Evaluation of manual-based cognitive-behavioral therapy for bulimia nervosa in a service setting

Behaviour Research and Therapy 39 (2001) 299–308www.elsevier.com/locate/brat

Shorter Communication

Evaluation of manual-based cognitive-behavioral therapy forbulimia nervosa in a service setting

Brunna Tuschen-Caffier a,*, Martin Pook a, Monika Frank b

a Department of Psychology, Philipps University, Gutenbergstrasse 18, 35032, Marburg, Germanyb Christoph Dornier Foundation for Clinical Psychology, Ernst-Giller-Strasse 20, 35039, Marburg, Germany

Received 29 September 1999

Abstract

In the present study manual-based cognitive-behavioral therapy for bulimia nervosa was evaluated onan unselected sample of an out-patient service facility. A total of 73 female patients who asked for treatmentreceived the primary diagnosis of bulimia nervosa. Of these, 67 took up treatment. Treatment was completedby 66 patients. Outcome variables were the number of binge episodes along with questionnaire scores forrestraint eating, emotional eating, body dissatisfaction and depressiveness. At the end of treatment and 1year after the end of treatment significant improvements were found in all outcome variables. Effect sizesfor outcome variables were within the range of those of controlled research. Therefore, the present studydelivered empirical evidence that manual-based cognitive-behavioral therapy is an effective treatment forbulimia nervosa not only within the restricted area of research. 2001 Elsevier Science Ltd. All rightsreserved.

1. Introduction

Many studies employing randomized controlled design have demonstrated that cognitivebehavior therapy is effective in the treatment of bulimia nervosa (cf. Wilson & Fairburn, 1998,for a detailed review). Evaluated treatment components were available for core features of bulimianervosa such as binge eating, negative body attitudes, dietary-restraint and mood-related eatingbehavior as well as for related non-specific features like depressive mood. These componentswere described in several manuals (e.g. Fairburn, Marcus & Wilson, 1993) so that they could beapplied in clinical practice.

There is no doubt that controlled randomized studies are needed to deliver evidence for the

* Corresponding author. Tel.: +49-6421-2823656; fax: +49-6421-2828904.E-mail address: [email protected] (B. Tuschen-Caffier).

0005-7967/01/$ - see front matter 2001 Elsevier Science Ltd. All rights reserved.PII: S0 005- 796 7(00 )000 04- 8

300 B. Tuschen-Caffier et al. / Behaviour Research and Therapy 39 (2001) 299–308

efficacy of a treatment. On the other hand, it is generally a serious problem of these outcomestudies that they are unrepresentative of clinical practice (cf. Wilson, 1996). In particular, highlyhomogenous samples were studied in most of the studies in which a treatment for bulimia nervosawas evaluated. However, any selection of patients with regard to comorbidity, weight, age, etc.limits the comparability to the general population of bulimic patients. Mitchel, Hoberman, Peter-son, Mussell and Pyle (1996) pointed out further aspects that limit the generalizability of studiesnot carried out in a natural setting. For example, it remains unclear whether the study participantsrepresent treatment-seeking patients when participants are recruited through newspaper advertise-ments or by selected general practitioners. Moreover, little is known about whether patients whoshare at least some financial responsibility for their treatment are more or less motivated thanthose who do not pay any fees because of their participation in a study. In addition, not only thepatients, but also the therapists, participating in clinical studies are assumed to be different fromthose in natural settings (Mitchel et al., 1996). For instance, it might make a difference whethertherapists are especially trained for the treatment program under study or whether bulimia nervosais one among other disorders the therapists treat in their clinical routine.

For generalization of the research results it is essential to evaluate evidence-based treatmentsin different settings with heterogeneous patient groups and a variety of therapists. The bench-marking strategy described by Wade, Treat and Stuart (1998) is an excellent approach for examin-ing the generalizability of proven treatment components. Here, a manual-based treatment for panicdisorder which had been evaluated in two controlled studies was applied by several therapists tounselected patients of a community mental health center. Employing the same questionnaires asthose in the controlled research the percentages of patients that score in the normal range werecompared. The benchmarking strategy represents a standard, however, that is hard to achieve forevaluating a cognitive-behavioral therapy as it is routinely employed in a service setting. Thedifficulties become obvious in a study by Wetzel, Bents and Florin (1999). These authors evalu-ated a high-density exposure therapy for patients with obsessive-compulsive disorder that wasprovided by numerous therapists to an unselected sample of an in-patient treatment center. Intheir study, evaluation was not based on exactly the same questionnaires as in a particular studyemploying controlled design, but on questionnaires that were employed as a matter of routine inthe treatment center. As a consequence, in a naturalistic study like the one by Wetzel et al.(1999) the comparisons of effect sizes to those of controlled research are less conclusive than ina benchmarking study. Moreover, the percentage of patients willing to complete questionnairesat follow-up among the unselected patients in the study of Wetzel et al. (1999) was much smallerthan among participants of controlled trials.

