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Although a number of pretreatment prognostic indicators have been identi ed (Keel & Mitchell, 1997; Vaz, 1998), few of them have been replicated across studies and across different treatments For example, severity and duration of bulimic symptoms have had an inconsistent link to outcome There seems to be somewhat more agreement that personality disorder features such as borderline or impulsive features predict a poorer outcome However, the main conclusion to be drawn with con dence about the literature on pretreatment outcome predictor variables is that none of the ones identi ed has any major utility in helping us to choose the treatment that is most helpful for a particular patient Given the general dearth of information on how to match treatments to patients, it can be argued that the use of a stepped care approach, starting with the least intensive, least costly and least invasive interventions, might generally be best.

In order to document these exceptions all working groups and TSGs had prepared and forwarded to TSG SA sheets describing the non-completed functionality for which they wished to have granted an exception from the general rule of no functional changes In addition to the description of the functionality, the sheet also indicated the consequences if this functionality was completely removed from Release 99 TSG SA collected the status reports from the different groups and created a relatively large table 10 where on one side was the different functionalities and on the other side the different groups and in the table an indication if a group had requested an exception for completion of the functionality After having created this table based on the status reports, TSG SA went through the table on a per functionality basis and evaluated the expected completion date and.

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The obvious candidate for the rst step in the treatment of BN is CBT self-help either with or without some therapeutic guidance However, although there are now a sizeable number of studies on the use of CBT self-help, very little work has been done on the additional treatment needs of these patients thereafter or on the potential harms of such an approach as the rst step in treatment (eg in terms of drop-out or demoralisation of more severely ill patients who may not do well with this approach) There is also some evidence suggesting that those who are more severely symptomatic may do less well with such an approach On the face of it, medication might also be a good starting point as a Step I intervention.

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However, the evidence suggests that drug treatments are less acceptable to patients (high drop-out rates, reduced take up, side-effects) and the longer term effects have not been studied in detail The Dose of Treatment Currently most evidence-based packages for the treatment of BN are brief (less than 20 sessions) A meta-analysis of psychotherapy studies of bulimia nervosa up to 1990 found that 36% of the variance in outcome was explained by the number of treatment sessions in combination with relationship orientation (Hartmann, Herzog & Drinkmann, 1992) If a longer duration of treatment yields potentially better outcomes it would be important to know what dose of treatment is needed to treat what proportion of patients presenting and whether there is a point beyond which offering more of the same is unlikely to improve outcome.

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The work of Ken Howard and others on the dose effectiveness relationship in psychotherapy addresses precisely these issues (Lutz et al, 2001) In general, the vast majority of people receiving psychotherapy improve quickly within the rst few sessions Those who have failed to improve at an early stage have much less of a chance of getting well and need vastly more input to get well than those who improve early And there is a point beyond which very few patients get better, if the same sort of treatment is continued However, the exact shape of this curve of the pattern of improvement varies according to diagnosis, type of symptoms, the presence of interpersonal problems and comorbidity (Lueger, Lutz & Howard, 2000) Unfortunately, at present we don t really know what the shape of this curve looks like for different treatments of bulimia nervosa.

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What we do know from Level II evidence is that, in CBT treatment, early response within 4 to 6 weeks is an excellent predictor of longer term outcome (Agras et al, 2000) In other words, if someone has failed to show any symptomatic improvement with CBT at an early stage,.

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