Clinical Psychology Review 32 (2012) 292300

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Clinical Psychology Review

A review of the denitions of outcome used in the treatment of bulimia nervosa

Sarah E. Williams 1, Thomas K.O. Watts 1, Tracey D. Wade
School of Psychology, Flinders University, Adelaide, South Australia, Australia

a r t i c l e

i n f o

Article history:
Received 4 October 2011
Received in revised form 15 December 2011
Accepted 30 January 2012
Available online 12 February 2012
Keywords:
Bulimia nervosa
Treatment outcome
Quality of life

a b s t r a c t
There are many terms used to describe treatment outcome for bulimia nervosa. However, the way such terms
are conceptualised across various studies differs dramatically, making comparison of outcomes difcult. A
consensus working denition of pivotal terms such as remission and recovery is important if treatments
are to be adequately evaluated and clinical meaning derived for individuals with bulimia nervosa (BN). The
central aim of the current review was to identify different denitions of remission and recovery and their
utility in terms of client outcome after treatment for BN. Seventy one unique published treatment studies
were identied that used 82 different outcome measures, of which 63 (77%) used behavioural outcomes
only, with the most commonly used outcome (n = 7 studies) being an abstinence of bingeing and vomiting
for a 4 week period. The problems with the denitions of outcomes used to date are explored, and the implications of research in anorexia nervosa for forming consensus denitions of remission and recovery for BN
will be examined. In addition, the review highlights the importance of considering the relationship between
quality of life and outcome in assessing the goodness of t of a denition of outcome.
2012 Elsevier Ltd. All rights reserved.

Contents
1.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.1.
Bulimia nervosa and eating disorder not otherwise specied (EDNOS)
1.2.
Method: literature search . . . . . . . . . . . . . . . . . . . .
2.
Treatment outcome . . . . . . . . . . . . . . . . . . . . . . . . . .
2.1.
Treatment outcome rates for bulimia nervosa and eating disorder not
2.2.
Denitions of outcome . . . . . . . . . . . . . . . . . . . . .
3.
Bulimia nervosa symptoms included in the denitions of outcome . . . .
3.1.
Behavioural symptoms . . . . . . . . . . . . . . . . . . . . .
3.2.
Cognitive and behavioural variables . . . . . . . . . . . . . . .
4.
Common methodological differences related to outcome . . . . . . . . .
5.
What can we learn from outcome research in anorexia nervosa? . . . . .
6.
Assessing the goodness of t of outcome: quality of life . . . . . . . . .
7.
Conclusions and recommendations . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1. Introduction
1.1. Bulimia nervosa and eating disorder not otherwise specied (EDNOS)
The Diagnostic and Statistical Manual of Mental Disorders (DSM,
2000) criteria for a diagnosis of bulimia nervosa (BN) include both
Corresponding author at: School of Psychology, Flinders University, PO Box 2100,
Adelaide, SA 5001, Australia. Tel.: + 61 8 8201 3736; fax: + 61 8 8201 3877.
E-mail address: tracey.wade@inders.edu.au (T.D. Wade).
1
Contributed equally to this work and are joint rst authors.
0272-7358/$ see front matter 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.cpr.2012.01.006

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behavioural and cognitive symptoms. A diagnosis is given when an

individual experiences recurrent episodes, at least twice per week
for three months, of both eating abnormally large quantities of
food over a discrete period of time while experiencing a loss of
control (objective binge eating) and engaging in inappropriate
compensatory behaviours to inhibit weight gain, including
excessive exercise, vomiting, fasting, and/or misusing medications,
laxatives, diuretics, and enemas. In addition, a diagnosis also requires
that individuals experience cognitive symptoms, including undue
inuence of body weight or shape on self-evaluation, also known
as importance of shape and weight, which has been described as

