Approach

Cognitive behavioural therapy (CBT) is considered the optimal primary treatment for bulimia. A guided self-help approach is recommended in the first instance.[86] Selective serotonin-reuptake inhibitors (SSRIs) or serotonin-noradrenaline reuptake inhibitors (SNRIs) may be used adjunctively to CBT, or as an alternative when CBT is not available or desired. Interpersonal psychotherapy (IPT) and psychoanalytic psychotherapy have also shown efficacy.

Treatment of comorbid psychiatric disorders, such as major depressive disorder and obsessive-compulsive disorder (OCD), is necessary to optimise the chance of recovery from bulimia nervosa. SSRIs are effective for additional treatment of comorbid psychiatric disease.

Patients should be assessed for suicidality, diabetes mellitus, and physical symptoms such as loss of consciousness, syncope, and seizures. These complications indicate the need for immediate referral to specialists. Alcohol-use disorder or other substance misuse, borderline personality disorder, or on-going self-injurious behaviour also indicates the need for immediate specialised psychiatric or psychological referral. Otherwise, treatment can progress in an outpatient setting.[11][87][88] Treatment using telemedicine may be useful. The most appropriate therapy depends on availability, the comfort of the patient and therapist with the therapy, and the concurrent issues, such as personality disorder, that may also require treatment.

Specific psychological and pharmacological treatments

CBT

  • This is the primary treatment for bulimia nervosa. It may begin with CBT guided self-help (e.g., CBT self-help materials supplemented with 9 twenty-minute supportive sessions over 16 weeks).[86] Switching to standard CBT after a 4-week trial is recommended if guided self-help is ineffective, unacceptable or contraindicated.[86]

  • One Cochrane review examined the evidence for the efficacy of CBT in treating bulimia. The conclusion was that, while there is evidence to support the use of CBT, the quality of trials is variable and sample sizes are often small.[89][90]

  • Email guidance-based CBT is reported to be useful in conjunction with individual therapy.[91]

  • One randomised trial found that family-based therapy may be more effective than CBT in the short term for adolescent patients with bulimia nervosa; however, there was no difference between groups at 1-year follow-up.[87][92]

IPT and psychoanalytic psychotherapy

  • There is evidence that IPT can be effective for reducing binge-eating episodes.[73]

  • Psychoanalytic psychotherapy has also shown efficacy, though a randomised trial reported that CBT was more effective.[93]

SSRIs or SNRIs

  • These are a useful adjunct in non-pregnant patients to temporarily reduce the frequency of bingeing and purging. They may also be used adjunctively (e.g., in patients with comorbid depression). They are also an alternative stand-alone treatment in non-pregnant patients when CBT is unavailable.

  • The time-course of medication varies depending on reason for use.

  • Pregnant patients are only rarely treated with medication, and only in severe, refractory cases under expert supervision at a psychiatrist's discretion, because of associated risks.

  • There is very little evidence for pharmacological treatments for children and adolescents with bulimia nervosa. Fluoxetine is not approved by the US Food and Drug Administration for paediatric bulimia nervosa; however, it is approved for child and adolescent depression and obsessive-compulsive disorder, so it could be considered if medication is required.[87]

It is important to note that bupropion, another antidepressant with a different mechanism of action, is contraindicated in patients with conditions that increase the risk of seizures, such as bulimia nervosa, because bupropion can cause seizures.

General approach and supportive therapies

Building of rapport and patient self-esteem

  • It is important to build a rapport with the patient and aim to improve patient self-esteem. Providers should encourage understanding of the condition and motivation to normalise eating behaviour. Kindness and positivity towards patients with bulimia nervosa is standard therapy.[94]

Nutrition

  • Patient should be seen by a registered dietitian (experienced nutritionist) to review the dietary history, formulate a plan with the patient to normalise nutritional intake, and follow up to ensure weight maintenance. This can help provide nutritional information and retraining.

  • There are mixed findings regarding weight suppression. Most studies show it does not predict outcome at the end of treatment in bulimia nervosa.[95]

Other types of supportive therapies

  • Core dysfunctional thoughts, attitudes, motives, conflicts, and feelings should be addressed. Treatment should consider personality factors.[96]

  • Family support should be enlisted. Family therapy can be useful in adolescents with bulimia nervosa.[87][92][97][98][99][100]​​

  • Other types of supportive therapy include self-help groups and internet use of CBT.[91][101][102]

  • Treatment of comorbid psychiatric disorders, such as major depressive disorder and OCD, is necessary for optimal treatment of bulimia nervosa.

Patients with diabetes

Bulimia nervosa causes marked fluctuations in blood sugar in diabetes mellitus. This can lead to the rapid progression of diabetic vascular complications. Admittance to a hospital may be necessary. Referral to an endocrinologist is recommended for optimal glucose control.[103]

Pregnancy

It is recommended that pregnant patients should be assessed for follow-up as a high-risk pregnancy. Therefore, referral to an obstetrician and psychiatrist is advised. The outcome of pregnancy is optimised when nutritional intake is normalised, contraindicated medications are avoided, and mood disturbance is treated.[104][105] Pregnant patients are only rarely treated with medication, and only in severe, refractory cases under expert supervision at a psychiatrist's discretion, because of associated risks. In pregnancy, a dietitian should be consulted to prepare the patient for the increase in caloric intake required and the associated weight gain and oedema. During pregnancy, proper nutrition is essential for the developing fetus. The mother is often able to abstain from bingeing and purging. Deficiencies of vitamins and minerals should be corrected as soon as pregnancy is diagnosed. Pregnant patients also require close fetal monitoring.

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