**1. Introduction**

The term 'interpersonal' encompasses not only the patterns of interaction between the individual and significant others, but also the process by which these interactions are internalised and form part of the self-image (Sullivan, 1953). Interpersonal functioning is considered crucial to good mental health. According to Klinger (1977), when people are asked what makes their lives meaningful, most will mention their close relationships with others. Being involved in secure and fulfilling relationships is perceived by most individuals as critical to wellbeing and happiness (Berscheid & Peplau, 1983).

Maladaptive interpersonal functioning is considered central to several psychiatric disorders, such as depression (e.g. Petty, et al, 2004), anxiety (e.g. Montgomery et al, 1991), schizophrenia (e.g. Sullivan & Allen, 1999) and autistic spectrum disorders (e.g. Travis & Sigman, 1998). Interpersonal skill deficits may cause vulnerability to developing mental health problems and may also play a role in maintaining it. This is the chicken and egg question: are interpersonal problems vulnerability factors for the development of a psychiatric disorder or are they the result of this disorder?

## **2. Interpersonal problems and eating disorders**

Considering that unhealthy interpersonal functioning is central to several mental health problems, it is not surprising that evidence suggests this is also the case in eating disorders. Walsh et al (1985) demonstrated a high frequency of affective disorder, particularly major depression, among patients with bulimia nervosa (BN), which may explain the strong correlation found between this disorder (BN) and interpersonal problems (Hopwood et al, 2007). Research in this area have found that people suffering from BN were more likely to display domineering, vindictive, cold, socially avoidant, non-assertive, exploitable, overly nurturing, or intrusive characteristics than non-BN (Hopwood et al, 2007).

Social support and social networks have also been studied in people with BN. Grisset and Norvell (1992) found that people with BN reported receiving less emotional and practical support from friends and family. They argue that this inadequate support creates a

Interpersonal Problems in People with Bulimia Nervosa and the Role of Interpersonal Psychotherapy 5

Since the conception of IPT, the original manual has been updated (Weissman et al, 2000; Weissman et al, 2007) and several manuals have been written concerning modifications of IPT, including those for depressed adolescents (Mufson et al, 2004), the elderly (Hinrichsen & Clougherty, 2006), perinatal women (Weissman et al, 2000), HIV patients (Pergami et al 1999), bipolar disorder (Frank, 2005), social phobia (Hoffart et al., 2007), dysthymic disorder

IPT-BN was not developed systematically through an adaptation from IPT for depression, but instead was discovered to be effective when used as a control treatment for CBT during a randomised controlled trial for individuals with BN (Fairburn et al., 1991). IPT was not adapted specifically for BN in the treatment trial, and beyond limited initial psychoeducation, eating problems were not addressed during the treatment. It was hypothesised that as IPT shared some non-specific factors with CBT, its inclusion in the trial would highlight the benefits of cognitive behavioural techniques in CBT that were not present in IPT. However, while CBT was considered most effective, IPT also resulted in the improvement of eating disorder symptoms. This discovery led to the further development of IPT-BN as a viable treatment option, and it was manualised in 1993 (Fairburn, 1993). Since its conception, IPT has been compared to CBT, the current treatment of choice, with equally positive results in both individual and group settings (Fairburn, 1997; Fairburn et al, 1993; Fairburn et al., 1991; Fairburn et al, 2000; Roth & Ross, 1988; Wilfley et al., 2003; Wilfley et al., 1993). Agras et al (2000) found that CBT was superior to IPT at the end of treatment however there was no significant difference between the two treatments at one year follow-up. Based on these findings, the NICE guidelines for eating disorders in the UK (NICE, 2004) recommends IPT as an alternative to CBT for the treatment of BN but patients

should be informed that it could take longer that CBT to achieve comparable results.

lives and therefore may lessen their need to control their eating, weight and shape.

chapter to differentiate it from the IPT-BN developed by Fairburn.

**5. Modification of IPT-BN** 

The efficacy of IPT in patients with BN has been explained by Fairburn (1997). He claimed that IPT might work through several mechanisms. Firstly, IPT helps patients to overcome well established interpersonal difficulties, for example when focusing on interpersonal 'role transitions' this can be helpful for those patients who have missed out on the interpersonal challenges of early adulthood as a result of their eating disorder. Secondly, IPT can open up new interpersonal opportunities and as a result patients learn to rely more on interpersonal functioning for self evaluation instead of focusing wholly on eating, weight and shape. Finally, IPT gives patients a sense that they are capable of influencing their interpersonal

The IPT Team in Leicester (UK) adapted IPT-BN further by bringing back the original components of IPT (psycho-education, directive techniques, problem solving, modelling, role play and symptom review) and modifying the treatment for individual with BN where the eating disorders problems are taken into consideration. Although they have been using this model of treatment for BN for more than 15 years, only recently they have manualised it (Whight et al, 2010). This new modified version of IPT for BN is called IPT-BNm in this

IPT-BNm uses a time frame of 12-20 weekly sessions. The usual number of sessions is 16, which roughly breaks down into three areas: 4 assessment sessions, 10 middle sessions and 2 termination sessions. There is also a pre-treatment session (Session 0) where the patient

**4. The development of IPT for Bulimia Nervosa** 

(Markowitz, 1998) and finally bulimia nervosa (IPT-BN; Fairburn, 1993).

vulnerability towards developing eating disorder symptoms as a coping mechanism. Eating disordered individuals are also less likely to utilise support from others, particularly due to a negative attitude towards emotional expression (Meyer et al 2010). In terms of relationship satisfaction, women with eating problems report more discomfort with closeness and have been described to fear intimacy with a partner (Evans & Wertheim, 1998; Pruitt et al, 1992). Therefore in view of the correlation between interpersonal problems and BN, it is not surprising that a specific therapy aimed at helping patients with interpersonal problems (IPT) was considered as a treatment of this disorder.
