatment tools, is gaining greater importance. The aim of the present study was to evaluate the addition of personalized feedback to a guided cognitive-behavioural (CBT) self-help programme for patients with bulimia nervosa. DESIGN: Randomised-controlled trial. METHOD: 61 patients with DSM-IV bulimia nervosa or eating disorder not otherwise specified (EDNOS) were randomly allocated to receive 14 sessions of cognitive behavioural guided self-care with or without added personalised feedback on current physical and psychological status, risk and problems, and variables facilitating or hindering change. Feedback to patients was delivered in a number of ways: (a) personalised letters after assessment and at the end of treatment, (b) a specially designed feedback form administered half-way through treatment, (c) computerised feedback about bulimic and other symptoms, such as anxiety, depression and interpersonal functioning repeated at intervals throughout treatment and follow-up. RESULTS: Outcome was assessed using patient-rated measures of bulimic symptoms at the end of treatment and at 6-month follow-up. The data were analysed using maximum likelihood methods of assess group differences at the follow-up. Added feedback did not have an effect on take-up or drop-out from treatment. However, it improved outcome by reducing self-induced vomiting and dietary restriction more effectively. CONCLUSIONS: The findings lend support to the notion that the addition of repeated personalised feedback improves outcome from guided CBT self-help treatment and deserves further study.

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J Abnorm Psychol. 2006 Feb;115(1):62-7.
Weight suppression is a robust predictor of outcome in the cognitive-behavioral treatment of bulimia nervosa.
Butryn ML, Lowe MR, Safer DL, Agras WS.
Department of Psychology, Drexel University, Philadelphia, PA 19102, USA.

This study examined weight suppression (difference between highest premorbid weight and pretreatment weight) as a predictor of outcome in 188 outpatients with bulimia nervosa enrolled in a cognitive-behavioral therapy intervention. Participants who dropped out of treatment had significantly higher levels of weight suppression than treatment completers. Of participants who completed treatment, those who continued to engage in binge eating or purging had significantly higher levels of weight suppression than those who were abstinent from bingeing and purging. Results did not change when body mass index, dietary restraint, weight and shape concerns, or other relevant variables were controlled. Relinquishing bulimic behaviors and adopting normal eating patterns may be most feasible for patients who are closest to their highest premorbid weights. 2006 APA, all rights reserved

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Behav Res Ther. 2006 Feb 1; [Epub ahead of print]
Evaluation of a healthy-weight treatment program for bulimia nervosa: A preliminary randomized trial.
Burton E, Stice E.
Department of Psychology, University of Texas at Austin, 1 University Station, A8000 Austin, TX 78712, USA.

Objective: Conduct a randomized treatment trial to test whether healthy dieting maintains bulimic symptoms or effectively reduces this eating disturbance. Methods: Female participants (n=85) with full- and sub-threshold bulimia nervosa were randomly assigned to a 6-session healthy dieting intervention or waitlist condition and assessed through 3-month follow-up. Results: Relative to control participants, intervention participants showed modest weight loss during treatment and demonstrated significant improvements in bulimic symptoms that persisted through follow-up. Discussion: These preliminary results suggest that this intervention shows potential for the treatment of bulimia nervosa and may be worthy of future refinement and evaluation. Results also provide experimental evidence that dieting behaviors do not maintain bulimia nervosa, suggesting the need to reconsider maintenance models for this eating disorder.

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Adv Psychosom Med. 2006;27:86-93.
Cognitive behavior therapy of binge eating disorder.
Vaidya V.
Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA. vvaidya@jhmi.edu

Binge eating disorder (BED) is characterized by recurrent episodes of uncontrollable eating, even when not hungry, until uncomfortably full, occurring at least twice a week for a 6-month period. This is differentiated from bulimia nervosa (BN) by the lack of compensatory mechanisms such as purging/laxative abuse. There are significantly higher levels of psychiatric symptoms in patients with BED as compared to those without BED. Furthermore, depressive symptomatology may increase the patient's vulnerability to binge eating as well as to relapse after treatment. Grazing is defined as eating small amounts of food continuously. BED in the pre-bariatric patient can manifest as 'grazing' about 2 years post-bariatric surgery. Treatment should be directed at eating behavior, associated psychopathology, weight and psychiatric symptoms. Cognitive behavior therapy is based on changing the patient's erroneous ways of thinking about themselves, the world and how others perceive them. This includes a focus on normalizing food intake as well as challenging dysfunctional thinking, identifying feelings, and developing non-food coping skills. It increases a sense of control and therefore helps the patient adhere to behavior change strategy, as well as improving mood and reducing associated psychopathology. Interpersonal therapy is based on the relationship between negative mood low self-esteem traumatic life events, interpersonal functioning and the patient's eating behavior. The rationale being that eating represents maladaptive coping with underlying difficulties. While psychotherapy either CBT or IPT leads to decrease in disordered eating behaviors and improved psychiatric symptoms, it has little effect on weight hence; its benefit is optimal when used in conjunction with bariatric surgery.

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Behav Res Ther. 2006 Feb;44(2):273-88.
Does individualization matter? A randomized trial of standardized (focused) versus individualized (broad) cognitive behavior therapy for bulimia nervosa.
Ghaderi A.
Department of Psychology, Uppsala University, Box 1225, SE-751 42 Uppsala, Sweden.

Does higher level of individualization increase treatment efficacy? Fifty patients with bulimia nervosa were randomized into either manual-based (focused) or more individualized (broader) cognitive behavioral therapy guided by logical functional analysis. Eating disorders Examination and a series of self-report questionnaires were used for assessment at pre-, and post-treatment as well as at follow-up. Both conditions improved significantly at post-treatment, and the results were maintained at the 6 months follow-up. There were no statistically and clinically significant differences between the two conditions at post-treatment with the exception of abstinence from objective bulimic episodes, eating concerns, and body shape dissatisfaction, all favoring the individualized, broader condition. Both groups improved concerning self-esteem, perceived social support from friends, and depression. The improvements were maintained at follow-up. Ten patients (20%) did not respond to the treatment. Notably, a majority of non-responders (80%) were in the manual-based condition. Non-responders showed extreme dominance of rule-governed behavior, and lack of contact with actual contingencies compared to responders. The study provided preliminary support for the superiority of higher level of individualization (i.e. broader CBT) in terms of the response to treatment, and relapses. However, the magnitude of effects was moderate, and independent replications, with blind assessment procedures, and a larger sample sized are needed before more clear cut conclusions can be drawn.

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Int J Eat Disord. 2006 Jan;39(1):72-5.
Early response to desipramine among women with bulimia nervosa.
Walsh BT, Sysko R, Parides MK.
Department of Psychiatry, College of Physicians and Surgeons of Columbia University, New York, New York.

OBJECTIVE: Numerous trials have demonstrated the efficacy of antidepressant medications for the treatment of bulimia nervosa (BN). The current study examined whether early response to medication predicted response to medication at the end of a controlled trial. METHOD: Data from two previously published studies of desipramine (DMI) were used. Seventy-seven patients with BN were included in the analysis. Receiver operating characteristic (ROC) curves were constructed to examine the relation between the percentage reduction in symptoms at each week and failure to respond to antidepressant medication at the end of the trial. RESULTS: Eventual nonresponders to DMI could be reliably identified in the first 2 weeks of treatment. CONCLUSION: The current study provides preliminary evidence that patients with BN who will not respond to antidepressant medication can be identified in the first 2 weeks of treatment. (c) 2005 by Wiley Periodicals, Inc.

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J Consult Clin Psychol. 2005 Dec;73(6):1089-96.
Coping strategies in bulimia nervosa treatment: impact on outcome in group cognitive-behavioral therapy.
Binford RB, Mussell MP, Crosby RD, Peterson CB, Crow SJ, Mitchell JE.
Department of Psychiatry, University of Chicago, Chicago, IL, US. rbinford@yoda.bsd.uchicago.edu.

This study's purpose was to examine the extent to which participants (N = 143) receiving cognitive-behavioral therapy for bulimia nervosa (BN) reported implementing therapeutic strategies to abstain from BN behaviors, and to assess whether use of specific strategies predicts outcome at treatment end and 1- and 6-month follow-up. Frequency of outcome expectancies (OE), stimulus-response prevention (SRP), and social support-seeking (SSS) strategies significantly increased by end of treatment. By 1-month follow-up, use of SSS, not OE or SRP, declined significantly relative to treatment end. Although frequency of coping strategy use at treatment end did not predict 1-month BN symptom remission, SSS use at 1-month follow-up predicted 6-month remission. Findings highlight the importance of social support to maintain treatment gains. ((c) 2006 APA, all rights reserved).

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Int J Eat Disord. 2005 Dec;38(4):295-300.
Topiramate treatment in bulimia nervosa patients: a randomized, double-blind, placebo-controlled trial.
Nickel C, Tritt K, Muehlbacher M, Pedrosa Gil F, Mitterlehner FO, Kaplan P, Lahmann C, Leiberich PK, Krawczyk J, Kettler C, Rother WK, Loew TH, Nickel MK.
Clinic for Psychosomatic Medicine, Inntalklinik, Simbach am Inn, Germany. m.nickel@inntalklinik.de

OBJECTIVE: The aim of the current study was to test the influence of topiramate on behavior, body weight, and health-related quality of life (HRQOL) in bulimic patients. METHOD: Thirty patients with bulimia nervosa were treated with topiramate in a 10-week randomized, double-blind, placebo-controlled study. The subjects were randomly assigned to receive topiramate (topiramate group [TG]; n = 30) or a placebo (control group [CG]; n = 30). Primary outcome measures were changes in the frequency of binging/purging, in body weight, and on the SF-36 Health Survey (SF-36) scales. RESULTS: In comparison to the CG group (according to the intent-to-treat principle), significant changes in the frequency of binging/purging (a > 50% reduction: TG, n = 11 [36.7%]; CG, n = 1 [3.3%]; p < .001), body weight (difference in weight loss between the two groups: 3.8 kg, 95% confidence interval [CI] = -5.4 to -2.1; p < .001), and SF-36 (all ps < .001) could be seen. All patients tolerated topiramate well. CONCLUSION: Topiramate appears to safe and effective in influencing the frequency of binging/purging, body weight, and HRQOL in bulimic patients. Copyright 2005 by Wiley Periodicals, Inc.

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MMW Fortschr Med. 2005 Nov 17;147(46):56-8.
[Bulimia nervosa--a modern eating disorder]
[Article in German]
Kopp W.
koeppwe@zedat.fu-berlin.de

Bulimia nervosa is characterized by episodes of compulsive eating of large amounts of food that are followed by measures undertaken to avoid weight gain, and an exaggerated concern about one's figure and weight. Bulimic symptomatology comprises a complex of various interacting components such as poor self-esteem, a negative attitude towards one's own body, eating behavior and current conflicts. Treatment must take account of all of these factors, and involves both internistic and psychotherapeutic elements. The severity of the condition, possible comorbidities, and psychosocial criteria are crucial for deciding whether treatment should be on an ambulatory or an inpatient basis.

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Eur Child Adolesc Psychiatry. 2005 Oct;14(7):376-85.
Why do adolescents with bulimia nervosa choose not to involve their parents in treatment?
Perkins S, Schmidt U, Eisler I, Treasure J, Yi I, Winn S, Robinson P, Murphy R, Keville S, Johnson-Sabine E, Jenkins M, Frost S, Dodge L, Berelowitz M.
Eating Disorders Unit, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London, UK.

BACKGROUND: Although the use of family therapy for adolescents with anorexia nervosa is well established, there has been limited research into the efficacy of family therapy in adolescents with bulimia nervosa (BN). No previous research has investigated why individuals with BN do or do not involve their parents in treatment. This is an exploratory study aimed at determining whether there are any differences between these individuals in terms of eating disorder symptomatology, psychopathology, familial risk factors, patients' perception of parental expressed emotion (EE) and family functioning. METHODS: Participants were 85 adolescents with BN or Eating Disorder Not Otherwise Specified, recruited to a randomised controlled evaluation of the cost-effectiveness of cognitive-behavioural guided self-care vs. family therapy. Participants were interviewed regarding the history of their eating disorder and completed self-report measures. RESULTS: Patients who did not involve their parents in treatment were significantly older, had more chronic eating disorder symptoms, exhibited more co-morbid and impulsive behaviours and rated their mothers higher in EE. However, they did not have more severe eating disorder symptomatology. CONCLUSIONS: These preliminary findings, although in need of replication with a larger sample and limited by the attrition rate in some of the self-report measures, indicate that patients who did not involve their parents in treatment may perceive their mothers as having a more blaming and negative attitude towards the patient's illness. Public awareness about BN needs to be raised, focusing on reducing the stigma and negative views attached to this illness.

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Int J Eat Disord. 2005 Oct 17;39(2):117-127 [Epub ahead of print]
A comparison of sequenced individual and group psychotherapy for patients with bulimia nervosa.
Nevonen L, Broberg AG.
Anorexia-Bulimia Unit, Queen Silvia Children's Hospital, Goteborg, Sweden.

OBJECTIVE: The current study examined the effectiveness of individual (IND) versus group (GRP) therapy for patients with bulimia nervosa (BN), using a manual of sequenced treatment with cognitive-behavioral therapy (CBT) followed by interpersonal psychotherapy (IPT). METHOD: Eighty-six participants with BN were matched and randomized to 23 sessions of IND or GRP. Participants were measured pretreatment and posttreatment and at 1-year and 2.5-year follow-ups using both intent-to-treat and completer samples. RESULTS: The intent-to-treat analysis revealed that the percentage of participants recovered and remitted was equivalent between IND and GRP. Significant group differences were found between completers on binge eating and compensatory behavior with greater improvement for IND. On most measures, effect sizes were larger for IND at 1-year follow-up. CONCLUSION: Sequencing CBT and IPT worked well in both IND and GRP formats. We found few outcome differences between IND as opposed to GRP. (c) 2005 by Wiley Periodicals, Inc.

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Clin Psychol Rev. 2005 Sep 29; [Epub ahead of print]
The empirical status of cognitive-behavioral therapy: A review of meta-analyses.
Butler AC, Chapman JE, Forman EM, Beck AT.
University of Pennsylvania and the Beck Institute for Cognitive Therapy and Research, United States.