S.E. Williams et al. / Clinical Psychology Review 32 (2012) 292300

the core psychopathology of eating disorders (Cooper & Fairburn,

1993).
The most common eating disorder to present clinically is EDNOS
(Fairburn et al., 2007; Turner & Bryant-Waugh, 2004; Zimmerman,
Francione-Witt, Chelminski, Young, & Tortolani, 2008). A diagnosis of
EDNOS is given if an individual experiences some but not all of the criteria
for BN. For example, the behavioural criteria may occur less than twice
per week or the person may not experience objective binge episodes
but may engage in compensatory behaviours (DSM, 2000). Research
has demonstrated that people with EDNOS are at increased risk of developing BN (Schmidt et al., 2007), and that the psychopathology of this
group is commensurate with full syndrome BN (e.g., Garnkel et al.,
1995; le Grange et al., 2006; Lewinsohn, Striegel-Moore, & Seeley, 2000;
Ricca et al., 2001; Sullivan, Bulik, & Kendler, 1998; Turner & BryantWaugh, 2004; Wilson & Elredge, 1991).
Lifetime BN ranges from 1.5% to 4.6%, with the addition of partial
BN syndromes increasing this to between 4% and 6.7% (Wade, KeskiRahkonnen, & Hudson, 2011). If left untreated, BN tends to continue
into adulthood (Schmidt et al., 2007). BN and EDNOS are related to,
and pose a risk for, the development of a range of secondary cognitive,
behavioural and physical impairments and disorders, including anxiety and depressive disorders, substance abuse, suicide attempts, obesity, and other health related disorders (Burton & Stice, 2006;
Johnson, Cohen, Kasen, & Brook, 2002a, 2002b; Stice, Marti, Shaw, &
Jaconis, 2009).
1.2. Method: literature search
The central aim of the current review is to identify different denitions of remission and recovery and their utility in terms of client
outcome after treatment for BN and EDNOS. To this end, a literature
search was conducted by using the PsychINFO database (OvidSP)
which covers the professional and academic literature in psychology
and related disciplines, including medicine, psychiatry, nursing, sociology, pharmacology, physiology and linguistics. In an attempt to balance thoroughness with manageability, the keywords bulimia nervosa
(Title) AND treatment (Title) AND outcome (All elds) were used to
locate pertinent publications in all journals in a multi-eld search.
One hundred and thirty seven studies were listed. All relevant peerreviewed published studies in English were then evaluated and included in the review. Additional articles from reference lists were included if relevant. Case studies were excluded, leaving 71 published
treatment studies in the nal review that used 82 different primary
outcome measures. While not all relevant studies may have been located using this methodology, it was considered that it was unlikely
that substantially different denitions of outcome would be revealed
using different search methodology.
2. Treatment outcome
2.1. Treatment outcome rates for bulimia nervosa and eating disorder not
otherwise specied
Reviews of psychotherapy treatment studies for BN have reported
wide variability in outcome between studies, with reported recovery
rates ranging from 13% to 74% (Herzog et al., 1993; Hsu, 1995; Keel &
Mitchell, 1997; Mitchell, Hoberman, Peterson, Mussell, & Pyle, 1996).
Good outcome after treatment for BN has been found in a review of
25 articles to range between 24% and 74% (Clausen, 2004). One recent
study of 840 eating disorder patients applied a range of denitions of
remission to a single dataset and found that remission rates ranged
between 30% and 44% for BN, and 20% and 59% for EDNOS, depending
on the denition used (Bjork, Clinton, & Norring, 2011). While across
different studies variability in rates may be attributed to factors such
as sample size, type of therapy, treatment history, concurrent treatments, symptom duration and severity (Jarman & Walsh, 1999), it

293

has been estimated that 52% of the variance in outcome rates can be
accounted for by the combination of denition of outcome chosen
by researchers and length of time from post-treatment to follow-up
(Clausen, 2004).
2.2. Denitions of outcome
The primary terms used to describe outcome are remission, recovery and relapse. While these terms are not dependent on the occurrence of treatment, they are often used as indicators of treatment
effectiveness. Some studies have dened remission as the abstinence
from two or more behavioural symptoms (i.e., Binford et al., 2005;
Burton & Stice, 2006; Fairburn, 1997; Fairburn, Cooper, & Shafran,
2003; Fairburn et al., 2003; Fairburn, Cooper, Doll, Norman, &
O'Connor, 2000; Fittig, Jacobi, Backmund, Gerlinghoff, & Wittchen,
2008; Ghaderi, 2006; Keel, Mitchell, Miller, Davis, & Crow, 1999;
Keel, Mitchell, Davis, Fieselman, & Crow, 2000; le Grange, Crosby, &
Lock, 2008; le Grange, Crosby, Rathouz, & Leventhal, 2007; Lock, le
Grange, & Crosby, 2008; Mitchell et al., 1987; Mitchell, Raymond, &
Specker, 1993; Mussell et al., 2000; Zaitsoff, Doyle, Hoste, & le
Grange, 2008) for one week (i.e., Romano, Halmi, Sarkar, Koke, &
Lee, 2002) to six months (i.e. Fairburn, 1997; Fairburn, Cooper, &
Shafran, 2003; Fairburn, Stice, et al., 2003; Fairburn et al., 2000;
Keel et al., 1999). Other studies have required symptom frequency
to be at or below a pre-determined cut-off level, e.g. bingeing less
than twice weekly for 4 weeks (Agras, Walsh, Fairburn, Wilson, &
Kraemer, 2000; Chui, Safer, Bryson, Agras, & Wilson, 2007; Fairburn,
Agras, Walsh, Wilson, & Stice, 2004). Another denition of remission
has been the requirement of a signicant change in symptom severity
from baseline, such as a reduction of one or more symptoms by 50%
(Romano et al., 2002). Alternatively, studies have dened remission
as the absence of a clinical diagnosis of BN (i.e., Kroger et al., 2010).
Remission has sometimes been assessed post-treatment (i.e.,
Romano et al., 2002) and sometimes at follow-up (i.e., Fairburn,
1997; Fairburn, Cooper, & Shafran, 2003; Fairburn, Stice, et al., 2003;
Fairburn et al., 2000; Hartmann, Orlinsky, Weber, Sandholz, & Zeeck,
2010; Zeeck et al., 2009a, 2009b). Time between post-treatment and
follow-up has varied between 1 month (i.e. Mussell et al., 2000) and
at least 11.5 years (i.e., Keel et al., 1999).
Remission is often subdivided in the literature into partial and full
remission (i.e., le Grange et al., 2008; le Grange et al., 2007; Lock et al.,
2008; Zaitsoff et al., 2008). Partial remission has been dened in the
literature as continuing to experience several DSM criteria for BN
but to a less severe degree than required for a diagnosis of BN (i.e.,
Keel et al., 1999; le Grange et al., 2007; Zeeck, Weber, Sandholz,
Wetzler-Burmeister, Wirsching, et al., 2009a, 2009b). In contrast,
full remission has been described as abstinence from bingeing, purging and compensatory behaviours (i.e., Keel et al., 1999; le Grange et
al., 2007; Zeeck, Weber, Sandholz, Wetzler-Burmeister, Wirsching, et
al., 2009a, 2009b). In some cases, an additional criterion of weight
and shape not being allowed to unduly inuence self-evaluation has
been included (i.e., Keel et al., 1999; Zeeck, Weber, Sandholz,
Wetzler-Burmeister, Wirsching, et al., 2009a, 2009b).
Recovery has similarly been assessed at post-treatment and/or
follow-up (i.e. Ljotsson et al., 2007) and has shared many of the
same denitions as remission. Some studies dene recovery as the
abstinence from two or more BN related symptoms (i.e., Agras,
Walsh, Fairburn, Wilson, & Kraemer, 2000; Bailer et al., 2004; Chui
et al., 2007; Fairburn et al., 2004; Ljotsson et al., 2007) for one (i.e.,
Treasure et al., 1996) to 4 weeks (i.e., Agras et al., 2000; Butryn,
Lowe, Safer, & Agras, 2006; Halmi et al., 2002). Other studies require
symptom frequency to be at or below a pre-determined cut-off level
(i.e., Reas, Williamson, Martin, & Zucker, 2000). Alternatively, studies
have dened recovery as the absence of a clinical diagnosis of BN (i.e.,
Abraham, 1998; Kroger et al., 2010). Recovery has been assessed
post-treatment (i.e., Kroger et al., 2010) and/or at follow-up (i.e.,

