What is the treatment for bulimia nervosa?

Treatment for Bulimia Nervosa

Cognitive-behavioral therapy (CBT) specifically designed for eating disorders is the first-line treatment for adults with bulimia nervosa, and fluoxetine 60 mg daily should be added either initially or if there is minimal response to psychotherapy alone by 6 weeks. 1, 2

Core Treatment Framework

Multidisciplinary Team Approach

• All patients with bulimia nervosa require coordinated care from a multidisciplinary team that includes a primary care physician for medical monitoring, a mental health practitioner for specialized eating disorder psychotherapy, and a registered dietitian for nutritional rehabilitation and meal planning. 1
• Additional specialists may be necessary depending on complications, including a psychiatrist for medication management and complex psychiatric comorbidities, a cardiologist for cardiac complications from purging, and an endocrinologist for hormonal issues. 1

First-Line Psychotherapy

Eating Disorder-Focused CBT

• CBT specifically targeting bulimia nervosa is the cornerstone of treatment, focusing on normalizing eating behaviors, eliminating binge-purge cycles, and addressing distorted cognitions about shape, weight, and self-esteem. 1, 2
• The evidence base for CBT in bulimia nervosa is robust, with approximately 50% of patients achieving complete abstinence from binge eating and purging behaviors. 3, 4
• CBT should address all five core symptoms of bulimia nervosa: binge eating, purging behaviors, restrictive eating patterns, concerns with shape and weight, and self-esteem issues. 5

Treatment Delivery Options

• Traditional face-to-face CBT remains the gold standard, but guided computer-based and internet-based CBT interventions show efficacy, particularly for compliant patients, and can improve access to care when specialized providers are unavailable. 6
• Online chat-based group CBT may be slower to produce results than face-to-face therapy but achieves comparable outcomes by 12-month follow-up, making it a viable option for increasing treatment accessibility. 7
• Videoconferencing represents another promising delivery method for CBT when in-person treatment is not feasible. 6

Pharmacotherapy

Fluoxetine as Primary Medication

• Fluoxetine 60 mg/day is the recommended medication for bulimia nervosa, as it is the only dose that has been shown to be statistically superior to placebo in reducing binge-eating and vomiting frequency. 8
• The 60 mg dose should be administered in the morning, and for some patients it may be advisable to titrate up to this target dose over several days. 8
• Fluoxetine can be initiated either at the start of treatment or added if there is minimal response to psychotherapy alone by 6 weeks. 2
• Maintenance treatment with fluoxetine 60 mg/day for up to 52 weeks has demonstrated benefit in preventing relapse in patients who responded during acute treatment. 8

Important Medication Considerations

• Doses above 60 mg/day have not been systematically studied in bulimia nervosa patients and should not be used. 8
• Lower or less frequent dosing should be considered in patients with hepatic impairment, elderly patients, and those with concurrent diseases or multiple medications. 8

Age-Specific Approaches

Adolescents and Emerging Adults

• Family-based treatment is recommended for adolescents with bulimia nervosa when an involved caregiver is available, with emphasis on caregiver education to normalize eating behaviors. 1, 2
• Fluoxetine may be considered in adolescents but should be used cautiously in this population. 2

Medical Monitoring Requirements

Essential Assessments

• Regular monitoring must include vital signs (temperature, resting heart rate, blood pressure, orthostatic measurements), weight, laboratory values (complete blood count, comprehensive metabolic panel with electrolytes, liver and renal function), and cardiac function via ECG. 1, 2
• Particular attention should be paid to electrolyte abnormalities, especially hypokalemia in patients with severe purging behaviors, as this can lead to cardiac arrhythmias. 2

Treatment Duration and Maintenance

• While controlled trials established efficacy over 8-16 weeks, maintenance treatment should be considered for responding patients, as bulimia nervosa is a chronic condition. 8
• Patients should be periodically reassessed to determine ongoing need for treatment and to maintain them on the lowest effective dosage. 8

Common Pitfalls to Avoid

• Do not fail to weigh patients due to sensitivity concerns - weight monitoring is essential for medical safety even though BMI may be normal or near-normal. 2
• Do not focus solely on weight rather than on eating behaviors and psychological aspects - the cognitive and behavioral components are central to recovery. 2
• Do not overlook medical complications from purging - cardiac arrhythmias, electrolyte disturbances, and dehydration require immediate attention. 2
• Do not neglect screening for co-occurring psychiatric disorders - these are common and affect treatment outcomes. 2

When Standard Treatment Fails

• Approximately 50% of patients do not achieve complete abstinence with standard CBT, with some showing partial improvement and others deriving minimal benefit. 4
• For nonresponders to CBT, consider more intensive or expanded CBT approaches rather than switching to alternative therapies, as both antidepressant medication and interpersonal psychotherapy have shown limited success after unsuccessful CBT. 4
• Comorbid personality disorder is associated with poorer response to all treatment modalities and may require more intensive intervention. 4