Bulimia Nervosa Treatments

Bulimia nervosa is an eating disorder characterized by recurrent episodes of binge eating in combination with inappropriate compensatory behaviours (e.g., self-induced vomiting, laxative misuse) and an overvaluation of weight and shape ¹American Psychiatric Association. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.: DSM 5. Virginia: American Psychiatric Association 2013..

Below, I provide an in-depth review of current bulimia nervosa treatments and the scientific evidence supporting their effectiveness.

Bulimia nervosa primarily affects younger women, although there is emerging evidence showing that more and more men are beginning to develop the disorder. The lifetime global prevalence of bulimia nervosa is estimated to be around 2.0% for women and 0.5% for men²Keski-Rahkonen A, Hoek H, Linna M, et al. Incidence and outcomes of bulimia nervosa: a nationwide population-based study. Psychological Medicine. 2009;39:823-831..

The consequences of bulimia nervosa can also be significant³Fairburn CG, Harrison PJ. Eating disorders. The Lancet. 2003;361:407-416., and can include:

Physical health consequences

1. Electrolyte and chemical imbalances
2. Irregular heartbeat and heart failure
3. Rupture of the oesophagus
4. Dental erosion
5. Death

Psychosocial health consequences

1. Depression and/or anxiety
2. Substance abuse and risky drinking
3. Relationship problems
4. Self-harm behaviours
5. Low self-esteem

Treatments for Bulimia Nervosa

The significant consequences of this devastating eating disorder means that effective treatments are urgently needed. Current bulimia nervosa treatments include:

Cognitive-Behavioural Therapy

Cognitive-Behavioural Therapy (CBT) is currently the most effective treatment for bulimia nervosa. Clinical guidelines all over the world recommend CBT as a first-line treatment or treatment of choice for bulimia nervosa⁴Hilbert A, Hoek H, Schmidt R. Evidence-based clinical guidelines for eating disorders: international comparison. Current Opinion in Psychiatry. 2017..

CBT aims to target the factors that maintain the binge eating and purging behaviour in bulimia nervosa⁵Fairburn CG. Cognitive behavior therapy and eating disorders. New York, NY: Guilford Press 2008.. These factors are:

1. Overvaluation of weight and shape
2. Inflexible dieting
3. Maladaptive emotion regulation strategies

CBT usually lasts between 16-20 sessions with a therapist to be optimally effective. It follows a treatment manual that specifies when each treatment strategy is delivered, while also placing a lot of importance on the therapeutic alliance⁶Fairburn CG. Cognitive behavior therapy and eating disorders. New York, NY: Guilford Press 2008..

Some key CBT strategies are:

1. Self-monitoring of eating behaviour
2. Engaging in a pattern of regular eating
3. Planned, weekly weighing with the therapist
4. Enhancing problem solving skills
5. Cognitive restructuring around body image
6. Exposure to forbidden foods

Evidence for Cognitive-Behavioural Therapy

CBT is the most widely studied bulimia nervosa treatment. Many meta-analyses have synthesized the findings from randomized controlled trials of CBT. Key findings from these meta-analyses are:

1. CBT for bulimia nervosa is more effective than other psychological therapies, including interpersonal psychotherapy and behaviour therapy, in reducing symptoms of bulimia nervosa⁷Linardon J, Wade T, De la Piedad Garcia X, et al. The efficacy of cognitive-behavioral therapy for eating disorders: A systematic review and meta-analysis Journal of Consulting and Clinical Psychology. 2017;85:1080–1094.⁸Linardon J. Meta-analysis of the effects of cognitive-behavioral therapy on the core eating disorder maintaining mechanisms: Implications for mechanisms of therapeutic change. Cognitive Behaviour Therapy. 2018;47:107-125..
2. These effects are sustained more than a year after CBT ends⁹Linardon J, Wade T, De la Piedad Garcia X, et al. The efficacy of cognitive-behavioral therapy for eating disorders: A systematic review and meta-analysis Journal of Consulting and Clinical Psychology. 2017;85:1080–1094..
3. CBT for bulimia nervosa is effective regardless of whether it delivered in an individual or group setting, in adults or adolescents, or in a therapist led or guided self-help format¹⁰Linardon J, Wade T, De la Piedad Garcia X, et al. The efficacy of cognitive-behavioral therapy for eating disorders: A systematic review and meta-analysis Journal of Consulting and Clinical Psychology. 2017;85:1080–1094.¹¹Linardon J, Wade T. How many individuals achieve symptom abstinence following psychological treatments for bulimia nervosa? A meta-analytic review. International Journal of Eating Disorders. 2018;51:287-294..
4. 43% of people with bulimia nervosa completely stop bingeing and purging after receiving CBT¹²Linardon J, Wade T. How many individuals achieve symptom abstinence following psychological treatments for bulimia nervosa? A meta-analytic review. International Journal of Eating Disorders. 2018;51:287-294..
5. CBT is also effective in improving quality of life and reducing co-occuring depressive symptoms in bulimia nervosa¹³Linardon J, Brennan L. The effects of cognitive‐behavioral therapy for eating disorders on quality of life: A meta‐analysis. International Journal of Eating Disorders. 2017;50:715–730.¹⁴Linardon J, Wade T, De la Piedad Garcia X, et al. Psychotherapy for bulimia nervosa on symptoms of depression: A meta-analysis of randomized controlled trials International Journal of Eating Disorders. 2017;50:1124–1136..