This review summarizes the current meta-analysis literature on treatment outcomes of CBT for a wide range of psychiatric disorders. A search of the literature resulted in a total of 16 methodologically rigorous meta-analyses. Our review focuses on effect sizes that contrast outcomes for CBT with outcomes for various control groups for each disorder, which provides an overview of the effectiveness of cognitive therapy as quantified by meta-analysis. Large effect sizes were found for CBT for unipolar depression, generalized anxiety disorder, panic disorder with or without agoraphobia, social phobia, posttraumatic stress disorder, and childhood depressive and anxiety disorders. Effect sizes for CBT of marital distress, anger, childhood somatic disorders, and chronic pain were in the moderate range. CBT was somewhat superior to antidepressants in the treatment of adult depression. CBT was equally effective as behavior therapy in the treatment of adult depression and obsessive-compulsive disorder. Large uncontrolled effect sizes were found for bulimia nervosa and schizophrenia. The 16 meta-analyses we reviewed support the efficacy of CBT for many disorders. While limitations of the meta-analytic approach need to be considered in interpreting the results of this review, our findings are consistent with other review methodologies that also provide support for the efficacy CBT.

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Psychol Med. 2005 Sep;35(9):1283-94.
Guided self-help for bulimia nervosa in primary care: a randomized controlled trial.
Banasiak SJ, Paxton SJ, Hay P.
Psychology Department, University of Melbourne, Australia. sjbanasiak@iprimus.com.au

BACKGROUND: To increase access to cognitive behavioural therapy for bulimia nervosa new delivery modes are being examined. Guided Self-Help (GSH) in primary care is potentially valuable in this respect. This research aimed to compare outcomes following GSH delivered by general practitioners (GPs) in the normal course of their practice to a delayed treatment control (DTC) condition, and to examine the maintenance of treatment gains at 3 and 6 months following completion of GSH. METHOD: Participants were 109 women with full syndrome or sub-threshold bulimia nervosa, randomly allocated to GSH ( n = 54) and DTC ( n = 55). The GSH group received direction and support from a GP over a 17-week period while working through the manual in Bulimia Nervosa and Binge-Eating: A Guide to Recovery by P. J. Cooper (1995). GSH and DTC groups were assessed pre-treatment and 1 week following the 17-week intervention or waiting interval. The GSH group was reassessed at 3- and 6-month follow-up. RESULTS: Intention-to-treat analyses at end of treatment revealed significant improvements in bulimic and psychological symptoms in GSH compared with DTC, reduction in mean frequency of binge-eating episodes by 60% in GSH and 6% in DTC, and remission from all binge-eating and compensatory behaviours in 28% of the GSH and 11% of the DTC sample. Treatment gains were maintained at 3- and 6-month follow-up. CONCLUSION: Outcomes in GSH compare favourably with those of specialist-delivered psychological treatments. These findings are considered in light of the nature of the therapy offered and the primary care context.

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J Nerv Ment Dis. 2005 Sep;193(9):585-95.
A naturalistic study of psychotherapy for bulimia nervosa, part 2: therapeutic interventions in the community.
Thompson-Brenner H, Westen D.
Center for Anxiety and Related Disorders, Department of Psychology, Boston University, Boston, Massachusetts 02215, USA.

Data from naturalistic samples provide an important complement to findings from randomized trials of psychotherapy. A random national sample of US clinicians provided data on 145 completed treatments of patients with bulimic symptoms. We attempted to characterize the nature of treatments in the community and to examine the relation between treatment variables and outcome. Clinicians of all theoretical orientations report using interventions with polysymptomatic cases designed to address clinically significant personality characteristics and interpersonal patterns. Whereas cognitive-behavioral therapy is associated with more rapid remission of eating symptoms, psychodynamic interventions and increased treatment length predict better global outcome across treatment modalities, suggesting the importance of integrative treatments for the broad range of pathology seen in patients with bulimic symptoms.

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Int J Med Inform. 2005 Aug 19; [Epub ahead of print]
Evaluation and deployment of evidence based patient self-management support program for bulimia nervosa.
Carrard I, Rouget P, Fernandez-Aranda F, Volkart AC, Damoiseau M, Lam T.
Psychiatric Liaison Unit, University Hospitals of Geneva, Geneva, Switzerland.

OBJECTIVE:: This article presents initial results from a European multi-centre study to determine the effectiveness and feasibility of an online self-help treatment support program for Bulimia Nervosa (BN). METHOD:: The online program is based on Cognitive Behavioral Therapy (CBT) and consists of seven steps that patients work through progressively. An overall sample of 141 women suffering from BN used the program over a 6-month period. Patients were supported by three face-to-face evaluation interviews with a therapist, and a weekly e-mail contact. Data on general psychopathology and specific eating disorder symptoms were also collected at the evaluation interviews. RESULTS:: Initial results from the Swiss sample (N=41) showed significant improvement of overall psychological health (p<.001) as measured by the Symptom Checklist (SCL-90R), and for all dimensions of the Eating Disorder Inventory (EDI-2). CONCLUSION:: An online Self-Help program for BN can be used effectively to reduce eating disorder symptoms in Bulimic patients and user feedback showed that this approach contributed to increase patient involvement and service availability. Additional data from the other centers will further inform the efficacy and impact of this approach.

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Health Psychol. 2005 Jul;24(4):402-12.
Effects of a weight maintenance diet on bulimic symptoms in adolescent girls: an experimental test of the dietary restraint theory.
Stice E, Presnell K, Groesz L, Shaw H.
Department of Psychology, The University of Texas at Austin, Austin, TX, USA. estice@ori.org

It is widely accepted that dieting increases the risk for bulimia nervosa, but there have been few experimental tests of this theory. The authors conducted a randomized experiment with adolescent girls (N=188) to examine the effects of a weight maintenance diet on bulimic symptoms. A manipulation check verified that the diet intervention resulted in weight maintenance and significantly reduced the risk for obesity onset and weight gain observed in assessment-only controls. As hypothesized, the diet intervention resulted in significantly greater decreases in bulimic symptoms and negative affect than observed in controls. These experimental findings, which converge with those from a weight loss diet experiment, appear antithetical to dietary restraint theory and suggest instead that dietary restriction curbs bulimic symptoms.

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CNS Spectr. 2005 Aug;10(8):647-63.
Light therapy for seasonal and nonseasonal depression: efficacy, protocol, safety, and side effects.
Terman M, Terman JS.
Clinical Chronobiology, New York State Psychiatric Institute, New York, NY, USA.

Bright light therapy for seasonal affective disorder (SAD) has been investigated and applied for over 20 years. Physicians and clinicians are increasingly confident that bright light therapy is a potent, specifically active, nonpharmaceutical treatment modality. Indeed, the domain of light treatment is moving beyond SAD, to nonseasonal depression (unipolar and bipolar), seasonal flare-ups of bulimia nervosa, circadian sleep phase disorders, and more. Light therapy is simple to deliver to outpatients and inpatients alike, although the optimum dosing of light and treatment time of day requires individual adjustment. The side-effect profile is favorable in comparison with medications, although the clinician must remain vigilant about emergent hypomania and autonomic hyperactivation, especially during the first few days of treatment. Importantly, light therapy provides a compatible adjunct to antidepressant medication, which can result in accelerated improvement and fewer residual symptoms.

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Int J Eat Disord. 2005 May;37(4):285-93.
Treatment of overweight in children and adolescents: does dieting increase the risk of eating disorders?
Butryn ML, Wadden TA.
Department of Psychology, Drexel University, Philadelphia, Pennsylvania, USA.

OBJECTIVE: Overweight is a serious health problem in children and adolescents. Some investigators fear that dieting, the principal method of reducing body weight, may precipitate eating disorders and related complications. This review examined the literature on the effects of dieting on eating behavior and psychological status in youth. METHOD: Electronic databases were searched for articles containing combinations of the following keywords: weight loss, dieting, treatment, overweight, obesity, anorexia, bulimia, binge eating, eating disorder, children, and adolescents. A manual search of reference lists also was conducted. RESULTS: Five relevant studies were found. Their findings suggest that a professionally administered weight loss poses minimal risks of precipitating eating disorders in overweight children and adolescents. Significant improvements in psychological status also were observed in several studies. DISCUSSION: Concerns about potential ill effects of dieting should not dissuade overweight youth from pursuing sensible methods of weight loss. Copyright 2005 by Wiley Periodicals, Inc

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Prax Kinderpsychol Kinderpsychiatr. 2005 Apr;54(4):248-67.
[Adolescent eating disorders]
[Article in German]
Herpertz-Dahlmann B, Hagenah U, Vloet T, Holtkamp K.
Klinik fur Kinder- und Jugendpsychiatrie und -psychotherapie, Universitatsklinikum Aachen. bherpertz-dahlmann@ukaachen.de

Anorexia and Bulimia nervosa are common psychiatric disorders in adolescent girls. In discrepancy to ICD-10 and DSM-IV we would propose the 10th BMI percentile as weight criterium for anorexia nervosa. Both disorders have a high somatic and psychiatric comorbidity; the most severe complication at long term follow-up is osteoporosis. The most prevalent psychiatric disorders are affective disorders, anxiety and obsessive-compulsive disorder and substance abuse. There is undoubtedly a genetic predisposition and a range of general and personal environmental risk factors. Treatment of adolescent eating disorders mostly requires a multimodal approach which consists of several components, e.g. weight rehabilitation, nutritional counselling, individual and family psychotherapy, and treatment of comorbid psychiatric disorders.

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Int J Eat Disord. 2005 Apr 26;37(4):285-293 [Epub ahead of print]
Treatment of overweight in children and adolescents: Does dieting increase the risk of eating disorders?
Butryn ML, Wadden TA.
Department of Psychology, Drexel University, Philadelphia, Pennsylvania.

OBJECTIVE: Overweight is a serious health problem in children and adolescents. Some investigators fear that dieting, the principal method of reducing body weight, may precipitate eating disorders and related complications. This review examined the literature on the effects of dieting on eating behavior and psychological status in youth. METHOD: Electronic databases were searched for articles containing combinations of the following keywords: weight loss, dieting, treatment, overweight, obesity, anorexia, bulimia, binge eating, eating disorder, children, and adolescents. A manual search of reference lists also was conducted. RESULTS: Five relevant studies were found. Their findings suggest that a professionally administered weight loss poses minimal risks of precipitating eating disorders in overweight children and adolescents. Significant improvements in psychological status also were observed in several studies. DISCUSSION: Concerns about potential ill effects of dieting should not dissuade overweight youth from pursuing sensible methods of weight loss. (c) 2005 by Wiley Periodicals, Inc.

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Int J Eat Disord. 2005 Apr 25;37(S1):S64-S67 [Epub ahead of print]
Family-based treatment of eating disorders.
Lock J, le Grange D.
Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California.

The current article provides a brief description of the theory and empirical support for family treatment of eating disorders. The main literature related to family treatment for anorexia nervosa (AN) and bulimia nervosa (BN) is reviewed and the findings highlighted. Family treatment, particularly as devised by researchers at the Maudsley Hospital, appears to be an effective treatment for adolescents with short-term AN. It also may be an appropriate treatment for BN in the same age group, although evidence for this is in much shorter supply. Data support the use of family treatments for adolescents with eating disorders. Controlled trials and other systematic research are needed to determine whether family treatment is the best approach. (c) 2005 by Wiley Periodicals, Inc.

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Ann Gen Psychiatry. 2005 Feb 16;4(1):5.
Review of the use of Topiramate for treatment of psychiatric disorders.
Arnone D.
Department of Psychiatry, Springfield University Hospital, St George's Medical School, London, UK. Danilo.Arnone@swlstg-tr.nhs.uk.

BACKGROUND: Topiramate is a new antiepileptic drug, originally designed as an oral hypoglycaemic subsequently approved as anticonvulsant. It has increasingly been used in the treatment of numerous psychiatric conditions and it has also been associated with weight loss potentially relevant in reversing weight gain induced by psychotropic medications. This article reviews pharmacokinetic and pharmacodynamic profile of topiramate, its biological putative role in treating psychiatric disorders and its relevance in clinical practice. METHODS: A comprehensive search from a range of databases was conducted and papers addressing the topic were selected. RESULTS: Thirty-two published reports met criteria for inclusion, 4 controlled and 28 uncontrolled studies. Five unpublished controlled studies were also identified in the treatment of acute mania. CONCLUSIONS: Topiramate lacks efficacy in the treatment of acute mania. Increasing evidence, based on controlled studies, supports the use of topiramate in binge eating disorders, bulimia nervosa, alcohol dependence and possibly in bipolar disorders in depressive phase. In the treatment of rapid cycling bipolar disorders, as adjunctive treatment in refractory bipolar disorder in adults and children, schizophrenia, posttraumatic stress disorder, unipolar depression, emotionally unstable personality disorder and Gilles de la Tourette's syndrome the evidence is entirely based on open label studies, case reports and case series. Regarding weight loss, findings are encouraging and have potential implications in reversing increased body weight, normalisation of glycemic control and blood pressure. Topiramate was generally well tolerated and serious adverse events were rare.

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Biol Psychiatry. 2005 Feb 1;57(3):301-9.
Efficacy of cognitive behavioral therapy and fluoxetine for the treatment of binge eating disorder: a randomized double-blind placebo-controlled comparison.
Grilo CM, Masheb RM, Wilson GT.
Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut 06520, USA. carlos.grilo@yale.edu

BACKGROUND: Cognitive behavioral therapy (CBT) and certain medications have been shown to be effective for binge eating disorder (BED), but no controlled studies have compared psychological and pharmacological therapies. We conducted a randomized, placebo-controlled study to test the efficacy of CBT and fluoxetine alone and in combination for BED. METHODS: 108 patients were randomized to one of four 16-week individual treatments: fluoxetine (60 mg/day), placebo, CBT plus fluoxetine (60 mg/day) or CBT plus placebo. Medications were provided in double-blind fashion. RESULTS: Of the 108 patients, 86 (80%) completed treatments. Remission rates (zero binges for 28 days) for completers were: 29% (fluoxetine), 30% (placebo), 55% (CBT+fluoxetine), and 73% (CBT+placebo). Intent-to-treat (ITT) remission rates were: 22% (fluoxetine), 26% (placebo), 50% (CBT+fluoxetine), and 61% (CBT+placebo). Completer and ITT analyses on remission and dimensional measures of binge eating, cognitive features, and psychological distress produced consistent findings. Fluoxetine was not superior to placebo, CBT+fluoxetine and CBT+placebo did not differ, and both CBT conditions were superior to fluoxetine and to placebo. Weight loss was modest, did not differ across treatments, but was associated with binge eating remission. CONCLUSIONS: CBT, but not fluoxetine, demonstrated efficacy for the behavioral and psychological features of BED, but not obesity.