Despite these difficulties, the study by Wetzel et al. (1999) revealed important informationabout the clinical utility of manual-based treatment for obsessive-compulsive disorder in a servicesetting. To our knowledge, neither a benchmarking study nor even a naturalistic study like theone by Wetzel et al. (1999) has been conducted to evaluate a manual-based treatment for bulimianervosa in an unselected sample. However, as Wilson (1999) pointed out, “manual-based cogni-tive-behavioral therapy for bulimia nervosa is ripe for similar evaluations in service settings”(p. S86).

301B. Tuschen-Caffier et al. / Behaviour Research and Therapy 39 (2001) 299–308

2. Method

2.1. Subjects

A total of 73 women asking for therapy at an out-patient treatment center received the primarydiagnosis of bulimia nervosa. The diagnosis was given on the basis of a reliable and valid struc-tured clinical interview for DSM-III-R diagnosis (Margraf, Schneider & Ehlers, 1991). Sub-sequently the 73 patients are referred to as the intent-to-treat sample. During the diagnostic phase,all but one patient also completed the questionnaires described below. Of the intent-to-treat sam-ple, six women dropped out after the diagnostic phase and before the beginning of any treatment.Four out of these six women discontinued for financial reasons. Of the 67 patients who took uptreatment, one dropped out during therapy. We will refer to the remaining 66 women as com-pleters. Those completers who filled out questionnaires six weeks (post-treatment) and 1 year(follow-up) after the end of the therapy are referred to as responders (n=45 and n=32,respectively). Telephone interviews were conducted with those patients who did not fill out post-treatment or at follow-up questionnaires. At follow-up nine patients were lost, so that not evena telephone interview could be conducted.

Completers averaged 26.1 years in age (SD=6.9), 17% were older than 30 years, 11% youngerthan 18 years. Mean duration of bulimia nervosa was 8.1 years (SD=6.6) in the completers sample.Twenty-nine percent had been suffering from bulimia for 10 years or more. Mean BMI of thecompleters was 20.2 (SD=3.4). The seven patients who were in the intent-to-treat sample but didnot start or complete treatment were not different (p�0.10) from the completers with respect toage, duration of bulimia, BMI nor any of the other variables analyzed in the following.

2.2. Treatment

Treatments were conducted by 16 therapists. All therapists worked in an out-patient clinic andfollowed a treatment manual outlining the treatment phases and the techniques to be used duringeach phase (Tuschen & Bents, 1995; Tuschen & Florin, 1992). Most of the treatment sessionswere videotaped. Standardization of therapeutic techniques was ensured by monitoring these tapesduring supervision sessions which took place at least once a week. The treatment program ischaracterized by exposure as the main therapeutic strategy and by focus on target symptoms. Allpatients were seen individually. The program started with an intensive therapeutic phase of 10–14 days during which the patients participated in therapeutic interventions for several hours (upto 8 h each day). In the early stages of treatment the therapists assisted their patients during theexposure sessions. Patients were usually able to perform certain parts of the treatment alonealready by the end of the first day. The intensive treatment phase was followed by a period of6–8 weeks of structured self-management therapy. During this phase, patients usually had contactwith their therapist once a week in personal consultation or by phone.

The treatment program consisted of the following phases: cognitive preparation, intensive treat-ment phase, and self-management.


2.2.1. Cognitive preparationSimilar to other programs (e.g. Fairburn & Cooper, 1989; Fairburn et al., 1993), therapy started

with a cognitive preparation (duration: 2–3 h) during which therapist and patient developed aplausible model for the explanation of the etiology and maintenance of bulimia nervosa. Themodel assumed that bulimic symptoms are maintained by a vicious cycle of extreme anxietyregarding body weight and shape, unhealthy strategies to reduce weight (e.g. restraint eating) andbinge eating. Furthermore, it was assumed that stressful situations may trigger binge attacks,whereas negative mood states (e.g. depression) may precede as well as follow binge eating.