Interpersonal Psychotherapy

Interpersonal psychotherapy is another effective treatment for bulimia nervosa.

Interpersonal psychotherapy broadly aims to help people maintain or develop healthy interpersonal relationships.

Interpersonal problems are common in people with bulimia nervosa, and they contribute to the maintenance of binge eating, purging, and extreme weight control behaviours.

Therefore, Interpersonal psychotherapy aims to “disrupt” one of the central factors (i.e., interpersonal problems) that maintain bulimia nervosa¹⁵Murphy R, Straebler S, Basden S, et al. Interpersonal psychotherapy for eating disorders. Clin Psychol Psychother. 2012;19:150-158..

Interpersonal psychotherapy usually involves 16-20 sessions with a therapist. Treatment is broken up into 3 phases¹⁶Murphy R, Straebler S, Basden S, et al. Interpersonal psychotherapy for eating disorders. Clin Psychol Psychother. 2012;19:150-158.:

1. Phase 1: The aim of this phase is to engage people in treatment and to describe the reasons and nature of Interpersonal psychotherapy. The therapist also helps clients identify any current interpersonal problems.
2. Phase 2: This is where the interpersonal problems are addressed. Key strategies to address these problems include:
   • Role play
   • Decision analysis
   • Problem solving
   • Socratic questioning
3. Phase 3: The aims of this phase are to ensure that changes made in treatment are sustained and that the risk of relapse is prevented.

Evidence for Interpersonal psychotherapy

A small number of randomized controlled trials have examined the effectiveness of Interpersonal psychotherapy for bulimia nervosa. Key findings from these studies are as follows:

1. Interpersonal psychotherapy can produce large and long lasting improvements in core bulimia nervosa symptoms¹⁷Fairburn CG, Jones R, Peveler RC, et al. Three psychological treatments for bulimia nervosa: A comparative trial. Archives of General Psychiatry. 1991;48:463-469..
2. Interpersonal psychotherapy is slower to act than CBT, but is equally as effective one year after treatment ends¹⁸Fairburn CG, Bailey-Straebler S, Basden S, et al. A transdiagnostic comparison of enhanced cognitive behaviour therapy (CBT-E) and interpersonal psychotherapy in the treatment of eating disorders. Behaviour Research and Therapy. 2015;70:64-71..
3. Interpersonal psychotherapy is also effective in reducing co-occurring depressive and anxiety symptoms in bulimia nervosa¹⁹Fairburn CG, Bailey-Straebler S, Basden S, et al. A transdiagnostic comparison of enhanced cognitive behaviour therapy (CBT-E) and interpersonal psychotherapy in the treatment of eating disorders. Behaviour Research and Therapy. 2015;70:64-71..
4. Around 23% completely abstain from binge eating and purging after Interpersonal psychotherapy ²⁰Linardon J, Wade T. How many individuals achieve symptom abstinence following psychological treatments for bulimia nervosa? A meta-analytic review. International Journal of Eating Disorders. 2018;51:287-294..

Family-Based Therapy

Family-based therapy is another effective treatment for adolescents with bulimia nervosa. Family-based therapy is one of the recommended treatment approaches for younger populations.

Family-based therapy views the parents of adolescents with bulimia nervosa as a resource for resolving the problem, and corrects misperceptions of blame directed to the parents and to the ill adolescent²¹Le Grange D, Crosby RD, Rathouz PJ, et al. A randomized controlled comparison of family-based treatment and supportive psychotherapy for adolescent bulimia nervosa. Archives of General Psychiatry. 2007;64:1049-1056..