294

S.E. Williams et al. / Clinical Psychology Review 32 (2012) 292300

Table 1 (continued)

Table 1
Primary outcome measures (N = 82) for published studies of Bulimia Nervosa.
Outcome denition
Behavioural symptoms only
Bingeing and vomiting: abstinence
for 4 weeks

Bingeing, vomiting and laxatives:

abstinence for 2 weeks

Bingeing and purging: abstinence

for 4 weeks

Bingeing and vomiting: 75%

decrease in symptom frequency

Bingeing and purging: abstinence

for 2 weeks
Bulimic episodes (objective and
subjective) and compensatory
behaviours: abstinence for
4 weeks
Bingeing, vomiting and laxatives:
abstinence for 12 weeks

Bingeing and compensatory

behaviours: abstinence for
3 months at two consecutive
follow-up points and all
subsequent assessment points
Bingeing and/or vomiting:
abstinence for 4 weeks
Bingeing and vomiting: signicant
reduction in symptom frequency
Bulimic episodes (objective and
subjective), vomiting and
laxatives: abstinence for 4 weeks
Vomiting: decrease 50% from
baseline frequency during 1 of
the 2 preceding weeks
Bingeing: signicant decrease
in frequency
Bingeing: 1 binge per week
for 4 weeks
Bingeing, vomiting, laxative abuse,
dieting or excessive exercise:
btwice weekly
Bingeing, vomiting, laxative abuse,
diuretics or diet pills: abstinence
for 1 week
Bingeing, vomiting, laxatives and
diuretics: abstinence for 4 weeks
Bingeing, vomiting, laxatives,
diuretics and exercise:
abstinence for 1 week
Purging: signicant decrease in
frequency
Bingeing and/or purging: signicant
reduction in bingeing and/or
purging days per week
Bingeing and/or purging:
abstinence for 1 week
Bingeing and/or purging:
75% reduction for 3 months
Bingeing and purging: Less than
1 binge or purge for 12 weeks
Bingeing and purging: signicant
reduction in symptom frequency

Outcome denition

Studies using the denition

N
(%)

Agras, Crow, et al., 2000; Bailer et al.,

2004; Butryn et al., 2006; Cooper et al.,
1996; Halmi et al., 2002; Schmidt et
al., 2007, 2008
Bulik, Sullivan, Carter, McIntosh, &
Joyce, 1998; Bulik, Sullivan, Joyce,
Carter, & McIntosh, 1998; Carter et al.,
2004; Carter, McIntosh, Joyce, & Bulik,
2008; Rowe et al., 2010
deGroot et al., 1995; Ghaderi, 2006;
Ljotsson et al., 2007; Mitchell et al.,
2008; Marrone, Mitchell, Crosby,
Wonderlich, & Jollie-Trottier, 2009
Fluoxetine Bulimia Nervosa
Collaborative Study Group, 1992;
Goldstein et al., 1995; Palmer, Birchall,
McGrain, & Sullivan, 2002; Sysko, Sha,
Wang, Duan, & Walsh, 2010
Binford et al., 2005; Keel et al., 2000;
Mitchell et al., 1993; Mussell et al.,
2000
le Grange et al., 2007; le Grange et al.,
2008; Lock et al., 2008; Zaitsoff et al.,
2008

7
(8.5)

