Treatment
Treatment approaches to bulimia nervosa are outlined in

Table 26-4.

Multiple studies have been published describing the efficacy of both psychotherapy and psychopharmacology in the treatment of bulimia nervosa.

Dynamically based psychotherapies, particularly those that focus on interpersonal conflicts, eg, assertiveness, negotiation of needs, intimacy fears, etc, are effective, but cognitive-behavioral therapies are by far the most studied. Such therapies focus on the thought patterns and feeling states that lead to episodes of binge eating and purging with special emphasis on attitudes pertaining to body weight and shape. Coping strategies for handling the feelings associated with these attitudes, such as maintaining a food journal that includes both “what you are eating, and what’s eating you,” are suggested to the patient. Patients are expected to eat structured meals and their irrational fears regarding weight gain are addressed. Obsessive preoccupation with body shape and size is challenged, as patients are helped to better tolerate painful affect, and to be more direct in interpersonal problem solving.

Psychoeducational approaches are also helpful. For example, advising patients to not fast during the day, because fasting leads to binge eating (the normal tendency to purchase more groceries, including more “junk foods,” if shopping while hungry is an easily recognized example of this phenomenon), usually results in symptom reduction. Patient education and cognitive-behavioral approaches can be easily implemented in primary care settings.

Group therapies, including psychodynamic, cognitive-behavioral, and self-help formats, are usually recommended.

The most dramatic reports of treatment success are of studies using pharmacological therapies, with antidepressant medications being particularly effective. Tricyclic antidepressants, monoamine oxidase inhibitors, and selective serotonin reuptake inhibitors such as fluoxetine, sertraline, and paroxetine have all shown efficacy in the treatment of bulimia nervosa, with responses ranging between reduction of binge eating and/or purging behavior to complete remission of symptoms. The antidepressant venlafaxine and the antiobsessional drug fluvoxamine also have proven efficacy. The antidepressant bupropion is contraindicated in anorexia nervosa and bulimia nervosa because of an increased risk of seizures. Studies show that if one antidepressant is ineffective or poorly tolerated, a trial of an alternative antidepressant may be successful. Mood-stabilizing drugs such as carbamazepine and valproic acid are sometimes helpful (lithium is contraindicated because of the electrolyte imbalance that is commonly present in bulimia nervosa). Anxiolytics may also play a helpful role in some cases, but their potential for abuse necessitates careful monitoring.