Management of Bulimia Nervosa
For adults with bulimia nervosa, treatment should include eating disorder-focused cognitive-behavioral therapy (CBT) combined with fluoxetine 60 mg daily, as this combination has demonstrated superior efficacy in reducing binge-eating and purging behaviors. 1, 2
Initial Assessment
- A comprehensive psychiatric evaluation should include weighing the patient, quantifying eating and weight control behaviors (frequency, intensity, time spent on dietary restriction, binge eating, purging, exercise) 1
- Identification of co-occurring psychiatric disorders is essential, as these are common in bulimia nervosa 1, 2
- Physical examination should assess vital signs (temperature, heart rate, blood pressure, orthostatic measurements), height, weight, BMI, and signs of purging behaviors 1
- Laboratory assessment should include complete blood count, comprehensive metabolic panel (electrolytes, liver enzymes, renal function tests) 1
- An electrocardiogram is recommended for patients with severe purging behavior 1, 2
Treatment Approach
Psychological Treatment
- Eating disorder-focused cognitive-behavioral therapy (CBT) is the first-line psychological treatment for adults with bulimia nervosa 1, 2
- CBT for bulimia nervosa focuses on normalizing eating behaviors and addressing psychological aspects such as fear of weight gain and body image disturbance 2, 3
- CBT has demonstrated superior efficacy compared to supportive psychotherapy in reducing behavioral symptoms of bulimia nervosa 4
- For adolescents and emerging adults with involved caregivers, eating disorder-focused family-based treatment is suggested 1
Pharmacological Treatment
- Fluoxetine at 60 mg daily is the recommended pharmacological treatment, administered in the morning 2, 5
- This specific dose (60 mg/day) has been shown to be statistically significantly superior to placebo in reducing the frequency of binge-eating and vomiting 5
- The combination of medication and psychological treatment produces greater improvement in binge eating and depression than psychological treatment alone 4
- If fluoxetine is not tolerated or ineffective, consider alternative serotonin reuptake inhibitors, though these have less evidence specifically for bulimia nervosa 2
Combined Approach
- The combination of CBT plus medication is superior to medication alone 4
- A coordinated multidisciplinary team incorporating medical, psychiatric, psychological, and nutritional expertise is recommended for comprehensive treatment 1
- Nutritional therapy may be beneficial as part of a combined approach, but cognitive therapy remains the psychological treatment of choice 6
Alternative Treatment Modalities
- Technology-based interventions, including guided computer-based interventions and videoconferencing, show promise for treating bulimia nervosa 1, 2
- These approaches may help overcome barriers such as shame, stigma, and shortage of specialized providers 2
- Group CBT has also shown effectiveness in reducing bulimic symptoms, with improvements maintained at 6-month follow-up 7
- Self-help approaches using structured CBT treatment manuals are promising alternatives when specialized treatment is unavailable 3
Treatment Duration and Follow-up
- The efficacy of fluoxetine 60 mg/day in maintaining response has been demonstrated for up to 52 weeks in patients who responded during an 8-week acute treatment phase 5
- Long-term usefulness of medication should be periodically reevaluated 5
- Regular monitoring of symptoms, weight, and laboratory parameters is essential throughout treatment 1
Common Pitfalls and Considerations
- Psychotherapy alone is unlikely to reduce or change body weight in people with bulimia nervosa 3
- Exposure and Response Prevention does not enhance the efficacy of CBT for bulimia nervosa 3
- Lower pre-treatment self-control scores may predict poorer outcomes, suggesting these patients may need more intensive intervention 6
- Careful monitoring for cardiac complications is necessary, especially in patients with severe purging behaviors 1, 2