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J Clin Psychopharmacol. 2005 Feb;25(1):85-88.
Effects of the Androgen Antagonist Flutamide and the Serotonin Reuptake Inhibitor Citalopram in Bulimia Nervosa: A Placebo-Controlled Pilot Study.
Sundblad C, Landen M, Eriksson T, Bergman L, Eriksson E.
Departments of *Pharmacology and daggerClinical Neuroscience, Goteborg University, Goteborg; double daggerDepartment of General and Forensic Psychiatry, Lund University, Malmo University Hospital, Malmo and section signPrivate Unit for Child Psychiatry, Goteborg, Sweden.

ABSTRACT:: Prompted by previous studies suggesting that bulimia nervosa in women may be associated with elevated serum levels of testosterone, we have evaluated the possible effect of androgen antagonism in this condition. To this end, women meeting the DSM-IV criteria of bulimia nervosa, purging type, were treated in a one-center study with the androgen receptor antagonist flutamide (n = 9), the serotonin reuptake inhibitor citalopram (n = 15), flutamide plus citalopram (n = 10), or placebo (n = 12) for 3 months using a double-blind design. Self-rated global assessment of symptom intensity suggests all active treatments to be superior to placebo. The reduction in binge eating compared with baseline was statistically significant in both groups given flutamide but not in the groups given citalopram only or placebo. A moderate and reversible increase in serum transaminase levels led to discontinuation in two subjects in the flutamide group. It is concluded that blockade of androgen receptors may reduce some of the symptoms of bulimia nervosa in women.

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Lancet. 2005 Jan 1;365(9453):79-81.
Eating disorders guidelines from NICE.
Wilson GT, Shafran R.
Graduate School of Applied and Professional Psychology, Rutgers, State University of New Jersey, Piscataway, NJ 08854, USA. tewilson@rci.rutgers.edu

CONTEXT: January, 2004, marked the publication of NICE guidelines for the treatment of eating disorders, a series of recommendations from a multidisciplinary, comprehensive, and rigorous process. The recommendations are assigned a grade from A (strong empirical support from well-conducted randomised trials) to C (expert opinion without strong empirical data). Over 100 recommendations were made, most of which were given a C grade. No specific recommendations were made for anorexia nervosa. Cognitive behavioural therapy for bulimia nervosa was assigned grade A because of the evidence showing that it is superior to other psychological and drug treatments. Antidepressants for bulimia nervosa were given grade B. No specific recommendations were made for atypical eating disorders except for binge-eating disorder (cognitive behavioural therapy was recommended [A]). STARTING POINT: The methodological rigour of the NICE guidelines is in contrast with the current Practice Guideline for Eating Disorders (PGED) of the American Psychiatric Association. PGED does not detail criteria for evaluating supporting research. Instead of making clear recommendations, PGED is uncritically inclusive and emphasises subjective judgment of individual clinicians. The NICE guidelines balance recommending specific treatments against the importance of clinical judgment when guideline recommendations are not readily applicable. WHERE NEXT: Evidence-based guidelines are limited by the quality of the available research and its clinical relevance. The NICE guidelines underscore the absence of sufficient evidence for guidance in several important areas, such as atypical eating disorders (eating disorders not otherwise specified) which are the most common. Research on the treatment of these atypical eating disorders is needed. Evidence-based psychological treatments are not routinely implemented in general practice. Dissemination of these demonstrably effective treatments poses a challenge, and learning how to implement evidence-based psychological treatments and monitor their use is a research priority.

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Int J Eat Disord. 2004 Dec;36(4):363-75.
Group cognitive-behavior therapy for bulimia nervosa: statistical versus clinical significance of changes in symptoms across treatment.
Openshaw C, Waller G, Sperlinger D.
West Kent NHS and Social Care Trust Eating Disorders Service, The Red House, Oakapple Lane, Maidstone, Kent ME16 9NW, UK. christine.openshaw@btinternet.com

BACKGROUND: Cognitive-behavior therapy (CBT) is the most effective treatment to date for bulimia nervosa. The current study investigated the effects of group CBT treatment (including some interpersonal elements) for bulimic clients. METHOD: Twenty-nine patients completed the Stirling Eating Disorder Scales, the Beck Depression Inventory, and the Beck Anxiety Inventory at assessment, pretreatment, end of treatment, and at 6 months follow-up. Symptom change was explored in two ways. Statistically significant change was determined using repeated-measures analyses of variance and clinically significant change was determined using criteria proposed by Jacobson & Truax (1991, Journal of Consulting and Clinical Psychology, 59, 12-19). RESULTS: There was an overall improvement in dimensional measures of bulimic and restrictive attitudes and behaviors (maintained at the 6-month follow-up), which was most closely matched by clinically significant changes in bulimic behaviors. Depression (but not anxiety) was also targeted effectively. Statistically significant improvements in psychological functioning were evident only for assertiveness, but the analysis of clinical significance showed improvement for some participants in self-evaluation (self-directed hostility). DISCUSSION: Group CBT (including interpersonal elements) is broadly effective when treating bulimia nervosa, but it does not work in all cases (and may lead to enhancement of restrictive characteristics in some cases). Tests of statistical and clinical significance provide different information, which can inform practice and aid in the development of treatments for patients who respond less well to current best practice. Copyright 2004 by Wiley Periodicals, Inc.

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Best Pract Res Clin Gastroenterol. 2004 Dec;18(6):1073-88.
Psychological aspects of eating disorders.
Williamson DA, Martin CK, Stewart T.
Pennington Biomedical Research Center, 6400 Perkins Road, Baton Rouge, LA 70808, USA. williada@pbrc.edu

Eating disorders (anorexia nervosa, bulimia nervosa, and binge eating disorder) are regarded as psychiatric syndromes that have some relationship to obesity. This review describes current clinical and scientific knowledge concerning the clinical descriptions of these disorders, etiology of each disorder, diagnostic signs, and treatment approaches that have been found to be efficacious. Anorexia nervosa is a very serious eating disorder that is associated with severe medical complications. Anorexia nervosa is very difficult to successfully treat, even when intensive inpatient methods are used. Bulimia nervosa and binge eating disorder are typically less severe eating disorders and are more easily treated using outpatient therapy. Pharmacotherapy has not been found to be an effective treatment for anorexia nervosa, but it has been used successfully with bulimia nervosa and binge eating disorder. Psychotherapy approaches have been successfully employed for all three eating disorders. The review concludes with an integrative perspective that illustrates the similarities and differences of the eating disorders and obesity.

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Int J Eat Disord. 2004 Dec;36(4):402-15.
Binge eating and satiety in bulimia nervosa and binge eating disorder: effects of macronutrient intake.
Latner JD, Wilson GT.
Department of Psychology, University of Canterbury, Private Bag 4800, Christchurch, New Zealand. janet.latner@canterbury.ac.nz

OBJECTIVE: The current study tested the hypothesis that supplemental dietary protein would reduce binge eating frequency and test meal intake in women with bulimia nervosa (BN) or binge eating disorder (BED). METHOD: Eighteen women with BN or BED ingested high-carbohydrate or high-protein supplements (280 kcal) three times daily over two 2-week periods. On the morning after each period, participants were given a high-protein or high-carbohydrate supplement (420 kcal) 3 hr before an ad libitum meal. RESULTS: Binge eating episodes occurred less frequently during protein supplementation (1.12 episodes per week) than during carbohydrate supplementation (2.94 episodes per week) or baseline (3.01 episodes per week). Participants reported less hunger and greater fullness, and consumed less food at test meals, after protein than after carbohydrate (673 vs. 856 kcal). DISCUSSION: Adding protein to the diets of women with BN and BED reduced food intake and binge eating over a 2-week period. These findings may have implications for the longer-term treatment of these disorders. Copyright 2004 by Wiley Periodicals, Inc.

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Adv Ther. 2004 Jul-Aug;21(4):232-7.
Treatment of bulimia nervosa with sertraline: a randomized controlled trial.
Milano W, Petrella C, Sabatino C, Capasso A.
Mental Health Operations Unit, District 44 ASLNAI Naples, Italy.

Bulimia nervosa (BN) is one of the most frequently encountered eating disorders in industrialized societies. It has been suggested that reduced serotonin activity may trigger some of the cognitive and mood disturbances associated with BN. Thus, pharmacologic treatment of BN is mainly based on the use of selective serotonin reuptake inhibitors, which have proved effective. At present, the biological basis of this disorder is not completely clear. The aim of this randomized, controlled trial was to verify the efficacy of sertraline, a selective serotonin reuptake inhibitor, in a group of patients with a diagnosis of BN. Twenty female outpatients, with an age range of 24 to 36 years and a diagnosis of purging type BN as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV), were assigned randomly to two treatment groups. The first group received sertraline 100 mg/day for 12 weeks; the second group received placebo. The study was conducted for 12 weeks, with weekly clinical assessments. At the end of the observation period, the group treated with sertraline had a statistically significant reduction in the number of binge eating crises and purging compared with the group who received placebo. In no case was treatment interrupted because of side effects. This study confirms that sertraline is well tolerated and effective in reducing binge-eating crises and purging in patients with BN.

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Panminerva Med. 2004 Sep;46(3):189-98.
Psychological treatment of eating disorders. A review of the literature.
Fassino S, Piero A, Levi M, Gramaglia C, Amianto F, Leombruni P, Abbate Daga G.
Psychiatry Unit, Department of Neurosciences, University of Turin, Center for Food Behaviour Disorders, Amedeo di Savoia Hospital, Turin, Italy.

The aim of this study is to review the existing literature (PubMed database) on the psychological treatments for eating disorders (EDs), subdivided in individual, group and family therapies. Moreover new approaches and directions in this field are addressed. An extensive literature review is performed to identify the psychological treatment trials in anorexia nervosa (AN) and bulimia nervosa (BN) published over the past 2 decades. Eighty-two studies focused on psychotherapeutic treatment of EDs are reviewed. Only a minor part of these studies are randomised and controlled. While there is evidence of the efficacy of cognitive behavioral therapy (CBT), this is still missing for other psychotherapeutic approaches. However, there is general agreement about the importance of psychotherapy in multimodal treatments. There is still a need for a shared concept of outcome in EDs, since the efficacy of psychological treatment is greatly influenced by the definition of outcome adopted (concerning symptoms, psychosocial functioning, personality).

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J Psychopharmacol. 2004 Sep;18(3):423-8.
Use of reboxetine in bulimia nervosa: a pilot study.
Fassino S, Daga GA, Boggio S, Garzaro L, Piero A.
Department of Neurosciences, Section of Psychiatry, University of Turin, Turin, Italy. secondo.fassino@unito.it

The pharmacological approach to bulimia nervosa is mainly based (BN) on selective serotonin reuptake inhibitors, but many elements suggest the possible involvement of the noradrenergic system in this disorder. The aim of the study was to assess the efficacy of reboxetine--a selective norepinephrine uptake inhibitor--in a sample of bulimic outpatients, after 3 months of treatment. Twenty-eight of 77 consecutively admitted patients with a DSM-IV diagnosis of BN (without Axis I comorbidity) received reboxetine. All patients were assessed at baseline (T0), and after 1 month (T1) and 3 months (T3), respectively, of treatment with reboxetine 4 mg/day. The subjects were administered the following questionnaires: Hamilton Rating Scale for Anxiety (HAM-A) and for Depression (HAM-D), Global Assessment Functioning (GAF), Eating Disorder Inventory-2 (EDI-2) and Body Shape Questionnaire (BSQ). Sixty percent of the patients were responsive to treatment(evaluated as a 50% decrease of bulimic behaviours). After 3 months of treatment, a significant reduction emerged in the scores of various EDI-2 subscales (Bulimia, Drive for Thinness, Body Dissatisfaction, Social Insecurity, Interpersonal Distrust, etc.) and in the BSQ total score. Moreover, depressive symptoms (HAM-D) and Global Functioning (GAF) scores showed a significant improvement. These data support a fast and favourable effect of reboxetine in the treatment of BN, both on symptoms and psychopathological features. Moreover, the specific and strong action of reboxetine on improvement of social functioning is also supported in this disorder.

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Tidsskr Nor Laegeforen. 2004 Sep 9;124(17):2254-7.
[Eating disorders--how to work with the family?]
[Article in Norwegian]
Thune-Larsen KB, Vrabel K.
Ulleval universitetssykehus, Psykiatrisk divisjon, Regional avdeling for spiseforstyrrelser, 0407 Oslo. thka@uus.no

Working with families with a child or an adult with an eating disorder is to work with the resources and limitations in the families, how they could cope with this challenge. Family interventions in eating disorders are counselling, working with the family and family-oriented therapy. Studies show documented effects, especially for patients below 18 with anorexia nervosa who have had this disorder for less than three years. Indications for going from working with the family to family therapy are conflicts between parents or between the child and parents, delayed or disturbed psychological development of the child, or when siblings or other family members are believed to have an effect on the healing. Family therapy is to work with the family as a system. The professional responsibilities, the practical tasks and the goals are about interaction in the family, about relations and communication patterns. Interventions in the family are mainly rooted in systemic family therapy. Motivational methods are important, as are cognitive methods and psychoeducational methods, information and learning how to cope with eating disorders.

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Int J Eat Disord. 2004 Sep;36(2):144-56.
A case series evaluation of guided self-help for bulimia nervosa using a cognitive manual.
Pritchard BJ, Bergin JL, Wade TD.
School of Psychology, Flinders University of South Australia, Adelaide, Australia.

OBJECTIVE: The current study examined the usefulness of a new, cognitive-based self-help manual for bulimia nervosa. METHOD: Twenty people were provided with assessment and six sessions of guided self-help using the manual. Participants were assessed for eating-related behaviors and attitudes and psychopathology at pretreatment, posttreatment, and at the 3-month follow-up. Assessment instruments included the Eating Disorder Examination, Symptom Checklist-90-Revised, Rosenberg Self-Esteem Scale, Screening Test for Co-morbid Personality Disorders, and The University of Rhode Island Change Assessment. Data from 15 people were available at posttreatment and from 13 people at follow-up. RESULTS: Using intention-to-treat analyses, binge eating, vomiting, four of the five eating attitudes and self-esteem significantly improved between pretreatment and posttreatment. At follow-up, there was continued improvement on all measures, with the exception of binge eating. DISCUSSION: Guided self-help using cognitive techniques is a promising first-line treatment for bulimia nervosa, with further evaluation required in a randomized, controlled trial with long-term follow-up.