Bulik, Sullivan, Carter, McIntosh, &

Joyce, 1998; Bulik, Sullivan, Joyce,
Carter, & McIntosh, 1998; Rowe et al.,
2010
Fairburn, 1997; Fairburn et al., 2000;
Fairburn, Cooper, & Shafran, 2003;
Fairburn, Stice, et al., 2003

5
(6.0)

5
(6.0)

4
(4.8)

4
(4.8)
4
(4.8)

3
(3.7)

3
(3.7)

Jacobi, Dahme, & Dittmann, 2002;

Palmer et al., 2002
Pritchard et al., 2004; Furber, Steele,
& Wade, 2004
Fairburn, Jones, Peveler, Hope, &
O'Conner, 1993; Fairburn, Peveler,
Jones, Hope, & Doll, 1993
Romano et al., 2002

2
(2.4)
2
(2.4)
2
(2.4)

Bossert et al., 1992

1
(1.2)
1
(1.2)
1
(1.2)

Baell & Wertheim, 1992

Murray et al., 2007

Hsu et al., 2001

Steele & Wade, 2008

Treasure et al., 1996

Mitchell et al., 2001

Hoopes et al., 2003

Grifths, Hadzi-Pavlovic, & ChannonLittle, 1994

Ro, Martinsen, Hoffart, & Rosenvinge,
2003
Banasiak, Paxton, & Hay, 2005
Shapiro et al., 2010
El-Giamal et al., 2003

1
(1.2)

1
(1.2)
1
(1.2)
1
(1.2)
1
(1.2)
1
(1.2)
1
(1.2)
1
(1.2)
1
(1.2)
1
(1.2)

Bingeing and purging: 50%

reduction for 1 week
Bingeing, purging and restrictive
eating: signicant reduction
in symptom frequency
Bingeing, purging and dietary
restriction: abstinence for 4 weeks
Bingeing and compensatory
behaviours: less than two per
week for 4 weeks
Bingeing and compensatory
behaviours: less than six
behaviours for 12 weeks
Bingeing and compensatory
behaviours: abstinence for
4 weeks
Bulimic episodes: 75% decrease in
frequency for 4 weeks
Bulimic behaviours: abstinence
for 1 week
Bulimic behaviours: abstinence
for 8 weeks
Behavioural and cognitive symptoms
DSM: not meet criteria for
6 months
DSM: not meet criteria for
4 weeks
Bingeing, vomiting and
compensatory behaviours:
abstinence for 4 weeks at posttreatment, 12 weeks at followup+ SIAB: global ratings of 0 or
1 on the item preoccupation
with body slimness, shape and
weight (4 weeks at
post-treatment, 12 weeks
at follow-up)
Signicant reduction in bulimic
symptoms (BITE)
Bulimic and restrictive attitudes
and behaviours: signicant
change on scales
Bulimic behaviours: abstinence for
6 months + weight and shape
cannot unduly inuence
self-evaluation
PSR: rating of 1 or 2 + SIAB-P:
global ratings of 0 or 1
YBC-EDS (signicant decrease
in scores)
Global EDE: b 1 SD above the
community mean
(i.e., below 1.74)
Bingeing and purging (abstinence
for 3 months) + EDI: drive for
thinness, bulimia and body
dissatisfaction subscales: scores
within health norm range

Studies using the denition

Reas et al., 2000

Maddocks et al., 1992

Bailer et al., 2004

N
(%)
1
(1.2)
1
(1.2)
1
(1.2)
1
(1.2)

Fahy & Russel, 1993

1
(1.2)

Burton & Stice, 2006

1
(1.2)

Cooper et al., 1996

1
(1.2)
1
(1.2)
1
(1.2)

Peterson et al., 2004

Keel et al., 1999

le Grange et al., 2007; le Grange et al.,

2008; Lock et al., 2008; Zaitsoff et al.,
2008
Abraham, 1998; Fairburn et al., 1995;
Kroger et al., 2010
Hartmann et al., 2010; Zeeck, Weber,
Sandholz, Wetzler-Burmeister,
Wirsching, et al., 2009a, 2009b

4
(4.8)
3
(3.7)
3
(3.7)

Durand & King, 2003; Robinson &

Serfaty, 2001
Openshaw et al., 2004

2
(2.4)
1
(1.2)

Keel et al., 1999

1
(1.2)

Fichter & Quadieg, 1997

1
(1.2)
1
(1.2)
1
(1.2)

Erzegovesi et al., 2004

Fairburn et al., 2009

Fittig et al., 2008

Behavioural symptoms and quality of life

Nickel et al., 2005
Bingeing and purging: signicant
reduction in frequency for
1 week + QOL (SF-36):
signicant improvement in score

1
(1.2)

1
(1.2)

Note: SIAB = Structured Inventory for Anorexic and Bulimic Disorder; BITE = Bulimic
Investigatory Test, Edinburgh; PSR = Psychiatric Status Rating Scale; YBC-EDS = YaleBrown-Cornell Eating Disorder Scale; EDI = Eating Disorder Inventory; SF-36 = Short
Form (36) Health Survey. Studies that are italicised used more than one denition of
outcome and are included twice in the table.