2.2.2. Intensive treatment phaseSimilar to other programs (e.g. Cooper & Steere, 1993; Fairburn et al., 1993) the treatment

program consisted of nutritional management in which patients learned to develop a pattern ofregular eating. Patients were instructed to have three meals and two snacks per day. In the earlyphase of treatment, therapists accompanied their patients during the meals.

Moreover, based on the assumed vicious circle of bulimia nervosa, exposure therapy focusedon situations and behaviors that induced anxieties of gaining weight and that increased cravingfor binge food such as exposure to binge food, exposure to specific triggers of binges, as well asbody shape and weight. Therefore, patients were exposed to their binge food and were asked todescribe the taste, smell, consistency and appearance of the food. Furthermore, considerable atten-tion was paid to the simulation of natural conditions as triggers of craving and binge eating (e.g.mood induction).

Furthermore, to change negative attitudes and anxieties regarding body weight and shape,patients were exposed to body shape and weight under various conditions (e.g. when the patientswore normal clothes or tight fitting clothes, when the patients were hungry or after they had eatena rich meal). Similar to therapeutic programs for binge eaters (Rosen, Orosan & Reiter, 1995) orbody dysmorphic patients (Rosen, 1996), the body confrontation was done with a mirror whichprovided a full view of the body.

2.2.3. Self-managementThis phase followed the program outlined by Fairburn and Cooper (1989). The aim was to assist

patients in maintaining their treatment gains after therapy terminated. By phone or, if necessary, inpersonal consultation patients were encouraged to review the principles to which they had beenintroduced during treatment.

2.3. Measures

A 7-point rating scale was used to assess the subjective change in impairment due to bulimianervosa since beginning of therapy (1=very much better, 2=much better, 3=better, 4=no change,5=worse, 6=much worse, 7=very much worse). This scale was given to the completers six weeks(post-treatment) and 1 year (follow-up) after end of treatment, either in a questionnaire-batteryor during a telephone interview. Based on the assumed vicious circle of bulimia nervosa, fiveoutcome variables were defined for evaluation. The following five variables were measured atpre-treatment, post-treatment and follow-up.


2.3.1. Binge episodesA single item assessed how many binge attacks occurred during the last month.

2.3.2. Restraint eatingFor the assessment of chronic dieting behavior a German version (cf. Laessle, Tuschl, Kot-

thaus & Pirke, 1989) of the Restraint Scale (Heatherton, Herman, Polivy, Kling & McGree, 1988)was used.

2.3.3. Emotional eatingEating as reaction to negative feelings was assessed by the emotional eating scale of the FEVII

(Grunert, 1989). This is a German version of the Dutch Eating Behavior Questionnaire (van Strien,Frijters, Bergers & Defares, 1986).

2.3.4. Body dissatisfactionA German version of the Body Shape Questionnaire (Cooper, Taylor, Cooper & Fairburn, 1987)

was used for measurement of negative concerns about body shape. Although the employed Ger-man version is unpublished, it is widely used in research on eating disorders in Germany (e.g.Laessle et al., 1989).

2.3.5. DepressivenessPatients completed the German version (Hautzinger, Bailer, Worall & Keller, 1992) of the BDI

(Beck, Ward, Mendelson, Mock & Erbaugh, 1961).

2.4. Data analysis

A last-value-carried-forward procedure was used for most of the analyses. This procedure leadsto smaller differences between means but usually it artificially increases degrees of freedom. Toavoid the artificial increase, the degrees of freedom for paired t-tests were adjusted according tothe number of responders. Since 10 paired t-tests were computed, the level of significance wasadjusted to pa=0.05/10=0.005.

For computation of all effect sizes, the difference between means was divided by the standarddeviation of the intent-to-treat sample at pre-assessment. These standard deviations were the larg-est, so that their usage led to more conservative results. For computation of effect size ofresponders questionnaire data were stratified by global change scores. This led to more conserva-tive results, since return rates were smaller for patients who did not improve much according tothe rating of global change.