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Acta Psychiatr Scand. 2004 Aug;110(2):138-45.
Social and health adjustment of bulimic women 7-9 years following therapy.
Jager B, Liedtke R, Lamprecht F, Freyberger H.
Department of Psychosomatics and Psychotherapy, Hanover Medical School, Hanovern, Germany. jaeger.burkard@mh-hannover.de

OBJECTIVE: To examine the long-term social adaptation and long-term follow-up of bulimic women after therapy. METHOD: Eighty women with bulimia nervosa were investigated 7-9 years after the beginning of either conflict-oriented in-patient therapy or systemic out-patient therapy. Data was gathered through interviews and patient questionnaires. RESULTS: At the time of follow-up, 28.9% still had DSM-III-R bulimia, 10.1% suffered from subthreshold bulimia or anorexia (EDNOS), 61.2% did not suffer from any DSM-III-R eating disorder. Compared with statistics on the normal population, the social adaptation of the women was quite good with regard to work, household and living conditions. Some dimensions representing probable aetiological factors (i.e. restrictions of intake, feelings of ineffectiveness) showed a delayed reaction to therapy. CONCLUSION: Long-term outcome of bulimia nervosa may be expected to be moderately good. During therapy, greater attention should be paid to characteristics of the disorder less responsive to treatment.

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Int J Eat Disord. 2004 Jul;36(1):83-8.
Comparing two measures of eating restraint in bulimic women treated with cognitive-behavioral therapy.
Safer DL, Agras WS, Lowe MR, Bryson S.
Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California 94305-5722, USA. dlsafer@stanford.edu

OBJECTIVE: To examine changes in dietary restraint patterns revealed by the Eating Disorders Examination Restraint subscale (EDE-R) and the Three-Factor Eating Questionnaire Cognitive Restraint scale (TFEQ-CR) in a large sample of women with bulimia nervosa (BN) who completed 18 weeks of cognitive-behavioral therapy (CBT). METHOD: Data from 134 subjects were obtained from a larger study and analyzed using repeated-measures analysis of variance (ANOVA). RESULTS: The EDE-R showed statistically and clinically significant decreases post-CBT, whereas the TFEQ-CR did not change significantly. DISCUSSION: This is the first study to directly compare the EDE-R and TFEQ-CR before and after CBT in the same population. The contrasting results suggest the two measures tap different aspects of the dietary restraint construct. The EDE-R may primarily reflect dieting to lose weight whereas the TFEQ-CR may reflect dieting to avoid weight gain. In assessing changes in dietary restraint targeted by CBT for BN, the TFEQ-CR appears less useful. Copyright 2004 by Wiley Periodicals, Inc.

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Int J Eat Disord. 2004 Jul;36(1):48-54.
Efficacy of sertraline for bulimia nervosa.
Sloan DM, Mizes JS, Helbok C, Muck R.
Department of Psychology, Temple University, Philadelphia, Pennsylvania 19122, USA. dsloan@temple.edu

OBJECTIVE: The current study examined the efficacy of sertraline in the treatment of individuals diagnosed with bulimia nervosa. METHOD: Eighteen women enrolled in an 8-week open trial of sertraline. Eating disorder psychopathology and depressive symptoms were assessed at baseline and at the end of the trial using both semistructured interviews and self-report questionnaires. RESULTS: Findings indicated significant reductions in eating disorder psychopathology, including the number of binges and purges per week, as well as significant reductions in depressive symptoms. In addition, participants did not experience significant weight gain or any other sertraline side effect assessed at the end of the trial compared with baseline. DISCUSSION: Findings from the current study indicate that sertraline is efficacious in the treatment of bulimia nervosa. A double-blind controlled trial of sertraline is recommended for future research. Copyright 2004 by Wiley Periodicals, Inc.

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Int J Eat Disord. 2004 Jul;36(1):12-21.
Patterns of weight change after treatment for bulimia nervosa.
Carter FA, McIntosh VV, Joyce PR, Gendall KA, Frampton CM, Bulik CM.
Department of Psychological Medicine, Christchurch School of Medicine and Health Sciences, University of Otago, Christchurch, New Zealand. frances.carter@chmeds.ac.nz

OBJECTIVE: The current study examined changes in weight and body mass index (BMI) at 5-year follow-up among women treated for bulimia nervosa. METHOD: The study comprised 80 women who had participated in a randomized clinical trial evaluating cognitive-behavior therapy for bulimia nervosa. The women had attended assessments at posttreatment and at 5-year follow-up while not pregnant. RESULTS: Changes in mean weight and BMI between posttreatment and 5-year follow-up were small in absolute terms and were not statistically significant. However, by the 5-year follow-up, approximately one half of the participants had either lost (31%) or gained (18%) 5 or more kilograms or were underweight (31%) or overweight (24%) as defined by BMI. Univariate analyses suggest that it is the patients who gain weight over the follow-up that are distinctive. Patients who gained weight over the follow-up were more likely to have commenced menstruation at a younger age, to have a lifetime history of being heavier, and to have been heavier and more dissatisfied with their body at pretreatment, posttreatment, and at 5-year follow-up. CONCLUSION: Five years after treatment for bulimia nervosa, approximately one half of the participants had changed substantially in weight. For those who had changed, weight loss was more common than weight gain. Copyright 2004 by Wiley Periodicals, Inc.

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Cochrane Database Syst Rev. 2004;3:CD000562.
Psychotherapy for bulimia nervosa and binging.
Hay P, Bacaltchuk J, Stefano S.
Psychiatry, School of Medicine, James Cook University, School of Medicine, James Cook University, Townsville, Queensland, AUSTRALIA, 4811.

BACKGROUND: Bulimia nervosa and related syndromes such as binge eating disorder are common in young Western women. A specific manual-based form of cognitive behaviour therapy (CBT) has been developed for the treatment of bulimia nervosa (CBT-BN). Other psychotherapies, some from a different theoretical framework, and some modifications of CBT are also used. OBJECTIVES: To evaluate the efficacy of CBT and CBT-BN and compare them with other psychotherapies in the treatment of adults with bulimia nervosa or related syndromes of recurrent binge eating. SEARCH STRATEGY: A handsearch of The International Journal of Eating Disorders since its first issue; database searches of MEDLINE, EXTRAMED, EMBASE, PsycInfo, CURRENT CONTENTS, LILACS, SCISEARCH, CENTRAL and the The Cochrane Collaboration Depression, Anxiety & Neurosis Controlled Trials Register; citation list searching and personal approaches to authors were used. SELECTION CRITERIA: All studies that have tested any form of psychotherapy for adults with non-purging bulimia nervosa, binge eating disorder and/or other types of eating disorders of a bulimic type (eating disorder, not otherwise specified, or EDNOS), and which applied a randomised controlled and standardised outcome methodology. DATA COLLECTION AND ANALYSIS: Data were analysed using the Review Manager software program. Relative risks were calculated for binary outcome data. Standardized mean differences were calculated for continuous variable outcome data. A fixed effects model was used to analyse the data. Sensitivity analyses of a number of measures of trial quality were conducted. Data were not reported in such a way to permit subgroup analyses, but the effects of treatment on depressive symptoms, psychosocial and/or interpersonal functioning, general psychiatric symptoms and weight were examined where possible. Funnel plots were drawn to investigate the presence of publication bias. MAIN RESULTS: The review supported the efficacy of cognitive-behavioral psychotherapy (CBT) and particularly CBT-BN in the treatment of people with bulimia nervosa and also (but less strongly due to the small number of trials) related eating disorder syndromes. CBT was also shown to be effective in group settings. Other psychotherapies were also efficacious, particularly interpersonal psychotherapy in the longer-term. Self-help approaches that used highly structured CBT treatment manuals, were promising albeit with more modest results generally, and their evaluation in bulimia nervosa merits further research. Exposure and Response Prevention did not appear to enhance the efficacy of CBT.Psychotherapy alone is unlikely to reduce or change body weight in people with bulimia nervosa or similar eating disorders. REVIEWERS' CONCLUSIONS: There is a small body of evidence for the efficacy of cognitive-behavior therapy in bulimia nervosa and similar syndromes, but the quality of trials is very variable and sample sizes are often small. More trials of CBT are needed, particularly for binge eating disorder and other EDNOS syndromes. Trials evaluating other psychotherapies and less intensive psychotherapies should also be conducted.

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Mt Sinai J Med. 2004 May;71(3):155-61.
Nutrition and eating disorders in adolescents.
Seidenfeld ME, Sosin E, Rickert VI.
Mount Sinai Adolescent Health Center, The Mount Sinai School of Medicine, New York, NY, USA.

Adequate nutrition is essential during adolescence, since growth and development during this period play key roles in achieving normal adult size and reproductive capacity. This article briefly reviews recommended caloric intake; the healthy balance of carbohydrates, fat and protein; and the appropriate dietary intake of iron, folic acid and calcium for the adolescent. A major potential obstacle to good nutrition for an adolescent is the development of an eating disorder such as anorexia nervosa or bulimia nervosa. Anorexia nervosa, characterized by severe underweight, fear of gaining weight, and low self-esteem and amenorrhea, is associated with many physiological and psychological complications with which the provider must be familiar. Similarly, bulimia nervosa, which presents with eating binges followed by compensatory behaviors such as vomiting, diet pill abuse and overexercise, may be harder to detect, but can also have devastating consequences, both physically and emotionally, for a young person. Both of these disorders are best treated by a multidisciplinary team of specialists to address the medical, psychological, and nutritional components of these illnesses.

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Int J Eat Disord. 2004 May;35(4):538-48.
A preliminary investigation into the feasibility and efficacy of a CD-ROM-based cognitive-behavioral self-help intervention for bulimia nervosa.
Bara-Carril N, Williams CJ, Pombo-Carril MG, Reid Y, Murray K, Aubin S, Harkin PJ, Treasure J, Schmidt U.
Eating Disorders Unit, South London and Maudsley NHS Trust, London, United Kingdom.

OBJECTIVE: Many patients with bulimia nervosa find it hard to access evidence-based treatment such as cognitive-behavioral therapy (CBT). The aim of the current study was to evaluate the feasibility and efficacy of a novel CD-ROM-based cognitive-behavioral multimedia self-help intervention for the treatment of bulimia nervosa. METHOD: Patients with bulimia nervosa referred to a catchment area-based eating disorder service were offered eight sessions of a novel CD-ROM cognitive-behavioral self-help treatment without any added therapist input. We report here the take-up and drop-out rates and efficacy of this intervention. RESULTS: Of 60 participants who were offered the intervention, 47 took it up. At follow-up, there were significant reductions in binging and compensatory behaviors, most clearly in self-induced vomiting. DISCUSSION: This intervention has potential as a first step in the treatment of bulimia nervosa and for dissemination to nonspecialist settings. Copyright 2004 by Wiley Periodicals, Inc. Int J Eat Disord 35: 538-548, 2004.

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MMW Fortschr Med. 2004 Apr 22;146(17):31-3.
[Eating disorders—how to recognize and treat them]
[Article in German]
Backmund M.
Klinik 3, Bereich Suchtmedizin, Krankenhaus Munchen-Schwabing. Markus.Backmund@kms.mhn.de

Eating disorders are common among adolescent girls and young women and are associated with potentially serious medical complications. Anorexia nervosa, bulimia nervosa, binge-eating disorder are characterized by a serious disturbance in eating, such as restriction of intake or bingeing, as well as distress or excessive concern about body shape or body weight. The mortality rate associated with anorexia nervosa alone, at 0.56 percent per year, is more than 12 times as high as the mortality rate among young women in the general population. All patients with eating disorders should be evaluated and treated for medical complications of the disease at the same time that psychotherapy and nutritional counselling are undertaken.

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Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2004 Mar;47(3):246-50.
[Eating disorders in childhood and adolescence. Anorexia nervosa, bulimia nervosa, binge eating disorder]
[Article in German]
Gerlinghoff M, Backmund H.
Max-Planck-Institut fur Psychiatrie, Munchen, info@t-c-e.de

The most important eating disorders are anorexia and bulimia, which most frequently occur for the first time during adolescence and continue into adulthood. Medical complications and accompanying psychological disturbances cause a significant mortality rate of up to 6% in anorexia and up to 3% in bulimia. The pathogenesis of eating disorders is still unclear. Current etiological concepts are multidimensional including biological, individual, familial, and sociocultural factors. In spite of a great variety of therapeutic possibilities, the prognosis for eating disorders is quite poor. In the long term, only about 50% of the persons affected overcome their illness. Preventive measures are therefore indispensable.

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Int J Eat Disord. 2004 Apr;35(3):262-74.
Cognitive-behavioral therapy for bulimia nervosa: An empirical analysis of clinical significance.
Lundgren JD, Danoff-Burg S, Anderson DA.
Department of Psychology, University at Albany, The State University of New York, Albany, New York.

OBJECTIVE: The purpose of this review was to assess the clinical significance of cognitive-behavioral therapy for bulimia nervosa using the reliable change index and normative comparison analyses. METHOD: Fifteen treatment outcome studies using either individual or group cognitive-behavioral therapy for bulimia nervosa were selected for inclusion. RESULTS: Results suggest that cognitive-behavioral therapy for bulimia nervosa produces clinically significant change for many treatment outcome measures when using the reliable change index. However, posttreatment symptomatology is rarely within a normative range when examined with normative comparison analyses. DISCUSSION: This review provides a first step in examining the clinical significance of treatment for bulimia nervosa. Future studies should further this work by comparing the clinical significance of different types of treatment for bulimia nervosa using additional assessment measures. Copyright 2004 by Wiley Periodicals, Inc. Int J Eat Disord 35: 262-274, 2004.