Treasure et al., 1996). Time to follow-up has varied between

6 months (i.e., Openshaw, Waller, & Sperlinger, 2004) and 15 years
(i.e., Abraham, 1998). The term maintenance of remission or

S.E. Williams et al. / Clinical Psychology Review 32 (2012) 292300

remission maintenance has been recommended as a practical way of

dening recovery (Cooper, Coker, & Fleming, 1996; Couturier & Lock,
2006b).
Relapse is said to occur when a recurrence of previously absent
symptoms occurs, or when symptoms have deteriorated to a former
worse state. A study examining denitions of relapse in BN suggested
that relapse be dened as meeting diagnostic criteria for BN after remission has been deemed to have occurred (Stein, 2005).
3. Bulimia nervosa symptoms included in the denitions of
outcome
3.1. Behavioural symptoms
The most common way of measuring outcome for BN in the research literature is to focus on one or more behavioural variables, notably objective binge episodes, purging behaviour such as self
induced vomiting, laxative and diuretic abuse, and the use of fasting
and excessive exercise to control weight or shape. Of all the outcomes
included in the present review, 77% included a measure of behavioural functioning only (see Table 1). However, these studies differed in the specic variables and measures used, with only 11
(33%) behavioural denitions of outcome used more than once.
Some studies required a statistically signicant or pre-dened reduction in behavioural symptoms (Jones, Peveler, Hope, & Fairburn,
1993; Steele & Wade, 2008; Treasure et al., 1996). Other studies
used an arbitrary cut-off number of binges or purges over an arbitrary
length of time (Bulik, Sullivan, Carter, McIntosh, & Joyce, 1998; Bulik,
Sullivan, Joyce, Carter, & McIntosh, 1998; Fahy & Russel, 1993;
Fairburn, Jones, Peveler, Hope, & O'Conner, 1993; Fairburn, Peveler,
Jones, Hope, & Doll, 1993; Fairburn, Jones, Peveler, et al., 1991;
Fairburn et al., 1995; Fallon, Walsh, Sadik, Saoud, & Lukasik, 1991;
Fallon, Sadik, Saoud, & Garnkel, 1994; Fichter & Quadieg, 1997;
Herzog et al., 1993; Hsu & Holder, 1986; Jager et al., 1996; Swift,
Ritholz, Kalin, & Kaslow, 1987). Alternatively, some studies required
abstinence from all behaviours for 3 to 52 weeks (Agras, Crow, et
al., 2000; Agras, Walsh, Fairburn, Wilson, & Kraemer, 2000; Collings
& King, 1994; Cooper et al., 1996; deGroot, Rodin, & Omsted, 1995;
Fairburn, Kirk, O'Conner, & Cooper, 1986; Garner, 1987; Halmi et al.,
2002; Hsu & Sobkiewicz, 1989; Johnson-Sabina, Reiss, & Dayson,
1992; Keel et al., 1999; Keel et al., 2000; Keski-Rahkonen et al.,
2009; Kordy et al., 2002; Maddocks, Kaplan, Woodside, Langdon, &
Piran, 1992; Reiss & Johnson-Sabine, 1995).
All of these behavioural outcome denitions have a variety of limitations. Reduction in symptoms based on a frequency or statistically
signicant change may be useful in situations where the cost impact
on health systems are being measured but pose difculties when
comparing rates of recovery and remission and deriving clinical
meaning across different studies. High baseline frequencies of behaviour may also reduce signicantly yet remain clinically signicant
(Berkman, Lohr, & Bulik, 2007). In contrast, comparing cut-off measures of reduction is difcult because studies differ on the predened
cut-off point. As outlined in Table 1, cut off points have ranged from
one or less binge per month (Fallon et al., 1991, 1994; Herzog et al.,
1993), to two or less per week (Fairburn, Jones, Peveler, Hope, &
O'Conner, 1993; Fairburn, Peveler, Jones, Hope, & Doll, 1993;
Fairburn et al., 1991, 1995; Fichter & Quadieg, 1997; Jager et al.,
1996). These differences may lead to the large discrepancy observed
in the literature concerning the ability to predict treatment outcome
based on behavioural symptom reduction alone. Some studies report
that poorer treatment outcome may be predicted by a higher
frequency of vomiting (Davis, Olmsted, & Rockert, 1992; Fahy &
Russel, 1993; Keller, Herzog, Lavori, Bradburn, & Mahoney, 1992) or
bingeing (Baell & Wertheim, 1992; Fahy & Russel, 1993; Garner
et al., 1990; Wilson & Elredge, 1991). However, other studies have
been unable to replicate these results (Fairburn, Jones, Peveler,