3. Results

Means and standard deviations for the five outcome variables are presented in Table 1. A last-value-carried-forward procedure was used to test whether the intent-to-treat-sample was improvedwith respect to all of the five outcome variables. Statistically significant improvements (p�0.005)occurred for all of the five variables at post-treatment: binge episodes (t=3.55, dfadj.=17), restraint


Table 1Outcome variables at pre-treatment, post-treatment and follow-up

Variable Pre-treatmenta Post-treatmentb Follow-upb

n M SD n M SD n M SD

Binge episodes 68 40.74 37.65 19 3.00 4.91 30 11.33 22.40Restraint eating 70 22.40 5.38 41 15.66 4.96 29 14.93 5.28Emotional eating 72 40.47 8.38 43 26.60 10.58 31 26.48 9.51Body dissatisfac. 71 122.30 31.42 43 77.58 26.94 31 72.97 25.34Depressiveness 71 20.28 9.91 45 9.41 10.11 30 10.22 9.88

a Intent-to-treat sample.b Responders.

eating (t=6.34, dfadj.=40), emotional eating (t=7.04, dfadj.=42), body shape dissatisfaction (t=6.93,dfadj.=42) and depressiveness (t=5.68, dfadj.=43). At follow-up improvements were also statisticallysignificant (p�0.001) for binge episodes (t=3.68, dfadj.=29), restraint eating (t=6.56, dfadj.=30),emotional eating (t=7.00, dfadj.=32), body shape dissatisfaction (t=7.14, dfadj.=30) and depress-iveness (t=4.07, dfadj.=30).

At post-treatment, seven out of 19 patients reported no episodes of binging while 13 out of 30did so at follow-up. These findings represent remission rates of 36.8 and 43.3%, respectively.The global ratings of change indicated that 73% of the patients felt at least “much better” post-treatment, while at follow-up 69% did so (Table 2). Finally, effect sizes were computed for theintent-to-treat sample, for completers and for responders (Table 3).

Table 2Global rating of change and response rates of completers

Rating Post-treatment assessment Follow-up assessment

All (n) Responders All (n) Responders

n % n %

1 — Very much better 21 14 66.7 20 14 70.02 — Much better 27 19 70.3 15 10 66.73 — Better 10 8 80.0 8 5 62.54 — No change 6 3 50.0 6 2 33.35 — Worse 1 1 100.06 — Much worse 2 1 50.0 1 0 0.07 — Very much worseAvailable 66 45 68.2 51 32 62.7Before follow-up assessm. 6Lost 9


Table 3Effect sizes for outcome variables at post-treatment (Post) and follow-up (FU)

Variable Intent-to-treata Completersa Respondersb

Post (n=68–72) FU (n=62–66) Post (n=62–65) FU (n=56–59) Post (n=18–44) FU (n=28–31)

Binge episodes 0.28 0.38 0.31 0.42 1.07 0.72Restraint eating 0.67 0.82 0.74 0.90 1.13 1.09Emotional eating 0.98 1.07 1.09 1.20 1.55 1.59Body dissatisfac. 0.80 0.97 0.89 1.09 1.36 1.63Depressiveness 0.64 0.48 0.71 0.62 1.01 0.87

a Last value carried forward.b Available data (questionnaire data were stratified by global change scores).

4. Discussion

After several “efficacy” studies to evaluate manual-based cognitive-behavioral therapy forbulimia nervosa have been conducted in research settings, “effectiveness” studies to examineclinical utility of these treatments in service settings are of interest (cf. Wilson, 1999). Our findingson an unselected sample of a service facility revealed statistically significant improvement in bothcore and unspecific features of bulimia nervosa. Thus, there is empirical evidence that it is possibleto treat bulimia nervosa effectively outside the restricted area of research employing manual-basedcognitive-behavioral therapy. The present study does not allow “benchmarking” comparisons (cf.Wade et al., 1998) with any particular controlled efficacy trial. However, some well-constructedquestionnaires were used as a matter of routine for quality assurance in the service unit in whichthe present study was performed. Thus, we employed a naturalistic design (e.g. Wetzel et al.,1999) to compare the changes on these questionnaire scales to changes on similar scales reportedin controlled research.