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Curr Drug Targets. 2004 Apr;5(3):301-7.
Pharmacological approaches in the treatment of binge eating disorder.
Appolinarion JC, McElroy SL.
Obesity and Eating Disorders Group--Institute of Psychiatry, Federal University of Rio de Janeiro and Institute of Endocrinology and Diabetes of Rio de Janeiro, Brazil. appolinario@biohard.com.br

Binge eating disorder (BED) is a newly defined diagnostic category characterized by recurrent episodes of binge eating not followed by the inappropriate compensatory weight loss behaviors characteristic of bulimia nervosa. BED is usually associated with overweight or obesity and psychopathology. Pharmacotherapy may be a useful component of a multidimensional treatment approach. Although pharmacotherapy research in BED is still in its preliminary stages. some drugs have been shown to be promising agents. This paper reviews available pharmacological treatment studies of BED and related conditions. Currently, three main classes of drugs have been studied in double-blind, placebo controlled trials in BED: antidepressants, anti-obesity agents, and anticonvulsants. Serotonin selective reuptake inhibitors (SSRIs) are the best studied medications. Thus, fluoxetine, fluvoxamine, sertraline and citalopram have been shown to modestly but significantly reduce binge eating frequency and body weight in BED over the short term. More recently, the anti-obesity agent sibutramine and the anticonvulsant topiramate have been shown to significantly reduce binge eating behavior and body weight in BED associated with obesity. Special issues concerning current pharmacological trials and future research directions in this area are also discussed.

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Am J Psychiatry. 2004 Mar;161(3):556-61.
Treatment of bulimia nervosa in a primary care setting.
Walsh BT, Fairburn CG, Mickley D, Sysko R, Parides MK.
Department of Psychiatry, College of Physicians and Surgeons of Columbia University, New York, NY 10032, USA. btw1@columbia.edu

OBJECTIVE: The authors' goal was to determine whether treatments known to be effective for bulimia nervosa in specialized treatment centers can be used successfully in primary health care settings. They examined the benefits of two treatments for bulimia: 1) fluoxetine, an antidepressant medication, and 2) guided self-help, an adaptation of cognitive behavior therapy. METHOD: Ninety-one female patients in two primary care settings were randomly assigned to receive fluoxetine alone, placebo alone, fluoxetine plus guided self-help, or placebo and guided self-help. RESULTS: The majority of the patients did not complete the treatment trial; many patients found the treatment program too demanding, but others indicated it was not sufficiently intensive. Patients assigned to fluoxetine attended more physician visits, exhibited a greater reduction in binge eating and vomiting, and had a greater improvement in psychological symptoms than those assigned to placebo. There was no evidence of benefit from guided self-help. CONCLUSIONS: The treatment of patients with bulimia nervosa in a primary care setting is hampered by a high dropout rate. Guided self-help, a psychological treatment based on cognitive behavior therapy, appears ineffective, but treatment with fluoxetine is associated with better retention and substantial symptomatic improvement.

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J Child Psychol Psychiatry. 2004 Jan;45(1):63-83.
Management of child and adolescent eating disorders: the current evidence base and future directions.
Gowers S, Bryant-Waugh R.
University of Liverpool, UK. simon.gowers@cwpnt.nhs.uk

Although eating disorders in children and adolescents remain a serious cause of morbidity and mortality, the evidence base for effective interventions is surprisingly weak. The adult literature is growing steadily, but this is mainly with regard to psychological therapies for bulimia nervosa and to some extent in the field of pharmacotherapy. This review summarises the recent research literature covering management in three areas, namely physical management, psychological therapies, and service issues, and identifies prognostic variables. Findings from the adult literature are presented where there is good reason to believe that these might be applied to younger patients. Evidence-based good practice recommendations from published clinical guidelines are also discussed. Suggestions for future research are made, focusing on 1) the need for trials of psychological therapies in anorexia nervosa, 2) applications of evidence-based treatments for adult bulimia nervosa to the treatment of adolescents, and 3) clarification of the benefits and costs of different service models.

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Ann Gen Hosp Psychiatry. 2004 Feb 12;3(1):2.
Fluoxetine: a review on evidence based medicine.
Rossi A, Barraco A, Donda P.

Background: Fluoxetine was the first molecule of a new generation of antidepressants, the Selective Serotonin Re-uptake Inhibitors (SSRIs). It is recurrently the paradigm for the development of any new therapy in the treatment of depression. Many controlled studies and meta-analyses were performed on Fluoxetine, to improve the understanding of its real impact in the psychiatric area. The main objective of this review is to assess the quality and the results reported in the meta-analyses published on Fluoxetine. Design Published articles on Medline, Embase and Cochrane databases reporting meta-analyses were used as data sources for this review. Articles found in the searches were reviewed by 2 independent authors, to assess if these were original meta-analyses. Only data belonging to the most recent and comprehensive meta-analytic studies were included in this review. Results Data, based on a group of 9087 patients, who were included in 87 different randomized clinical trials, confirms that fluoxetine is safe and effective in the treatment of depression from the first week of therapy. Fluoxetine's main advantage over previously available antidepressants was its favorable safety profile, that reduced the incidence of early drop-outs and improved patient's compliance, associated with a comparable efficacy on depressive symptoms. In these patients, Fluoxetine has proven to be more effective than placebo from the first week of therapy. Fluoxetine has shown to be safe and effective in the elderly population, as well as during pregnancy. Furthermore, it was not associated with an increased risk of suicide in the overall evaluation of controlled clinical trials. The meta-analysis available on the use of Fluoxetine in the treatment of bulimia nervosa shows that the drug is as effective as other agents with fewer patients dropping out of treatment. Fluoxetine has demonstrated to be effective as chlomipramine in the treatment of Obsessive-Compulsive-Disorder (OCD). Conclusion Fluoxetine can be considered a drug successfully used in several diseases for its favorable safety/efficacy ratio. As the response rate of mentally ill patients is strictly related to each patient's personal characteristics, any new drug in this area, will have to be developed under these considerations.

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J Clin Psychiatry. 2003 Nov;64(11):1335-41.
Treatment of bulimia nervosa with topiramate in a randomized, double-blind, placebo-controlled trial, part 1: improvement in binge and purge measures.
Hoopes SP, Reimherr FW, Hedges DW, Rosenthal NR, Kamin M, Karim R, Capece JA, Karvois D.
Mountain West Clinical Trials, Boise, Idaho 83704, USA. hoopes@cableone.net

BACKGROUND: This randomized, double-blind, placebo-controlled trial was designed to assess the efficacy and safety of topiramate in bulimia nervosa. METHOD: Patients with DSM-IV bulimia nervosa were randomly assigned in equal proportions to receive topiramate (N = 35) or placebo (N = 34) for 10 weeks (between April 1999 and Dec. 2000). Topiramate treatment was started at 25 mg/day and titrated by 25 to 50 mg/week to a maximum of 400 mg/day. The primary efficacy measure was mean weekly number of binge and/or purge days. Related outcome measures included mean weekly number of binge days and binge frequency, as well as mean weekly number of purge days and purge frequency. RESULTS: Sixty-four outpatients (33 placebo, 31 topiramate) were included in the intent-to-treat analysis. The median topiramate dose was 100 mg/day (range, 25-400 mg/day). Mean +/- SD baseline number of weekly binge and/or purge days was 5.0 +/- 1.6 for topiramate patients and 5.1 +/- 1.5 for placebo patients. The primary efficacy measure, mean weekly number of binge and/or purge days, decreased 44.8% from baseline with topiramate versus 10.7% with placebo (p =.004). The mean weekly number of binge days decreased 48.2% with topiramate versus 17.7% with placebo (p =.015), and mean binge frequency decreased 49.2% with topiramate versus 28.0% with placebo (p =.071). The mean weekly number of purge days decreased 43.4% with topiramate versus 16.6% with placebo (p =.016), and mean purge frequency decreased 49.8% with topiramate versus 21.6% with placebo (p =.016). Three patients (2 placebo, 1 topiramate) discontinued from the trial due to adverse events. CONCLUSION: Topiramate was associated with significant improvements in both binge and purge symptoms in this study population and represents a potential treatment for bulimia nervosa.

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J Child Adolesc Psychopharmacol. 2003 Fall;13(3):329-35.
An open trial of fluoxetine for adolescents with bulimia nervosa.
Kotler LA, Devlin MJ, Davies M, Walsh BT.
Department of Child Psychiatry, Columbia University, College of Physicians and Surgeons/New York State Psychiatric Institute, New York, New York 10032, USA. kotlerl@childpsych.columbia.edu

OBJECTIVE: This open clinical trial examined the feasibility, tolerability, and efficacy of treating adolescents who suffer from bulimia nervosa with fluoxetine. METHODS: Ten adolescents, ages 12-18 years received 8 weeks of fluoxetine 60 mg/day with supportive psychotherapy. Primary outcome measures included frequencies of binge eating and purging and ratings on the Clinical Global Impressions-Improvement scale (CGI-I). Secondary outcome measures included self-report measures of eating disorder, depression, and anxiety symptoms. Safety and tolerability of this dose of fluoxetine were also assessed. RESULTS: Average weekly binges decreased significantly from 4.1 +/- 3.8 to 0 (p < 0.01). Average weekly purges decreased significantly from 6.4 +/- 5.2 to 0.4 +/- 0.9 (p < 0.005). All patients improved on the CGI-I scale, with 20% rated as much improved, 50% improved, and 30% slightly improved. All subjects tolerated the 60-mg dose of fluoxetine, and there were no dropouts due to adverse effects from the medication. DISCUSSION: Fluoxetine is generally well tolerated and may be an effective treatment option for adolescents with bulimia nervosa.

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Eat Weight Disord. 2003 Sep;8(3):242-8.
Adolescents and eating disorders: an examination of a day treatment program.
Dancyger I, Fornari V, Schneider M, Fisher M, Frank S, Goodman B, Sison C, Wisotsky W.
Division of Child and Adolescent Psychiatry, North Shore University Hospital, New York University School of Medicine, Manhasset, USA. IDancyge@nshs.edu

OBJECTIVE: In this study, we report on our day treatment program (DTP) for adolescents and young adults with eating disorders (EDs). METHOD: Data for the 82 female patients in DTP were examined, compared across ED diagnosis and by age (adolescents vs. young adults). At admission, patients completed the Eating Disorder Inventory-2 (EDI-2) and the Beck Depression Inventory (BDI) and the Family Adaptability and Cohesion Evaluation Scale- II (FACES-II). RESULTS: Forty-nine percent of patients successfully completed the day program and 13% required hospitalization following day treatment. Overall, there were no significant differences between the adolescents and adults at discharge of the day program. DISCUSSION: With shortened inpatient (IP) hospitalizations, DTPs can provide the long-term care required by many adolescent patients for psychological and physical recovery. This may be particularly important for the development of children and adolescents.

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Seishin Shinkeigaku Zasshi. 2003;105(11):1363-86.
[Efficacy of intervention with externalization therapy for eating disorders]
[Article in Japanese]
Ono H, Kojima K, Higashi Y, Yoshioka S, Kawahara R.
Department of Neuropsychiatry, Faculty of Medicine, Tottori University.

Externalization has been one of the effective methods in the fields of brief therapy, family therapy, and psycho-education in recent years. In this study, we investigated the efficacy of intervention with externalization at the first stage of therapy in 25 patients with eating disorders. The subjects consisted of 11 patients with anorexia nervosa (AN) and 14 with bulimia nervosa (BN). The Eating Disorder Inventory (EDI) was evaluated at the first session, the 10th session, and six months later. The obtained results showed intervention with externalization resulted in significant decreases in not only total EDI score but also all the EDI subscale scores. We also found that there were great differences between the EDI subscale scores of anorexia nervosa and bulimia nervosa patients. Therapy was significantly less effective for patients with anorexia nervosa than for those with bulimia nervosa, and much less effective for the restricting type of anorexia nervosa. In addition, all the EDI subscale scores were significantly decreased, irrespective of the complication of personality disorder. The efficacy of intervention with externalization continued for six months. Especially in patients with anorexia nervosa, there were significant decreases in the EDI subscale scores when compared with the scores in the 10th session. The present findings indicates that initial intervention with externalization is effective for treating eating disorders, regardless of the severity of illness.

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Expert Opin Pharmacother. 2003 Oct;4(10):1659-78.
Towards the pharmacotherapy of eating disorders.
Pederson KJ, Roerig JL, Mitchell JE.
The Neuropsychiatric Research Institute, 700 First Avenue South, Fargo, ND 58103, USA. jroerig@nrifargo.com

The purpose of this review is to discuss pharmacological options for the treatment of patients with eating disorders. Sequentially described are pharmacotherapy studies of anorexia nervosa (AN), bulimia nervosa (BN) and binge-eating disorder (BED). The quantity of drug trials performed with AN patients has been very limited. While the majority of studies have failed to show medication efficacy for the acute treatment of AN, there is data which suggests that fluoxetine hydrochloride may play a role in preventing relapse during maintenance therapy. Atypical antipsychotics, most often olanzapine, have shown promise in a number of uncontrolled studies. BN has been most extensively studied, with the majority of pharmacological trials focusing on antidepressants. Fluoxetine, at a dose of 60 mg/day, is FDA-approved for the treatment of BN. Psychotherapy, particularly cognitive behavioural therapy (CBT) is of well-established utility in BN and data suggests that the combination of an antidepressant plus CBT is superior to either treatment alone. Recently, there has been interest in the 5-HT(3) antagonist, ondansetron, and the anticonvulsant, topiramate. BED investigators have focused largely on antidepressants, which may reduce symptoms of depression and augment psychotherapy. While sibutramine and topiramate have both been associated with weight loss in controlled trials, the former appears to be fairly well-tolerated and the latter appears to be responsible for the emergence of significant cognitive and peripheral nervous system side effects in some patients. Further pharmacological research with eating disorder patients is needed, particularly in the areas of AN and BED. Also, pharmacological augmentation strategies for those not responding to primary therapies should be explored.

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J Psychosom Res. 2003 Oct;55(4):357-61.
Bulimia nervosa, childbirth, and psychopathology.
Carter FA, McIntosh VV, Joyce PR, Frampton CM, Bulik CM.
Department of Psychological Medicine, Christchurch School of Medicine, Otago University, P.O. Box 4345, Christchurch, New Zealand

OBJECTIVE: To examine whether having a baby following treatment for bulimia nervosa places women at increased risk for continuing or relapsing eating disorders or major depression. METHODS: Subjects were women who had participated in a large randomized controlled trial evaluating cognitive behavior therapy for bulimia nervosa, who were prospectively followed-up over 5 years. At follow-up assessments (at least yearly), life charts were completed with patients and childbirth was recorded. The presence of eating disorders and major depressive disorder was assessed using the Structured Interview for DSM-III-R. RESULTS: Childbirth was not specifically associated with increased symptomatology. This was found for both eating disorders and major depression in the same year as childbirth and for the year following childbirth. CONCLUSION: Childbirth is not specifically associated with symptomatology following treatment for bulimia nervosa.