295

Hope, & O'Conner, 1993; Fairburn, Peveler, Jones, Hope, & Doll,
1993; Fairburn, Kirk, O'Conner, Anastasiades, & Cooper, 1987;
Garner et al., 1990; Herzog, Dorer, Keel, et al., 1999; Hsu & Holder,
1986; Maddocks & Kaplan, 1991; Rossiter, Agras, Telch, & Schneider,
1993; Solberg, Norring, Holmgren, & Rosmark, 1989; Swift et al.,
1987).
Setting abstinence as the measure of good outcome for behavioural functioning may yield important clinical benets for clients
and make between study comparisons more possible. This approach
is supported by the National Institute for Clinical Excellence (NICE)
guidelines (2004), which states that terminating treatment before clients reach abstinence from BN behaviours may lead to poorer longterm outcomes. For example, a treatment study by Maddocks et al.
(1992) compared the 2-year post-treatment outcome of clients who
had reached total abstinence, to clients who reached one of the strictest cut-off criteria of no more than one binge and purge per week. The
study reported that abstinent clients achieved higher levels of selfesteem and social adjustment and lower levels of depression than
cut-off criteria clients, all of which are symptoms linked to the relapse
or maintenance of BN (Baell & Wertheim, 1992; Fairburn, Jones,
Peveler, Hope, & O'Conner, 1993; Fairburn, Peveler, Jones, Hope, &
Doll, 1993; Keller et al., 1992; Maddocks et al., 1992; Wilson,
Rossiter, Kleield, & Lindholm, 1986). Similarly, Kordy et al. (2002)
analysed data from 647 people with BN who had been followed up
for 2.5 years and found that stability of full remission was signicantly higher if abstinence from behavioural symptoms and clinically
non-signicant cognitive symptoms (i.e., preoccupation with gure)
were achieved for at least 4 months. They concluded that relapse prevention should be provided to BN clients for 4 months after symptoms remit. Thus the evidence to date seems to support the
inclusion of abstinence from behavioural symptoms in a denition
of recovery from BN.
However the use of behavioural variables as the only measure of
outcome has several disadvantages. Single time point evaluations of
outcome do not adequately take into consideration the uctuations
in symptoms that often occurs in BN. Thus, while abstinence is often
considered the best approach of evaluating behavioural symptoms
(NICE, 2004), if measured only once post-treatment or over a short
period of time the results may be positively biased (Bulik, Sullivan,
Carter, McIntosh, & Joyce, 1998). Consequently, behaviours may
need to be assessed at more than one follow-up point. Thus, the usefulness of reporting results based on behavioural improvement on a
select couple of behaviours is limited. In addition, while certain behaviours may have decreased or ceased, a person may in fact still
meet criteria for a diagnosis of BN, thereby rendering it difcult to ascertain clinical meaningfulness from the results and determining the
individual's eating disorder status.

3.2. Cognitive and behavioural variables

A further disadvantage of relying on behavioural symptoms alone
for denition of outcome is the complete avoidance of the cognitive
aspects of the diagnostic criteria. Clausen's (2004) analysis of published BN outcome studies reported that signicantly fewer clients
received good outcomes when cognitive symptoms were taken into
account. However, it is possible that these more modest rates are better indicators about the current and future states of outcome. Similarly, studies have demonstrated that many participants who had short
and long-term abstinence from behavioural symptoms continued to
possess signicant cognitive symptoms, such as body dissatisfaction
(Cogley & Keel, 2003; Keski-Rahkonen et al., 2009) even after being
classed as clinically recovered (Keski-Rahkonen et al., 2009). This is
problematic because unhelpful eating attitudes post treatment have
been linked with increased relapse of BN, with the risk increasing
from 3.4% for people with a moderate level of residual attitudinal

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S.E. Williams et al. / Clinical Psychology Review 32 (2012) 292300

disturbance and 45.2% for a severe level (Fairburn, Jones, Peveler,

Hope, & O'Conner, 1993; Fairburn, Peveler, Jones, Hope, & Doll, 1993).
Anderson and Maloney (2001) claim that improvements in behaviours alone will not be sustainable if cognitive components such as
self-esteem, perfectionism, weight and shape concern, mood regulation, and the importance of strict dieting rules, are not improved. Inclusion of cognitive measures may improve assessments of treatment
outcome and help predict relapse and recovery. For example, le
Grange et al. (2008) found that lower pre-treatment global Eating
Disorder Examination (EDE; Fairburn & Cooper, 1993) and cognitive
symptoms (i.e., Eating Concerns subscale of EDE) were related to
higher remission post-treatment and follow-up regardless of the
type of treatment received.
Some studies have used current diagnostic status as the primary
measure of outcome, thereby including both behavioural and cognitive symptoms in their denition. Four of the studies reviewed used
this denition as a measure of good outcome (Durand & King, 2003;
Gendall, Joyce, Carter, McIntosh, & Bulik, 2003) or recovery
(Abraham, 1998; Kroger et al., 2010). Although this method includes
both behavioural and cognitive elements of BN, a limitation is that the
denition may not adequately capture the pervasiveness of underlying symptoms that pose signicant risk for relapse. For example,
bingeing and purging or other BN symptoms may continue to be pervasive once diagnostic criteria are no longer met (Bulik, Sullivan,
Carter, McIntosh, & Joyce, 1998).
Another way that studies have included behavioural and cognitive
symptoms in their measure of outcome is to choose specic symptoms or measures and compare pre- and post-treatment scores
(Table 1). However, the symptoms, methods and measures used
vary drastically between studies. Some studies have used predetermined cut-off scores for behavioural and cognitive symptoms
(Fairburn et al., 2009; Fichter & Quadieg, 1997; Hartmann et al.,
2010; Keel et al., 1999; Zeeck, Weber, Sandholz, WetzlerBurmeister, Wirsching, et al., 2009a, 2009b). Other studies have required a signicant reduction in chosen behavioural and cognitive
symptoms (Erzegovesi et al., 2004; Openshaw et al., 2004; Robinson
& Serfaty, 2001). Due to the variety of outcome denitions chosen
the results from the studies are difcult to compare.
4. Common methodological differences related to outcome
In addition to the type of diagnostic criteria used in different definitions of outcome, there also exists a variety of methodological differences between outcome studies. With regard to the length of time
until follow-up, assessments have started anywhere between
2 weeks to several years post-treatment (Clausen, 2004). Discrepancy
with respect to length of time to follow-up may have important implications on study outcomes as it does account for some of the variance in outcome (Clausen, 2004). However, it is unclear whether
more time predicts better or worse prognoses. Some studies have
found that longer time until follow-up predicts better outcome
(Keel & Mitchell, 1997) even when controlling for the effects of attrition and other variations in outcome denition (Clausen, 2004). Similarly, studies have also reported that BN patients recover steadily
within the rst 125 weeks (Keller et al., 1992) or 250 weeks
(Herzog et al., 1999) after therapy, and that the rate of recovery
reaches a plateau after this period. Other studies have also found
that time until follow-up inuences rates of recovery, but that recovery and treatment outcome is negatively affected by overall time,
with 50% of BN clients relapsing within the rst 3 years following
treatment (Keller et al., 1992; Norring & Sohlber, 1993). In addition,
Steinhausen and Weber (2009) found in their review of 49 studies
comprising 4639 people with BN that recovery was strongest at
4 years follow-up but that it had decreased at 10 or more years
follow-up. Whether recovery rates are positively or negatively affected by time, the ndings of these studies indicate that in order to

