What are the guidelines for treating bulimia nervosa?

Guidelines for Treating Bulimia Nervosa

The American Psychiatric Association recommends treating adults with bulimia nervosa with eating disorder-focused cognitive-behavioral therapy (CBT) combined with a serotonin reuptake inhibitor (specifically fluoxetine 60 mg daily), either initially or if there is minimal response to psychotherapy alone after 6 weeks. 1

First-Line Treatment Approach

For Adults:

• Eating disorder-focused CBT is the primary psychological treatment 1

  • Typically delivered in 16-20 sessions over 4-5 months
  • Focuses on normalizing eating patterns, addressing dysfunctional thoughts about body image and weight, and targeting binge-purge cycles
  • Has shown 56-59% abstinence rates from binge eating and purging by end of treatment 2

• Medication therapy with fluoxetine (Prozac)

  • FDA-approved dose: 60 mg/day 3
  • Can be prescribed either initially or if minimal response to psychotherapy alone after 6 weeks 1
  • Maintenance treatment with fluoxetine has shown benefit for up to 52 weeks in patients who initially responded 3

For Adolescents:

• Family-based treatment (FBT) is recommended for adolescents and emerging adults who have an involved caregiver 1, 2
  • Focuses on empowering parents to disrupt the binge-purge cycle
  • Regular follow-up appointments to monitor progress

Comprehensive Assessment and Monitoring

• Initial physical examination should include 1:

  • Vital signs (temperature, resting heart rate, blood pressure, orthostatic pulse and blood pressure)
  • Height, weight, and BMI
  • Physical appearance assessment for signs of malnutrition or purging behaviors

• Laboratory assessment should include 1:

  • Complete blood count
  • Comprehensive metabolic panel (electrolytes, liver enzymes, renal function tests)

• Electrocardiogram is recommended for 1:

  • Patients with severe purging behavior
  • Patients taking medications that prolong QTc intervals

Treatment Plan Components

A comprehensive, multidisciplinary treatment plan should incorporate medical, psychiatric, psychological, and nutritional expertise 1, addressing all five core symptoms:

1. Binge eating
2. Purging
3. Restrictive eating
4. Shape/weight concerns
5. Self-esteem 2, 4

When First-Line Treatment Fails

• If CBT alone is not effective, adding fluoxetine (if not already prescribed) is recommended 1
• For non-responders to combined CBT and medication, consider:
  • More intensive CBT approaches 5
  • Inpatient treatment with concentrated exposure for severe cases 5

Technology-Based Interventions

• Guided computer and internet-based interventions, including videoconferencing, show promise for compliant patients 1, 2
• Mobile interventions may be useful as adjuncts to therapy or for relapse prevention 2
• These approaches can help overcome barriers such as shame, stigma, and limited access to specialized care 2

Treatment Duration and Follow-up

• Maintenance treatment should be considered for responding patients 3
• Regular reassessment is necessary to determine the need for continued treatment 3
• Patients should be periodically monitored for relapse, particularly during the first year after acute treatment

Common Pitfalls to Avoid

• Underestimating medical risks: Severe purging can lead to electrolyte abnormalities and cardiac complications
• Inadequate medication dosing: The standard dose of fluoxetine for bulimia (60 mg/day) is higher than typical depression dosing 3
• Premature termination of treatment: Maintenance therapy is often necessary to prevent relapse
• Neglecting comorbid conditions: Depression and anxiety frequently co-occur with bulimia and may require specific attention
• Focusing only on behavioral symptoms: Treatment must address both behavioral symptoms (binging/purging) and underlying cognitive distortions about body image and weight

By following these evidence-based guidelines, clinicians can provide effective treatment for patients with bulimia nervosa, significantly reducing morbidity and improving quality of life.