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Int J Eat Disord. 2003 Sep;34(2):227-34.
Cue exposure in the treatment of resistant bulimia nervosa.
Toro J, Cervera M, Feliu MH, Garriga N, Jou M, Martinez E, Toro E.
Servei de Psiquiatria i Psicologia Infantil i Juvenil, Hospital Clinic Universitari, University of Barcelona, Barcelona, Spain. jtoro@clinic.ub.es

OBJECTIVE: It was hypothesized that binge eating (bulimia nervosa [BN]) may be caused by the anticipatory and immediate anxiety associated with certain types of food. Consequently, an extinction schedule should reduce binge eating. METHODS: Cue exposure was carried out with 6 bulimic women who had responded poorly or not at all to the usual pharmacologic or cognitive-behavioral treatments. RESULTS: Binge eating and vomiting were almost totally suppressed in the 6 patients. Symptom suppression was maintained at two follow-ups, one at 4-20 months and another at 2.5-3 years. DISCUSSION: Cue exposure may be effective with BN that is resistant to conventional treatments. The anxiety associated with food plays an important role in provoking and/or maintaining binge eating. Motivation to change is likely to be an important mediator. Copyright 2003 by Wiley Periodicals, Inc.

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Expert Opin Investig Drugs. 2003 Aug;12(8):1441-3.
Academy for Eating Disorders International Conference on Eating Disorders. Denver, CO, USA, May 29-31, 2003.
Kaplan AS.
Loretta Anne Rogers Chair in Eating Disorders, Toronto General Hospital, 8-Eaton, Room 231, 200 Elizabeth Street, Toronto, Ontario, Canada. allan.kaplan@uhn.on.ca

The focus of this meeting was the interface between eating disorders and obesity. A symposium at this meeting dealt with advances in treatment for bulimia nervosa (BN) and binge eating disorder. There were two presentations in this symposium that addressed pharmacological treatments. One reviewed drug treatments for BN, which included reviewing the evidence for the efficacy of tricyclic antidepressants, monoamine oxidase inhibitors and selective serotonin inhibitors in the treatment of BN. All drug studies demonstrated greater reduction in binge eating and purging than with placebo. Other medications studied without evidence of efficacy for BN include opiate antagonists, lithium and anticonvulsants. Two promising agents for BN that require further study are odansitron and topiramate. For binge eating disorder, studies have examined the efficacy of antidepressants (tricyclic antidepressants, selective serotonin re-uptake inhibitors and serotonin/noradrenaline re-uptake inhibitors), antiobesity agents (sibutramine) and antiepileptics associated with weight loss (topiramate), with some evidence of efficacy for these agents.

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Vertex. 2003 Jun-Aug;14(52):103-15.
[Group therapy of bulimia nervosa and other related disorders]
[Article in Spanish]
Torrente FM, Crispo R.
Centro para Adolescentes La Casita, Buenos Aires, Argentina. torrent@ciudad.com.ar

The aim of this article is to present a brief group intervention model for the initial phase of the treatment of bulimia nervosa and other related eating disorders. The model combines elements from cognitive-behavioral and psychoeducational approaches. Along the article we will describe the theoretical foundations of the model, a review of the empirical evidence that supports it, and afterwards, the group procedure developed by us in our clinical experience. Later on, the clinical results of an uncontrolled study of a sample of patients who participated in the group will be introduced. Finally, we will discuss the scope and limitations of this experience.

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Curr Opin Pediatr. 2003 Jun;15(3):344-5.
What is the evidence basis for existing treatments of eating disorders?
Bergh C, Ejderhamn J, Sodersten P.
Karolinska Institutet, Section of Applied Neuroendocrinology, AB Mando Center for Eating Disorders, Novum, Huddinge, Sweden.

Most existing treatments of eating disorders (ED) produce a period of remission that is short lived and expressed in fewer than 50% of the patients. Antidepressants (eg, selective serotonin reuptake inhibitors [SSRI]) have a small effect in bulimia nervosa and they are not recommended in anorexia nervosa (AN) because serotonin inhibits food intake. In a randomized, controlled trial, training of eating behavior and satiety, supply of warmth, reduction of physical hyperactivity, and restoration of social activities brought 75% of patients with ED into remission, and 93% remained in remission during follow-up. Further randomized, controlled trials comparing presently used interventions will provide the evidence needed to improve the treatment of ED.

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Am J Psychother. 2003;57(2):237-51.
Family-based therapy for adolescents with bulimia nervosa.
Le Grange D, Lock J, Dymek M.
Department of Psychiatry, University of Chicago, 5841 S. Maryland Avenue, MC 3077, Chicago, IL 60637, USA.

Bulimia nervosa is occurring with increasing frequency among adolescents. Yet, no studies have examined effective treatments for this patient population. Involving the family in the treatment of adolescents with anorexia nervosa has proven to be helpful. A small series of cases has demonstrated that family-based treatment might also be beneficial for adolescents with bulimia nervosa. Moreover, treatment studies for adolescents with anorexia nervosa have demonstrated that family-based treatment does benefit binge eating/purging anorexics. Therefore, preliminary evidence seems to support the use of family-based treatment for adolescent bulimia nervosa. In this article, we review our current knowledge of family-based treatment for adolescents with an eating disorder, and present a case that has completed treatment in order to demonstrate the outline and main interventions of this manualized treatment. While this case demonstrates the successful resolution of bulimia in an adolescent female, at least in the short term, the efficacy of family-based treatment for this patient population is yet to be determined, and is currently being examined in a randomized controlled study at The University of Chicago.

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Am J Psychiatry. 2003 May;160(5):973-8.
Self-help for bulimia nervosa: a randomized controlled trial.
Carter JC, Olmsted MP, Kaplan AS, McCabe RE, Mills JS, Aime A.
Department of Psychiatry, Toronto General Hospital, 200 Elizabeth Street, Eaton Wing B-231, Toronto, Ontario M5G 2C4, Canada.

OBJECTIVE: The authors examined the effectiveness of unguided self-help as a first step in the treatment of bulimia nervosa. METHOD: A total of 85 women with bulimia nervosa who were on a waiting list for treatment at a hospital-based clinic participated. The patients were randomly assigned to receive one of two self-help manuals or to a waiting list control condition for 8 weeks. One of the self-help manuals addressed the specific symptoms of bulimia nervosa (cognitive behavior self-help), while the other focused on self-assertion skills (nonspecific self-help). RESULTS: Twenty patients (23.5%) dropped out of the study. The data were analyzed with intention-to-treat analysis. Although the group-by-time interaction for binge eating and purging was not statistically significant, simple effects showed that there was a significant reduction in symptom frequency in both self-help conditions at posttreatment but not in the waiting list condition. There were no statistically significant changes in levels of dietary restraint, eating concerns, concerns about shape and weight, or general psychopathology. A greater proportion of patients in the cognitive behavior self-help (53.6%) and nonspecific self-help (50.0%) conditions reported at least a 50% reduction in binge eating or purging at posttreatment, compared with the waiting list condition (31.0%). A lower baseline knowledge about eating disorders, more problems with intimacy, and higher compulsivity scores predicted a better response. CONCLUSIONS: The findings suggest that a subgroup of patients with bulimia nervosa may benefit from unguided self-help as a first step in their treatment. Cognitive behavior self-help and nonspecific self-help had equivalent effects.

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Curr Drug Target CNS Neurol Disord. 2003 Feb;2(1):17-29.
Drug therapy for patients with eating disorders.
Mitchell JE, de Zwaan M, Roerig JL.
The Neuropsychiatric Research Institute, 700 1st Avenue So., P.O. Box 1415, Fargo, ND 58107, USA. mitchell@medicine.nodak.edu

The purpose of this article is to review the psychopharmacology treatment literature for patients with eating disorders including bulimia nervosa, anorexia nervosa and binge eating disorder. The best-developed treatment literature concerns bulimia nervosa, which has been studied now in several dozen pharmacological treatment studies. The agents most commonly used are the antidepressants, with particular focus on the selective serotonin reuptake inhibitors including fluoxetine hydrochloride. These agents clearly impact significantly on the frequency of abnormal eating behaviors such as binge eating and purging. However, subjects treated with these drugs rarely achieve remission. Pharmacotherapy of anorexia nervosa has also traditionally focused on the use of antidepressants and there is some evidence that the use of SSRIs may help in preventing relapse in weight restored patients. Recently interest has developed in the use of atypical neuroleptics to help with the obsessionality and resistance to treatment frequently seen in low weight patients, the most commonly employed agent being olanzapine. Pharmacotherapy of binge-eating disorder is now being intensively investigated. In general medication alone seems inferior to psychotherapy in the short term. Antidepressants can increase the amount of weight loss when combined with psychological treatment and also appear to benefit symptoms such as depression. Further data are needed, but a number of drugs appear promising.

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Curr Womens Health Rep 2003 Jun;3(3):221-9
Outpatient management of eating disorders in adults.
Becker AE.
Adult Eating and Weight Disorders Program, Department of Psychiatry, Massachusetts General Hospital--WAC 816, 15 Parkman Street, Boston, MA 02114, USA. abecker@partners.org

Eating disorders are prevalent in the young adult female population. Given the serious medical, nutritional, and psychological risks associated with eating disorders, it is advisable that patients be seen within the framework of a multidisciplinary team. Psychotherapy is the most effective treatment modality for eating disorders and constitutes the core of mental health treatment. Although cognitive behavior therapy trials dominate the research literature on interventions for bulimia nervosa and binge-eating disorder, various modalities of psychotherapy have efficacy. Active weight management is also a key component of treatment for anorexia nervosa. Psychotropic medication therapy is not generally useful for the primary symptoms of anorexia nervosa, whereas it is moderately effective in the treatment of both bulimia nervosa and binge-eating disorder. Given the patient population at Massachusetts General Hospital, to which patients often present with serious and chronic symptoms, comorbid medical and psychiatric illness, and history of poor response to treatment, we have found a flexible and eclectic treatment approach most useful clinically.

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Int J Eat Disord 2003 May;33(4):468-72
Topiramate in the treatment of severe bulimia nervosa with comorbid mood disorders: A case series.
Barbee JG.
Department of Psychiatry, Louisiana State University Health Sciences Center, New Orleans, Louisiana.

OBJECTIVE: To report observations on the efficacy and tolerability of topiramate in a sample of five patients with severe symptoms of bulimia nervosa and comorbid mood and/or anxiety disorders. METHOD: Topiramate was added to other psychotropic medication under open-label conditions up to the maximum tolerated dose or until remission of the eating disorder was achieved. RESULTS: Topiramate almost completely eliminated binging and purging behavior in three of the five patients. Improvement was maintained throughout the period of follow-up for up to 18 months. One patient showed a partial, temporary response, and the fifth was intolerant of the drug and unable to complete an adequate trial. DISCUSSION: These results suggest strongly that the efficacy of topiramate in patients with bulimia nervosa with and without comorbid mood and anxiety disorders should be investigated more fully. Copyright 2003 by Wiley Periodicals, Inc. Int J Eat Disord 33: 468-472, 2003.

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Lancet 2003 Feb 1;361(9355):407-16
Eating disorders.
Fairburn CG, Harrison PJ.
Oxford University Department of Psychiatry, Warneford Hospital, Oxford, UK. credo@medicine.ox.ac.uk

Eating disorders are an important cause of physical and psychosocial morbidity in adolescent girls and young adult women. They are much less frequent in men. Eating disorders are divided into three diagnostic categories: anorexia nervosa, bulimia nervosa, and the atypical eating disorders. However, the disorders have many features in common and patients frequently move between them, so for the purposes of this Seminar we have adopted a transdiagnostic perspective. The cause of eating disorders is complex and badly understood. There is a genetic predisposition, and certain specific environmental risk factors have been implicated. Research into treatment has focused on bulimia nervosa, and evidence-based management of this disorder is possible. A specific form of cognitive behaviour therapy is the most effective treatment, although few patients seem to receive it in practice. Treatment of anorexia nervosa and atypical eating disorders has received remarkably little research attention.

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Eur Neuropsychopharmacol 2003 Mar;13(2):73-9
Milnacipran in the treatment of bulimia nervosa: a report of 16 cases.
El-Giamal N, de Zwaan M, Bailer U, Strnad A, Schussler P, Kasper S.
Department of General Psychiatry, University Hospital of Psychiatry, Wahringer Gurtel 18-20, 1090, Vienna, Austria

Controlled trials in patients with bulimia nervosa have demonstrated efficacy of antidepressant medications with serotonergic function (e.g. fluoxetine) as well as noradrenergic function (e.g. desipramine). Sixteen out-patients with bulimia nervosa according to DSM-IV criteria were treated in a drug surveillance with 100 mg of milnacipran, a specific serotonin and noradrenaline reuptake inhibitor (SNRI). Ten patients completed the 8-week observation period. The reasons for premature attrition were improvement in one patient (no. 12), a generalized exanthema in one patient (no. 7), severe nausea in one patient (no. 8) and non-compliance due to non-drug-related reasons in three patients (no. 1, 2, and 16). An intent-to-treat analysis exhibited a significant reduction in weekly binge eating and vomiting frequency from baseline to the end of treatment. Three patients stopped binge eating and purging completely during the last week of treatment. Furthermore, there was a concomitant decrease of depression ratings (HAMD, BDI). Our preliminary data give rise to the notion that milnacipran may be promising in the treatment of bulimia nervosa.

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Int J Eat Disord 2003 Mar;33(2):127-35
Role of exposure with response prevention in cognitive-behavioral therapy for bulimia nervosa: Three-year follow-up results.
Carter FA, McIntosh VV, Joyce PR, Sullivan PF, Bulik CM.
Department of Psychological Medicine, Christchurch School of Medicine, Otago University, Christchurch, New Zealand.

