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

4 New Insights into the Prevention and Treatment of Bulimia Nervosa

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 developed for the treatment of depression and originates from theories in which interpersonal functioning is recognised to be a critical component of psychological wellbeing. The work of 1930's psychiatrist Harry Sullivan first suggested that patients' mental health was related to their interpersonal contact with others. Challenging Freud's psychosexual theory, Sullivan emphasized the role of interpersonal relations, society and culture as the primary determinants of mental health (Sullivan, 1968). Sullivan's work was further developed by Gerald Klerman and Myrna Weissman in the 1980's, who studied depression treatments using the interpersonal approach. Whilst studying the efficacy of antidepressants, alone or paired with psychotherapy, it was found that 'high contact' counselling was effective, leading to the further development of the therapy which was renamed interpersonal psychotherapy (Klerman et al, 1984). These positive results led to the inclusion of IPT in the NIMH Treatment of Depression Collaborative Research Program, which compared this therapy with antidepressants, placebo and Cognitive Behavioural Therapy (CBT) for depression (Elkin et al., 1989). As a part of this study the original IPT manual, Interpersonal Psychotherapy for Depression, was published as a manual for the research project (Klerman et al, 1984). Patients in all conditions showed significant reduction in depressive symptoms and improvement in functioning, those having the antidepressant Imipramine plus clinical management generally doing best, the two psychotherapies second best, and placebo plus clinical management worst.

Since then, there have been several systematic reviews of studies investigating the efficacy of IPT for depression (Jarrett & Rush, 1994; Klerman, 1994; Feijo de Mello et al., 2005). They concluded that IPT was superior to placebo in nine of thirteen studies and better than CBT overall. However IPT plus medication was no more effective than medication alone. The researchers also found that several factors were associated with good therapy outcome, including the ability to engage in more than one perspective and to take responsibility for actions, empathy for others, a desire to change, good communication skills, and a sense of

Feske et al (1998) examined predictors of outcome in 134 female patients with major depression, and found that those who did not improve experienced higher levels of anxiety and were also more likely to meet diagnostic criteria for panic disorder. In addition, they found that poor outcome was associated with greater vocational impairment, longer duration of episode, more severe illness, and surprisingly, lower levels of social impairment. Other authors have found that despite comparable efficacy between IPT and CBT, IPT was more affected by personality traits and therefore less suitable for those with personality

(IPT) was considered as a treatment of this disorder.

**3. The development of Interpersonal Psychotherapy (IPT)** 

There was no significant difference between the two psychotherapies.

cooperation and willingness to engage with the therapist.

disorders (Joyce et al. 2007).

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

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.

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