In contrast to controlled studies, little attention was initially paid to motivating patients forfollow-up assessments. As a consequence, the willingness of former patients to complete question-naires after therapy was low. This led to a low response rate at follow-up assessments. Althoughresponse rate was low, we used the usual last-value-carried-forward strategy (e.g. Foa et al., 1999)for data analysis. Thus, the effect sizes for the treatment were lowered since pre-treatment scoreshad to be used to replace the data for the many patients who missed post-treatment assessment.Telephone interviews were an essential part of the quality assurance program of the service unitin which the present study was conducted (cf. Fiegenbaum, Tuschen & Florin, 1997). A telephoneinterview was conducted with those patients who refused to complete questionnaires. Thus, aglobal rating of change is available for all patients 6 weeks after the end of therapy. In addition,almost 84% of the completers gave that rating 1 year after end of treatment. The global ratingsindicated that at the end of treatment 73% of the patients felt at least “much better” while 1 yearafter end of therapy 69% did so. Further analysis of the global ratings of change revealed thatpatients who felt less improved or unimproved were less motivated to fill-out questionnaires afterthe end of treatment. Therefore, if effect sizes were calculated in the usual manner for respondersonly, the effects would have been artificially increased. To avoid this, we stratified the available


questionnaire data by the global change scores. We think the stratified effect sizes give the bestimpression of the effectiveness of the evaluated therapy.

While the structured telephone interview was helpful for getting an impression about the globalchange of a patient, it provided no information about the number of binge episodes. Unfortunately,for several years the questionnaire battery for post treatment and follow-up also did not includean item about the number of binge episodes. Therefore, information about this aspect is onlyavailable for a small number of patients. This small number, however, still exceeds the numberof patients in controlled efficacy trials (e.g. Cooper & Steere, 1995). Therefore, it seems justifiedto compare the present findings on this aspect with results of controlled research. In their reviewon controlled research, Wilson and Fairburn (1998) summarized that after cognitive-behavioraltherapy roughly half of the patients ceased binge eating. As our data indicate, a similar result canbe reached even in a clinical facility. To judge the improvement of our patients with respect toother core features of bulimia nervosa, we compared our findings to the results of well-controlledefficacy studies in which a 12 month follow-up was performed and detailed information was givento compute relevant effect sizes. For the cognitive behavior therapy condition in the study byCooper and Steere (1995) effect sizes of d=1.50 and d=0.59 were found for two dietary restraintscales. Interestingly, in the study by Agras et al. (1994), the group receiving cognitive-behavioraltherapy did not improve on a restraint scale. However, the effect size for emotionally-driveneating was d=0.63 in that study. Cooper and Steere (1995) did not assess this aspect in theirstudy. But in contrast to Agras et al. (1994) they focused on body shape dissatisfaction. Herethe effect size for cognitive behavior therapy condition was d=1.49. Questionnaires assessingdepressiveness were also employed in both studies. For this aspect, effect sizes were d=1.72 andd=1.66 in the study by Cooper and Steere (1995) and d=0.57 in the study by Agras et al. (1994).

To summarize, the effect size for core features of bulimia nervosa as well as for related psycho-pathological features as revealed in the present study were within the range of those found incontrolled research. In addition, it should be noted that it is common practice to exclude patientsduring the course of a controlled study due to reasons such as serious depression. In the presentstudy, however, no patient was withdrawn for any reason. The effect sizes for the treatmentevaluated in the present study are even more valuable in this light. Moreover, the rate of drop-outs from our treatment is below 2%. Compared to controlled studies this drop-out rate isextremely low. These aspects indicate that manual cognitive behavior therapy is not only veryeffective in a service setting but is also highly accepted by the patients.

Finally, a shortcoming of the present study should be discussed. In the clinical facility in whichthe study was conducted no diagnostic interview to assess personality disorders (PDs) wasemployed as a matter of routine. At present, it is difficult to judge the role of PDs for treatingbulimia nervosa (cf. Wilson & Fairburn, 1998). For example, in a study by Steiger and Stotland(1996) no differences with respect to the change of symptoms during and after therapy for bulimianervosa were found between patients with borderline PD, those with a different PD and thosewithout any PD. However, in the same study significantly more patients with borderline PDdropped out before the end of treatment. We had no indication for self selection of patients whichcould have led to a systematic exclusion of any form of comorbidity from our study. Nevertheless,we would recommend that special attention be paid to the problem of comorbidity of PDs infurther studies evaluating manual-based cognitive-behavioral therapy for bulimia nervosa in ser-vice settings.


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Evaluation of manual-based cognitive-behavioral therapy for bulimia nervosa in a service setting

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