BACKGROUND: Previous studies have not reported the longer-term outcome of exposure-based treatments for bulimia nervosa. The current study evaluated the 3-year outcome of a randomized clinical trial that compared the additive efficacy of exposure-based versus nonexposure-based behavioral treatments (BT) with a core of cognitive-behavior therapy (CBT). METHODS: One hundred thirteen women participated in the original treatment trial and attended a 3-year follow-up assessment. Eating disorder diagnoses and primary, secondary, and tertiary outcome measures were assessed. The impact of treatment completion on symptomatology and the stability of treatment effects over time were evaluated. RESULTS: At the 3-year follow-up, 85% of the sample had no current diagnosis of bulimia nervosa and 69% had no current eating disorder diagnoses of any sort. Failure to complete CBT was associated with inferior outcome. No clear advantages were evident for participants who completed BT in addition to CBT. For subjects who did complete both CBT and BT, outcome was mostly stable from posttreatment to follow-up. No differential effects were found for exposure versus nonexposure-based treatments at 3-year follow-up. DISCUSSION: The results of the current study compare favorably with other treatment outcome studies for bulimia nervosa and suggest that treatment gains are maintained after 3 years. Copyright 2003 by Wiley Periodicals, Inc. Int J Eat Disord 33: 127-135, 2003.

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Eat Weight Disord 2002 Dec;7(4):258-67
Nutritional interventions for individuals with bulimia nervosa.
Salvy SJ, McCargar L.
Department of Psychology, Universite du Quebec a Montreal, Canada.

Many physical and psychological effects of bulimia nervosa are caused by the patient's partial starvation and chaotic nutritional cycle. Attention should thus be initially directed to correcting nutritional deficiencies and abnormal eating patterns, and providing dietary counselling. Nevertheless, very little has been written about the nutritional management of this eating disorder. Nutritional counselling for bulimia patients is reviewed in this paper. Current knowledge about nutritional therapy and its efficacy, goals and objectives is presented, along with recommendations used in treatment programmes. Lastly, the key steps of nutritional management are summarised.

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Int J Eat Disord 2003 Apr;33(3):241-54
Comparison of group and individual cognitive-behavioral therapy for patients with bulimia nervosa.
Chen E, Touyz SW, Beumont PJ, Fairburn CG, Griffiths R, Butow P, Russell J, Schotte DE, Gertler R, Basten C.
Yale Center of Eating and Weight Disorders, Department of Psychology, Yale University, New Haven, Connecticut.

OBJECTIVE: The clinical effectiveness of group and individual cognitive-behavioral therapy (CBT) for bulimia nervosa (BN) was compared. METHOD: Sixty BN patients from hospitals and general practitioners in Sydney, Australia, were allocated randomly to group or individual CBT. Forty-four completed treatment (n = 22 in group CBT and n = 22 in individual CBT). Patients were assessed at pretreatment, posttreatment, and at 3 and 6 months follow-up with the Eating Disorder Examination-12 and self-report questionnaires examining weight and shape attitudes (Eating Disorder Inventory-2), social adjustment (Socail Adjustment Scale-Modified), self-esteem (Rosenberg Self-Esteem Scale), and general psychopathology (Symptom Checklist 90R). RESULTS: The effects of group and individual CBT were equivalent on most measures. However, a significantly greater proportion of individual CBT patients than group CBT patients were abstinent from bulimic behaviors at posttreatment, but not at follow-up. DISCUSSION: This has implications for the delivery of cost-effective and clinically effective treatment for BN. Copyright 2003 by Wiley Periodicals, Inc. Int J Eat Disord 33: 241-254, 2003.

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Cochrane Database Syst Rev 2003;(1):CD000562
Psychotherapy for bulimia nervosa and binging.
Hay PJ, Bacaltchuk J.
Psychiatry, The University of Adelaide, Royal Adelaide Hospital, Adelaide, SA, Australia. phillipa.hay@adelaide.edu.au

BACKGROUND: Bulimia nervosa and like syndromes, such as binge eating disorder, are common in young Western women. A specific manual based psychotherapy, cognitive behaviour therapy (CBT) has been developed for the treatment of bulimia nervosa (CBT-BN). Other psychotherapies, some from a different theoretical framework, and some modifications of CBT are also used. OBJECTIVES: To evaluate the efficacy of psychotherapeutic treatments for those with binge eating syndromes, that have been tested in randomised controlled trials. The efficacy of CBT in the specific treatment of bulimia nervosa and binge eating disorder was evaluated. CBT therapy was compared with waiting list or a non-treatment group, any other psychotherapy, CBT in a "pure self-help" form and CBT augmented by exposure and response therapy. In addition, the review aimed to evaluate the evidence for the efficacy of other psychotherapies when compared to a no treatment control group and to evaluate the evidence for the efficacy of other psychotherapies when compared to a 'placebo' therapy. SEARCH STRATEGY: A handsearch of The International Journal of Eating Disorders since its first issue; database searches of MEDLINE, EXTRAMED, EMBASE, PSYCHLIT, CURRENT CONTENTS, LILACS, SCISEARCH, The Cochrane Collaboration Controlled Trials Register and the Cochrane Depression, Anxiety and Neurosis Controlled Trials Register; citation list searching and personal approaches to authors were used. SELECTION CRITERIA: All studies that have tested any form of psychotherapy for adult patients with non-purging bulimia nervosa, binge eating disorder and/or EDNOS of a bulimic type, and which have applied a randomised controlled and standardized outcome methodology, were sought for the purpose of this review. DATA COLLECTION AND ANALYSIS: Data were entered into a spreadsheet programme, and into the REVMAN analysis program. Relative risk analyses were conducted of binary outcome data. The relative risk analysis was used rather than the odds ratio as the outcome measures proposed were not measuring a rare event (such as death) and the total number of studies was small. Standardized mean difference analyses were conducted of continuous variable outcome data, as the continuous outcome measures were not consistent across studies. Sensitivity analyses were conducted of a number of measures of trial quality. Data were not reported in such a way to permit subgroup analyses, but the effects of treatment on depressive symptoms, psychosocial and/or interpersonal functioning, general psychiatric symptoms and weight were examined where possible. Chi-square tests for homogeneity were done, at 5% level of significance, using a fixed effects model. Funnel plots to evaluate presence of publication bias were completed and are available in a text file upon request. MAIN RESULTS: To date, more than 1365 trials have been generated by searching and over 100 trials have been evaluated in detail. Because of a relatively high number of original exclusions (n=12) the trial inclusion criteria were broadened to include those with non-blinded outcome assessment, providing 34 trials for analyses. Because of incomplete published and available data, at best up to 12 studies had data available for any single analysis. The maximum number of total patients included in a single analysis was 602. The majority of studies evaluated patients with bulimia nervosa of a purging type. The review supported the efficacy of cognitive-behavioural psychotherapy (CBT) and particularly CBT-BN in the treatment of people with bulimia nervosa and also (but less strongly due to the small number of trials) like eating disorder syndromes. CBT had been used with efficacy in group settings. Other psychotherapies were also efficacious, particularly interpersonal psychotherapy in the longer-term. Self-help approaches that used highly structured CBT treatment manuals, were promising albeit with more modest results generally, and their evaluation in bulimia nervosa approach merits further research. Exposure and response prevention did not appear to enhance the efficacy of CBT. Psychotherapy alone is unlikely to reduce or change body weight in people with bulimia nervosa or similar eating disorders. REVIEWER'S CONCLUSIONS: There was a small body of evidence for the efficacy of cognitive-behaviour therapy in bulimia nervosa and similar syndromes, but the quality of trials was very variable (e.g. the majority were not blinded) and sample sizes were often small in comparison to pharmacotherapy trials. More trials are needed, particularly for binge eating disorder and other EDNOS syndromes, and trials evaluating other psychotherapies and less intensive psychotherapies.

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Expert Opin Investig Drugs 2003 Mar;12(3):491-9
Investigational drugs for eating disorders.
Crow S, Brown E.
Department of Psychiatry, University of Minnesota Medical School, F282/2A West, 2450 Riverside Avenue, Minneapolis, Minnesota 55454, USA. crowx002@umn.edu

The eating disorders anorexia nervosa, bulimia nervosa and binge eating disorder are common, significant public health problems which are treated with nutritional, psychotherapeutic and pharmacological interventions. A number of drugs (mostly antidepressant drugs) are currently used in their treatment to some benefit, but there is substantial room for improvement. A wide variety of compounds are listed as under investigation for the treatment of eating disorders. They have a diverse variety of mechanisms of action, reflecting the complex nature of the control of food intake. While none of these compounds are close to release at present, the diversity of mechanisms under study lend some optimism that more effective approaches will be identified.

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J Clin Psychiatry 2002 Nov;63(11):1028-33
A placebo-controlled, randomized trial of fluoxetine in the treatment of binge-eating disorder.
Arnold LM, McElroy SL, Hudson JI, Welge JA, Bennett AJ, Keck PE.
Women's Health Research Program, Department of Psychiatry, University of Cincinnati Medical Center, Cincinnati, Ohio, USA. Lesley.Arnold@uc.edu

BACKGROUND: The purpose of this study was to assess the efficacy and safety of fluoxetine in the treatment of binge-eating disorder. METHOD: Sixty outpatients with a DSM-IV diagnosis of binge-eating disorder were randomly assigned to receive either fluoxetine, 20 to 80 mg/day (N = 30), or placebo (N = 30) in a 6-week, double-blind, flexible-dose study. The primary measure of efficacy was frequency of binge eating. Secondary measures included body mass index, weight, Clinical Global Impressions-Severity of Illness score, Hamilton Rating Scale for Depression (HAM-D) score, and response categories. The outcome measures were analyzed using 2 random regression methods, a time trend analysis (primary analysis) and an endpoint analysis. In addition, response categories were analyzed using an exact trend test. RESULTS: Compared with placebo-treated subjects, subjects receiving fluoxetine (mean +/- SD endpoint dose = 71.3 +/- 11.4 mg/day) had a significantly greater reduction in frequency of binge eating (p =.033), body mass index (p <.0001), weight (p =.001), and severity of illness (p =.032) and a marginally significant reduction in HAM-D scores (p =.061). Differences between groups on response categories were not statistically significant. CONCLUSION: In a 6-week, placebo-controlled, flexible-dose trial, fluoxetine was efficacious in reducing binge-eating frequency, weight, and severity of illness and was generally well tolerated in subjects with binge-eating disorder.

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Psychopharmacol Bull 2002 Spring;36(2):88-104
How useful are pharmacological treatments in eating disorders?
Casper RC.
Department of Psychiatry, Stanford University Medical School, 401 Quarry Road, Stanford, CA 94305, USA. rcasper@stanford.edu

The eating disorders anorexia nervosa (AN) and bulimia nervosa (BN) are multifactorial syndromes of unknown origin which occur typically in female adolescents or young women. Nowadays, AN and BN are most often triggered by dietary restriction. Both are treatable conditions. As in other psychiatric disorders, a lower comorbidity, a shorter duration of illness, less familial psychopathology, and, in AN, a higher minimal weight have been shown to be associated with a better outcome. So far, no abnormalities specific to AN or BN that would shed light on their etiology have been identified. Controlled and uncontrolled studies testing antipsychotic, antidepressant, weight-promoting, and prokinetic drugs have demonstrated that the core symptoms of AN are refractory to currently available psychotropic medication. For relapse prevention, however, antidepressant medication may be useful. Renutrition, psychotherapy, and family therapy remain the cornerstones of treatment for AN. Placebo-controlled studies with antidepressant drugs have been far more promising for treating BN in the short term. Recent studies have found that lasting symptomatic improvement and remission require the addition of psychological treatments in the form of cognitive and interpersonal psychotherapy. The steady stream of newly identified peptides and other molecules involved in appetite and body weight control may ultimately provide cues to better targeted treatments of eating disorders.

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Int J Eat Disord 2002 Nov;32(3):271-81
A randomized secondary treatment study of women with bulimia nervosa who fail to respond to CBT.
Mitchell JE, Halmi K, Wilson GT, Agras WS, Kraemer H, Crow S.
Neuropsychiatric Research Institute and the Department of Neurosciences, University of North Dakota School of Medicine and Health Sciences, Fargo, North Dakota, USA. mitchell@mail.med.und.nodak.edu

OBJECTIVE: Since the description of bulimia nervosa as a distinct diagnostic entity in 1979, several psychological and pharmacological interventions have been developed and empirically tested. The existence of several effective treatments, none of which is completely effective, is common to most psychiatric conditions. The research question that flows from such findings is whether second-level treatments would be effective for those who fail initial treatment. METHOD: In the case of bulimia nervosa, the research findings suggest that cognitive behavioral therapy (CBT) is the first level of treatment and that both antidepressant medication and interpersonal psychotherapy (IPT) may potentially be effective second-level treatments. This was a multicenter study in which 194 patients were initially treated with CBT. Those treated unsuccessfully (n = 62) were then randomized to treatment with IPT or medication management. RESULTS: Of those assigned to secondary treatment, 37 completed such treatment and 25 dropped out or were withdrawn. The abstinence rate for subjects assigned to treatment with IPT was 16% and for those assigned to medication management was 10%. No significant differences were found between medication and IPT in either the intent-to-treat or completer analysis. DISCUSSION: Dropout rates were high, and response rates were low among BN patients assigned to secondary treatments who failed to achieve remission with CBT. Offering lengthy sequential treatments appears to have little value, and alternative models for therapy need to be tested. Copyright 2002 by Wiley Periodicals, Inc.

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Altern Med Rev 2002 Jun;7(3):184-202
Eating disorders: a review of the literature with emphasis on medical complications and clinical nutrition.
Patrick L.

Eating disorders, including anorexia nervosa, bulimia nervosa, binge-eating disorder, and atypical eating disorder (eating disorder not otherwise specified or NOS), are estimated to occur in 5-10 million young and adult women and one million males in the United States. The etiology of eating disorders is complex and appears to include predisposing genetic factors and serotonin dysregulation, as well as psychological factors that include a history of trauma and childhood sexual abuse. Both anorexia nervosa and bulimia nervosa are medical conditions complicated by multiple neuroendocrine dysfunctions, nutritional deficiencies, and psychiatric diagnoses. Medical complications, specific nutritional deficiencies, and research involving the therapeutic use of inositol and zinc are reviewed.

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Am J Psychiatry 2002 Jan;159(1):96-102
A placebo-controlled study of fluoxetine in continued treatment of bulimia nervosa after successful acute fluoxetine treatment.
Romano SJ, Halmi KA, Sarkar NP, Koke SC, Lee JS.
Pfizer Inc. New York, USA.