properly ascertain whether individuals have recovered from BN standard periods of longer term follow up are required.
The duration of symptom reduction required for good outcome or
recovery also differs between studies, with monitoring of symptoms
lasting from 1 week (Davis et al., 1992), 1 month (Agras, Crow, et
al., 2000; Agras, Walsh, Fairburn, Wilson, & Kraemer, 2000; Cooper
et al., 1996; deGroot et al., 1995; Jager et al., 1996; Maddocks et al.,
1992; Reiss & Johnson-Sabine, 1995), to 12 weeks (Clausen, 2004).
Keel et al. (1999) applied several denitions of full and partial recovery used in studies of BN with follow-up periods of at least 5 years to
a sample of 173 females followed up 10 or more years after presenting with BN. The authors found that poorer outcomes were obtained
when the duration for which BN symptom reduction was required to
be sustained was increased. The variance in duration of symptom
monitoring accounted for approximately 3% of variance in treatment
outcome. In contrast, Clausen (2004) did not nd a signicant relationship between measurement duration and outcome. Future research is needed to evaluate the predictive nature of measurement
duration and variance it accounts for in assessing good outcomes
and recovery from BN.
5. What can we learn from outcome research in anorexia nervosa?
The information summarized above suggests that there is need to
change the way that outcome for BN is dened so that it provides
more clinically meaningful results. While treatment outcome could
still report outcomes in general and of specic combinations of disordered symptoms, the way that diagnostic terms such as remission
and recovery are used should be stricter and more informative
about the current state of individuals, and where appropriate, be predictive of future states.
Specic suggestions for addressing outcome in BN can be informed by research into anorexia nervosa (AN), which has been
attempting to develop consensus denitions of treatment outcome
and determine the predictive nature of proposed denitions
(Couturier & Lock, 2006a, 2006b). This latter literature is somewhat
more advanced than similar work in BN, and thus can be used to inform progress in this area for BN. For example, two studies by
Couturier and Lock (2006a, 2006b) have attempted to examine denitions of remission (2000a) and recovery (2000b) to form useful
working denitions of each concept. In both studies a range of factors
were considered in the evaluations, including ideal body weight
(IBW), cognitive, and behavioural symptoms of AN. In their rst
paper, several denitions of remission were examined by applying
the denitions to the same dataset and the authors found that three
denitions led to similar results and proposed that full remission be
dened as one of the three ways. First, full remission could be dened
as weight 95% ideal body weight (IBW). Second, full remission
could be dened as EDE scores within 2 standard deviations (SD) of
non-ED population norms, or 1 SD if there was a high level of overlapping of the distributions. Third, full remission could be dened as
both weight 85% IBW and EDE within 12 SD of non-ED population
norms (scores within 2 SD of non-ED population norms, or if the distributions were highly overlapping, 1 or 2 SD of the non-ED norms).
In their second paper, they proposed that recovery at the end of treatment be dened as both weight 85% IBW and EDE restraint subscale
within 1 SD of non-ED population norms (Couturier & Lock, 2006b).
Bardone-Cone et al. (2010) also examined denitions of recovery
used in the eating disorder literature by applying the denitions to
the same dataset and suggested that full recovery be dened as a
combination of: (1) no longer meeting criteria for an eating disorder,
(b) abstinence from bingeing, purging and fasting for 3 months, (c)
body mass index 18.5, and (d) EDE or EDE-Questionnaire (EDE-Q)
subscale scores all within 1 SD of healthy, age-matched population
norms. Using their proposed denition, the authors found that participants with either AN, BN, or EDNOS who met criteria for full recovery

