Treatment for Bulimia Nervosa
The American Psychiatric Association recommends that adults with bulimia nervosa be treated with eating disorder-focused cognitive-behavioral therapy (CBT) and a serotonin reuptake inhibitor (fluoxetine 60 mg daily), either initially or if there is minimal or no response to psychotherapy alone by 6 weeks of treatment. 1
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
- Identify co-occurring psychiatric disorders, which are common in bulimia nervosa 1, 2
- Physical examination should assess vital signs, height, weight, BMI, and signs of purging behaviors 1
- Laboratory assessment should include complete blood count, comprehensive metabolic panel, electrolytes, liver enzymes, and renal function tests 1
- An electrocardiogram is recommended for patients with severe purging behavior 1
First-Line Treatment
Psychological Treatment
- Eating disorder-focused cognitive-behavioral therapy (CBT) is the cornerstone treatment for bulimia nervosa 1, 2, 3
- CBT focuses on normalizing eating behaviors and addressing psychological aspects like fear of weight gain and body image disturbance 2, 3
- For adolescents and emerging adults with involved caregivers, eating disorder-focused family-based treatment is suggested 1
Pharmacological Treatment
- Fluoxetine at 60 mg/day is the recommended medication, administered in the morning 2, 4
- This dose was statistically significantly superior to placebo in reducing the frequency of binge-eating and vomiting 4
- For some patients, it may be advisable to titrate up to the target dose over several days 4
- Fluoxetine doses above 60 mg/day have not been systematically studied in patients with bulimia 4
Treatment Delivery
- Treatment should be delivered by a coordinated multidisciplinary team incorporating medical, psychiatric, psychological, and nutritional expertise 1, 3
- The team typically includes a primary care physician, mental health practitioner, and registered dietitian/nutritionist 3
- A documented, comprehensive, culturally appropriate, and person-centered treatment plan is essential 1
When First-Line Treatment Fails
- If there is minimal or no response to psychotherapy alone by 6 weeks, add fluoxetine 60 mg daily 1, 2
- For patients who don't respond to CBT, more expanded or intensive CBT may be considered 5
- Systematic evaluation has demonstrated benefit of continuing fluoxetine 60 mg/day for up to 52 weeks in patients who have responded during an 8-week acute treatment phase 4
Technology-Based Interventions
- Guided computer-based interventions show promise for treating bulimia nervosa and may help overcome barriers such as shame, stigma, and shortage of specialized providers 1, 2
- Videoconferencing appears to be a promising approach for delivering care 1, 3
- These technology-based interventions can serve as a first step in a stepped-care model 1
Special Considerations
- Lower or less frequent dosage of fluoxetine should be used in patients with hepatic impairment 4
- Lower or less frequent dosage should also be considered for elderly patients and those with concurrent disease or on multiple medications 4
- Patient compliance is essential for treatment success, especially with technology-based interventions 1
- Patients should be periodically reassessed to determine the need for maintenance treatment 4