Online Cognitive–Behavioural Treatment of Bulimic Symptoms: A Randomized Controlled Trial


Correspondence to: Jeroen Ruwaard, Department of Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands.




Manualized cognitive–behavioural treatment (CBT) is underutilized in the treatment of bulimic symptoms. Internet-delivered treatment may reduce current barriers.


This study aimed to assess the efficacy of a new online CBT of bulimic symptoms.


Participants with bulimic symptoms (n = 105) were randomly allocated to online CBT, bibliotherapy or waiting list/delayed treatment condition. Data were gathered at pre-treatment, post-treatment and 1-year follow-up.

Outcome Measures

The primary outcome measures were the Eating Disorder Examination Questionnaire (EDE-Q) and the frequency of binge eating and purging episodes. The secondary outcome measure was the Body Attitude Test.


Dropout from Internet treatment was 26%. Intention-to-treat ANCOVAs of post-test data revealed that the EDE-Q scores and the frequency of binging and purging reduced more in the online CBT group compared with the bibliotherapy and waiting list groups (pooled between-group effect size: d = 0.9). At 1-year follow-up, improvements in the online CBT group had sustained.


This study identifies online CBT as a viable alternative in the treatment of bulimic symptoms. Copyright © 2012 John Wiley & Sons, Ltd.

Key Practitioner Message

  • In comparison with no treatment and unsupported bibliotherapy, online CBT induces strong reductions in bulimic symptoms.
  • Internet-delivered treatment may provide an acceptable treatment alternative for bulimic patients who are reticent about face-to-face contact.
  • Therapist support appears to be a critical determinant of treatment adherence and effectiveness.
  • Unsupported bibliotherapy may have only small immediate effects but may increase the probability of recovery in the long term by promoting positive attitudes towards treatment.