OBJECTIVE: The efficacy of fluoxetine in the acute management of bulimia nervosa is well established; however, few controlled studies have examined whether continuation of pharmacotherapy provides protection from relapse. This study compared the efficacy and safety of treatment with fluoxetine versus placebo in preventing relapse of bulimia nervosa during a 52-week period after successful acute fluoxetine therapy. METHOD: Patients who met DSM-IV criteria for bulimia nervosa, purging type, were assigned to single-blind treatment with 60 mg/day of fluoxetine. After 8 weeks of treatment, patients were considered responders if they experienced a decrease > or =50% from baseline in the frequency of vomiting episodes during 1 of the 2 preceding weeks. Responders were randomly assigned to receive 60 mg/day of fluoxetine or placebo and were monitored for relapse for up to 52 weeks. Patients met relapse criteria if they experienced a return to the baseline vomiting frequency that persisted for 2 consecutive weeks. RESULTS: Of the 232 patients who entered the acute phase, 150 patients (65%) met response criteria and were randomly assigned to receive fluoxetine (N=76) or placebo (N=74). Fluoxetine-treated patients exhibited a longer time to relapse than placebo-treated patients. Quantitative analysis of other efficacy measures, including frequency of vomiting episodes, frequency of binge eating episodes, Clinical Global Impression severity and improvement scores, the patient's global impression score, and Yale-Brown-Cornell Eating Disorder Scale score, indicated that the efficacy of fluoxetine treatment was statistically superior, compared to placebo. There were no clinically relevant differences in safety between groups. Attrition in this study was high, especially in the first 3 months after random assignment to treatment groups. CONCLUSIONS: Continued treatment with fluoxetine in patients with bulimia nervosa who responded to acute treatment with fluoxetine improved outcome and decreased the likelihood of relapse.

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Int J Group Psychother 2002 Jan;52(1):1-26
Integrative time-limited group therapy for bulimia nervosa.
Riess H.
Eating Disorders Unit, Massachusetts General Hospital, Harvard Medical School, USA. Hriess@Partners.org

This article presents an integrative group therapy model for the treatment of bulimia nervosa (BN) and describes the 12-session format, incorporating components of cognitive-behavioral therapy (CBT), psychoeducation, interpersonal therapy (IPT), and relational therapy (RT), in detail. Previous reports have found CBT, IPT, and RT to be effective approaches for BN when used separately. The integrative approach may have the advantage of achieving symptom reduction by two different mediating mechanisms, those that directly affect eating behaviors and those that address the interpersonal and relational context in which the disordered eating has developed. The group approach makes use of the peer group in providing new opportunities for self-exploration and self-correction. One advantage of an integrative model is patients' exposure to several different treatment modalities from which they can identify specific approaches that are most helpful to their recovery. This identification is valuable in directing future treatment, if needed. Pilot data for this approach are presented.

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Tidsskr Nor Laegeforen 2002 Jan 30;122(3):260-5
[Treatment of bulimia nervosa—results from Modum Bads Nervesanatorium]
[Article in Norwegian]
Ro O, Martinsen EW, Rosenvinge JH.
Institutt for psykologi Universitetet i Tromso Asgardsveien 9 9037 Tromso. oyvind.roe@modum-bad.no

BACKGROUND: Hospital admission for bulimia nervosa is rather uncommon, but may be indicated in cases of psychiatric comorbidity, long duration of treatment and previous treatment failures. We describe a multicomponent inpatient treatment programme consisting of cognitive-behavioural group and individual therapy, physical training and steps to normalize eating patterns. MATERIALS AND METHODS: All 47 patients treated between 1998 and 2000 were studied. Patients were interviewed and completed self-report instruments at admission and discharge. RESULTS: At discharge, a significant improvement with respect to bulimic as well as general psychiatric symptoms had occurred. INTERPRETATIONS: The results may indicate that improvement occurs even for severe bulimia with personality disorders, and that hospital treatment may be needed to accomplish this kind of change. Follow-up studies are necessary in order to corroborate these findings.

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J Psychosoc Nurs Ment Health Serv 2002 Feb;40(2):22-31
Effective management of adolescents with anorexia and bulimia.
Muscari M.
University of Scranton, Scranton, Pennsylvania, USA. maryswrite@aol.com

1. Anorexia and bulimia are common among adolescents, and both are complex, chronic disorders with high comorbidity and significant complications and mortality. 2. Eating disorders cultivate shame, denial, and lack of insight, making treatment difficult and necessitating careful development of a therapeutic alliance. 3. Treatment goals are to correct the biological and psychological sequelae, prevent or correct complications, restore normal eating patterns, reduce binging and purging, promote understanding and change in dysfunctional behaviors and attitudes, improve intrapersonal and interpersonal functioning, restore normal exercise patterns, and address comorbid psychopathology and psychological conflicts.

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Med Sci Sports Exerc 2002 Feb;34(2):190-5
The effect of exercise, cognitive therapy, and nutritional counseling in treating bulimia nervosa.
Sundgot-Borgen J, Rosenvinge JH, Bahr R, Schneider LS.
The Norwegian University of Sport and Physical Education, Oslo, Norway. jorunn@nih.no

OBJECTIVE: The aim of this treatment study on bulimia nervosa was (i) to examine the effect of physical exercise as an experimental treatment condition against the well-documented effect of cognitive-behavioral therapy (CBT), and (ii) to compare the effect of CBT versus the effect of nutritional advice as one single treatment component of CBT. METHOD: Normal weight female bulimic patients aged 18-29 yr were randomly assigned to a physical exercise program (N = 15), CBT (N = 16), nutritional advice (N = 17), or a waiting list control group (N = 16). Seventeen healthy female control subjects were also included. Treatment effects were determined by the frequency of binge eating and purging, scores on the Eating Disorder Inventory subscales "Drive for thinness," "Bulimia," and "Body dissatisfaction" and by a clinical interview to measure symptom severity. Assessments were made before and after treatment and at 6- and 18-month follow-up after the end of treatment. RESULTS: Nutritional counseling did not prove more effective than CBT. Physical exercise appeared more effective than CBT in reducing pursuit of thinness; change in body composition; aerobic fitness; and frequency of bingeing, purging, and laxative abuse. CONCLUSION: Physical exercise is important in the treatment of normal weight bulimic patients. Further studies should address possible additive effects of CBT and physical exercise.

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Int J Eat Disord 2002 Mar;31(2):151-8
Long-term impact of treatment in women diagnosed with bulimia nervosa.
Keel PK, Mitchell JE, Davis TL, Crow SJ.
Department of Psychology, Harvard University, Cambridge, Massachusetts 02138, USA. pkeel@wjh.harvard.edu

OBJECTIVE: Both cognitive-behavioral therapy (CBT) and antidepressant medication have demonstrated efficacy in the treatment of bulimia nervosa. However, data concerning the long-term impact of such treatments have been limited. This study sought to determine if treatment with CBT and antidepressant medication was associated with better long-term outcome among women diagnosed with bulimia nervosa. METHOD: Women (N = 101) who completed a controlled treatment study of bulimia nervosa participated in follow-up assessments approximately 10 years later. RESULTS: Women who received treatment with CBT or antidepressant medication or both reported improved social adjustment at long-term follow-up compared with women randomized to the placebo condition. DISCUSSION: Treatments with demonstrated efficacy for short-term outcome appear to improve psychosocial function at long-term follow-up among women initially diagnosed with bulimia nervosa. Copyright 2002 by Wiley Periodicals, Inc.

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J Consult Clin Psychol 2002 Apr;70(2):267-74
Cognitive-behavioral therapy for bulimia nervosa: time course and mechanisms of change.
Wilson GT, Fairburn CC, Agras WS, Walsh BT, Kraemer H.
Graduate School of Professional and Applied Psychology, Rutgers, The State University of New Jersey, Piscataway 08854, USA. tewilson@rci.rutgers.edu

Cognitive-behavioral therapy (CBT) is an effective treatment of bulimia nervosa, but its mechanisms of action have not been established. In this study the authors analyzed the results of a randomized control trial comparing CBT with Interpersonal Psychotherapy (IPT) to identify possible mediators of change of CBT for BN and its time course of action. Reduction in dietary restraint as early as Week 4 mediated posttreatment improvement in both binge eating and vomiting. Measures of self-efficacy concerning eating behavior, negative affect, and body shape and weight at midtreatment were also significantly associated with posttreatment outcome at 20 weeks. No evidence was found that the therapeutic alliance mediated treatment outcome. CBT had a significantly more rapid treatment effect than IPT, with 62% of posttreatment improvement evident by Week 6.

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Can J Psychiatry 2002 Apr;47(3):227-34
Pharmacologic treatment of eating disorders.
Zhu AJ, Walsh BT.
Department of Psychiatry, College of Physicians and Surgeons of Columbia University, 1051 Riverside Drive, Unit 98, New York, NY 10032, USA.

OBJECTIVE: Eating disorders are a serious group of conditions that affect 3% of women in industrialized nations over their lifetimes. Recent years have seen considerable progress in the treatment of these disorders. This article reviews the current body of evidence for the pharmacologic treatment of eating disorders. METHODS: We undertook a literature review. RESULTS: For patients with anorexia nervosa (AN), drug trials have been disappointing. In contrast, numerous studies have demonstrated a clear role for antidepressants in the treatment of bulimia nervosa (BN). Pharmacologic investigations of binge eating disorder (BED), a more recently defined entity, have identified several promising drugs. There is also support for the utility of combined medication and psychotherapy. CONCLUSION: Continued research efforts are necessary, particularly regarding the long-term effects of therapy and the development of new pharmacologic strategies.

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Proc Natl Acad Sci U S A 2002 Jul 9;99(14):9486-91
Randomized controlled trial of a treatment for anorexia and bulimia nervosa.
Bergh C, Brodin U, Lindberg G, Sodersten P.
Section of Applied Neuroendocrinology and Center for Eating Disorders, Karolinska Institutet, Novum, S-141 57 Huddinge, Sweden. cecelia.bergh@neurotec.ki.se

Evidence for the effectiveness of existing treatments of patients with eating disorders is weak. Here we describe and evaluate a method of treatment in a randomized controlled trial. Sixteen patients, randomly selected out of a group composed of 19 patients with anorexia nervosa and 13 with bulimia nervosa, were trained to eat and recognize satiety by using computer support. They rested in a warm room after eating, and their physical activity was restricted. The patients in the control group (n = 16) received no treatment. Remission was defined by normal body weight (anorexia), cessation of binge eating and purging (bulimia), a normal psychiatric profile, normal laboratory test values, normal eating behavior, and resumption of social activities. Fourteen patients went into remission after a median of 14.4 months (range 4.9-26.5) of treatment, but only one patient went into remission while waiting for treatment (P = 0.0057). Relapse is considered a major problem in patients who have been treated to remission. We therefore report results on a total of 168 patients who have entered our treatment program. The estimated rate of remission was 75%, and estimated time to remission was 14.7 months (quartile range 9.6 > or = 32). Six patients (7%) of 83 who were treated to remission relapsed, but the others (93%) have remained in remission for 12 months (quartile range 6-36). Because the risk of relapse is maximal in the first year after remission, we suggest that most patients treated with this method recover.

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Harv Rev Psychiatry 2002 Jul-Aug;10(4):193-211
A multidimensional meta-analysis of pharmacotherapy for bulimia nervosa: summarizing the range of outcomes in controlled clinical trials.
Nakash-Eisikovits O, Dierberger A, Westen D.
Department of Psychology and Center for Anxiety and Related Disorders, Boston University, Boston, MA 02215, USA.

The empirical literature on pharmacotherapy for bulimia nervosa reveals mixed results. We examined the results of controlled clinical trials of pharmacotherapies for bulimia published from 1980 to 1999. To do this, we employed a multidimensional meta-analysis, a method for aggregating a range of clinically meaningful indicators of outcome (including but not limited to effect-size estimates) across studies. We found that pharmacotherapy for bulimia yields a moderate initial effect. However, only a small minority of patients recover, and the average patient continues to meet full DSM-IV criteria for the disorder. Combined pharmacotherapy and short-term psychotherapy appears to produce better results, although most patients continue to show symptoms at termination, and few data are available on sustained recovery over time. In accordance with recent calls in the medical literature for standardization of reporting practices in clinical trials, we suggest that investigators and meta-analysts report a range of indices that bear on efficacy and generalizability to clinical practice. These include exclusion rates and reasons for exclusion, percentage recovered, percentage improved, percentage remaining improved or recovered at follow-up, and percentage seeking additional treatment at follow-up, as well as outcome data for both completer and intent-to-treat samples.

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Child Adolesc Psychiatr Clin N Am 2002 Apr;11(2):343-64
Art therapy, psychodrama, and verbal therapy. An integrative model of group therapy in the treatment of adolescents with anorexia nervosa and bulimia nervosa.
Diamond-Raab L, Orrell-Valente JK.
Department of Psychiatry and Behavioral Sciences, Children's National Medical Center, 111 Michigan Avenue Northwest, Washington, DC 20010, USA. lraab@cnmc.org

Anorexia nervosa and bulimia nervosa typically afflict individuals in adolescence. Given the intractability of these diseases in combination with the natural recalcitrance of adolescence, treatment with this population presents a daunting challenge. Traditional group therapy that focuses on verbal therapy is often not effective with this population, particularly in the acute stages of the diseases. A group therapy approach that integrates art therapy, psychodrama, and verbal therapy offers an innovative alternative to traditional group therapy.

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Child Adolesc Psychiatr Clin N Am 2002 Apr;11(2):279-309
Inpatient and partial hospital treatment for adolescent eating disorders.
Anzai N, Lindsey-Dudley K, Bidwell RJ.
Kapi'olani Counseling Center, 1441 Kapiolani Blvd, Suite 1800, Honolulu, HI 96814, USA. NealA@kapiolani.org

The eating disorders are complex illnesses that tend to have a chronic relapsing course with severe morbidity and high mortality rates. Outcome seems to be best when the disorders are recognized early, brought to treatment quickly, the family is involved, and the first episode of care results in full return and maintenance of weight and menstruation. Adolescents who reach the point of needing hospitalization should be treated aggressively. In this article the authors have tried to outline some key treatment principles not just for the hospital stay, but elements that should be carried throughout the entire program of recovery for adolescents with eating disorders: from medical evaluation, through inpatient stay, partial hospitalization, intensive outpatient program, and follow-up outpatient therapy. Recent reductions in insurance authorizations and decreased lengths of stay in the psychiatric hospital make the already difficult challenge of recovery from AN and BN even more daunting. Despite these difficulties, we are still able to get a high proportion of youths better and eventually fully recovered.

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