S.E. Williams et al. / Clinical Psychology Review 32 (2012) 292300

were indistinguishable from healthy controls on several eating disordered related cognitions.
Of particular importance has been the identication of the usefulness in including comparisons of scores to non-ED population norms
in denitions of outcome in the eating disorder literature (BardoneCone et al., 2010; Couturier & Lock, 2006a, 2006b). Comparing scores
to healthy norms is important in determining the clinical signicance
of results and has been recommended as the gold standard of assessing outcome in clinical research (Bauer, Lambert, & Nielsen, 2004).
Very few BN studies examining treatment outcome have used
this method of assessing clinical signicance with some exceptions
(Fairburn et al., 2009; Fittig et al., 2008). One BN study using this approach appropriately required scores to be b1 SD above the community mean with respect to the global EDE score (Fairburn et al., 2009).
Using a strict method of assessing clinical signicance may allow
more cohesive and clinically meaningful comparisons to be made.
6. Assessing the goodness of t of outcome: quality of life
A construct that may prove useful in further developing a denition of outcome in BN is quality of life (QOL). Impaired QOL is a diagnostic symptom included for many mental disorders in the DSM, such
as major depression, post traumatic stress disorder and insomnia
(DSM, 2000). While this is not a requirement for a diagnosis of BN, research has found that QOL is signicantly impaired in individuals
with BN (Hay, 2003) and EDNOS (Cotrufo, Beretta, Monteleone, &
Maj, 1998; Mond, Myers, Crosby, Hay, & Mitchell, 2010). For example,
Mond et al. (2010) found that a small sample of women (N = 24)
with BN, binge eating disorder and EDNOS had signicantly more impaired QOL related to disordered eating than healthy controls. A larger study examining the longitudinal progression of EDs over an eight
year period in 496 adolescent girls also found that functional impairment and distress levels were higher in people with EDNOS than people without eating disorders (Stice et al., 2009). In addition, Wade,
T.D., Wilksch, S.M., Lee, C. (2011) examined the longitudinal relationship between poor QOL and EDNOS in a sample of 9688 Australian
women over a nine year period and found that low levels of symptoms were still related to signicant decits in QOL over this time period. A study examining the effects of eating disorder treatment on
QOL found that treatment completion was related to improvements
in eating-related QOL (Abraham, Brown, Boyd, Luscombe, & Russell,
2006). Although the benets were maintained at one year followup, the scores were still lower than that of a control group.
It is proposed that both eating-related QOL and general QOL
should be considered when assessing the goodness of t of different
denitions of outcome for BN so that the research is as rigorous and
meaningful as that of many other mental health disorders. Use of eating disorder related QOL measures is important so that the confounding inuences of comorbidity with other psychiatric conditions on
QOL are reduced. Use of general QOL measures allows for comparability with a variety of other populations, including healthy populations
and groups with chronic physical and mental illnesses. The goodness
of t of a measure of outcome could be assessed in terms of degree of
improvement of QOL with respect to how commensurate this is to
healthy controls.
7. Conclusions and recommendations
Vast discrepancies exist in the denition of good outcome and recovery in BN treatment literature. While the majority of studies include behavioural measures of symptom reduction, many did not
include cognitive symptom reduction, despite the importance of cognitive symptoms with respect to determining the diagnostic status of
BN and as indicators of potential relapse (Fairburn, Jones, Peveler,
Hope, & O'Conner, 1993; Fairburn, Peveler, Jones, Hope, & Doll,
1993). Studies also varied in the length of time until follow-up and

297

the duration symptom reduction was required for a classication

of good outcome or recovery. These factors may confound results,
making treatment comparison difcult for researchers and client progress difcult to monitor for clinicians, thus impeding our ability to
detect meaningful improvements in therapeutic approaches.
It is suggested that outcome for BN takes into account both behavioural and cognitive symptoms, such as that outlined in the denition offered by Bardone-Cone et al. (2010). Thus remission would
include the following criteria: (1) abstinence from bingeing, purging
and fasting for a three-month period, accompanied by a body mass
index 18.5 which is the World Health Organisation cut-off for a
healthy weight, thus representing the behavioural domain, and (2)
a global EDE score over the previous three-month period within 1
SD of healthy, age-matched population norms, representing both
the behavioural and cognitive domains. The EDE would sufce as
the instrument of assessment for such a denition as it would cover
all the pertinent areas across both domains, where the items related
to the global EDE score could be modied to assess a 3-month period
instead of the currently utilised one-month period. We also suggest
that a period of at least 6 months following the end of therapy be considered to assess for the stability of remission which, if sustained,
could then be dened as recovery. In addition, a denition of good
outcome with respect to both remission and recovery could be
assessed in terms of its ability to result in a level of QOL no more
than one standard deviation from healthy norms. In terms of a meaningful QOL related to eating the Clinical Impairment Assessment
Questionnaire could be utilised (Bohn et al., 2008), and general QOL
could be assessed using the Medical Outcome Studies (MOS) ShortForm Scales, the SF-36 (Ware & Sherbourne, 1992), which would
allow for comparison across a wide range of populations. By denition, relapse would occur when remission has occurred but is not sustained for more than a 3-month period.
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