What is the treatment for bulimia?

Treatment of Bulimia Nervosa

The recommended treatment for bulimia nervosa is a combination of eating disorder-focused cognitive-behavioral therapy (CBT) and a serotonin reuptake inhibitor, specifically fluoxetine at 60 mg daily. 1

Comprehensive Treatment Approach

Psychological Treatment

1. First-line therapy: Eating disorder-focused CBT

   • Focuses on normalizing eating patterns
   • Addresses body image disturbance
   • Reduces binge eating and purging behaviors
   • Typically delivered in individual format
   • Weekly sessions initially recommended 1

2. Family-based treatment (FBT)

   • Suggested for adolescents and emerging adults with involved caregivers
   • Includes caregiver education about normalizing eating behaviors 1

Pharmacological Treatment

1. Fluoxetine (Prozac)
   • Recommended dose: 60 mg daily, administered in the morning 1, 2
   • May titrate up to this target dose over several days
   • FDA-approved specifically for bulimia nervosa 2
   • Should be prescribed either:
     • Initially alongside CBT, or
     • If minimal/no response to psychotherapy alone by 6 weeks 1
   • Common side effects: gastrointestinal symptoms, headache, somnolence, insomnia 3
   • Serious side effects to monitor: suicidal ideation (especially in patients under 24), behavioral activation, serotonin syndrome 3, 2

Important note: Fluoxetine doses above 60 mg/day have not been systematically studied in bulimia nervosa patients and are not recommended 2

Treatment Implementation

Initial Assessment

• Complete physical examination including vital signs, weight, BMI, and signs of malnutrition or purging 1
• Laboratory assessment including complete blood count and comprehensive metabolic panel 1
• Electrocardiogram for patients with severe purging behavior 1

Treatment Sequence

1. Begin with CBT and consider adding fluoxetine

   • CBT has established efficacy as standalone treatment 4, 5
   • Adding fluoxetine provides modest additional benefit 4
   • The combination of CBT plus medication is superior to medication alone 4

2. Duration and monitoring

   • Systematic evaluation supports continuing fluoxetine 60 mg/day for up to 52 weeks in responders 2
   • Regular reassessment to determine need for continued treatment
   • Monitor frequency of binge episodes, depression severity, and anxiety symptoms
   • Assess for medication side effects regularly

Special Considerations

Technology-Based Interventions

• Guided computer/internet-based CBT interventions show promise as adjuncts to treatment 1
• May help reach patients who otherwise would not access help due to barriers like shame or fear of stigmatization 1

Treatment-Resistant Cases

• Consider alternative psychological approaches if CBT is ineffective
• Interpersonal therapy (IPT) has shown efficacy similar to CBT in some studies 5
• Ensure comprehensive treatment plan addresses common comorbidities (mood disorders, anxiety disorders) 3

Common Pitfalls to Avoid

• Discontinuing medication too early (before 12 weeks)
• Rapid dose escalation of medication
• Failing to monitor for behavioral activation/agitation
• Focusing solely on weight rather than normalizing eating behaviors and reducing binge-purge cycles
• Neglecting to create a comprehensive, multidisciplinary treatment plan 1

Bulimia nervosa requires a structured treatment approach with both psychological and pharmacological components. While CBT remains the psychological treatment of choice, the addition of fluoxetine significantly enhances outcomes for most patients.