Siblings also play a supportive role in treatment, and are protected from the job assigned to the parents²²Le Grange D, Crosby RD, Rathouz PJ, et al. A randomized controlled comparison of family-based treatment and supportive psychotherapy for adolescent bulimia nervosa. Archives of General Psychiatry. 2007;64:1049-1056..

The focus of Family-based therapy is not on what caused bulimia nervosa, but on what can be done to resolve it²³Le Grange D, Lock J, Agras WS, et al. Randomized clinical trial of family-based treatment and cognitive-behavioral therapy for adolescent bulimia nervosa. Journal of the American Academy of Child & Adolescent Psychiatry. 2015;54:886-894..

Family-based therapy usually consists of 20 sessions over 6 months. Like interpersonal psychotherapy, there are three phases:

1. Phase 1: Parents are placed in charge of helping their child re-establish healthy eating patterns and prevent binge eating and purging episodes from occurring. Parents are instructed to take an authoritative role.
2. Phase 2: Core emphasis is placed on establishing a regular and flexible pattern of eating.
3. Phase 3: Addresses termination and issues of family structure and normal adolescent development.

Evidence for Family-based therapy

A small number of randomized controlled trials have examined the effectiveness of Family-based therapy for adolescents with bulimia nervosa. Key findings are:

1. Family-based therapy is more effective than both CBT and supportive counselling in producing abstinence from binge eating and purging behaviours²⁴Le Grange D, Lock J, Agras WS, et al. Randomized clinical trial of family-based treatment and cognitive-behavioral therapy for adolescent bulimia nervosa. Journal of the American Academy of Child & Adolescent Psychiatry. 2015;54:886-894..
2. On average, 28% are expected to experience full remission after FBT²⁵Darcy AM, Bryson SW, Agras WS, et al. Do in-vivo behaviors predict early response in family-based treatment for anorexia nervosa? Behav Res Ther. 2013;51(11):762-766..
3. Patients with less severe bulimia nervosa symptoms are expected to respond better to family therapy than patients with more severe bulimia nervosa symptoms.

Dialectical Behaviour Therapy

Dialectical behaviour therapy, originally developed for borderline personality disorder, is a psychological treatment that has been used to treat bulimia nervosa. It is gaining more and more evidence for its effectiveness.

Dialectical Behaviour Therapy primarily aims to teach people more effective and adaptive emotion regulation skills.

The Dialectical Behaviour Therapy model of bulimia nervosa views emotion dysregulation as the core problem in bulimia nervosa, with binge eating and purging understood to be an attempt to influence, modify, or control painful emotional states. Therefore, people are taught a repertoire of skills to replace these dysfunctional behaviours²⁶Safer DL, Telch CF, Agras WS. Dialectical behavior therapy for bulimia nervosa. The American Journal of Psychiatry. 2001;158:632-634..

Dialectical Behaviour Therapy usually lasts between 16-20 sessions with a therapist. There are three core modules within DBT:

1. Mindfulness module
2. Emotion regulation module
3. Distress tolerance module

Evidence for Dialectical Behaviour Therapy

Only a small number of randomized controlled trials have examined the effectiveness of Dialectical Behaviour Therapy for bulimia nervosa. Key findings include:

1. Dialectical Behaviour Therapy is significantly better at reducing all features of bulimia nervosa than a wait-list control group²⁷Safer DL, Telch CF, Agras WS. Dialectical behavior therapy for bulimia nervosa. The American Journal of Psychiatry. 2001;158:632-634.²⁸Hill DM, Craighead L, Safer D. Appetite‐focused dialectical behavior therapy for the treatment of binge eating with purging: A preliminary trial. International Journal of Eating Disorders. 2011;44:249-261..
2. On average, 28% are expected to experience full remission after Dialectical Behaviour Therapy²⁹Linardon J, Wade T. How many individuals achieve symptom abstinence following psychological treatments for bulimia nervosa? A meta-analytic review. International Journal of Eating Disorders. 2018;51:287-294..

Antidepressants

Antidepressant medications, such as fluoxetine (Prozac), desipramine and imipramine, are also used as a treatment for bulimia nervosa.

Treating depressive symptoms via antidepressants is said to indirectly target the core features of bulimia nervosa, as depressive symptoms are often a major trigger for binge eating and purging behaviour.

Getting in control of depressive symptoms is therefore assumed to have a positive effect on the symptoms of bulimia nervosa.

Evidence for Antidepressants

A number of studies have examined the effectiveness of antidepressant medications for bulimia nervosa. Key findings are:

1. Antidepressants are more effective than placebo pills³⁰Walsh BT, Wilson GT, Loeb KL, et al. Medication and psychotherapy in the treatment of bulimia nervosa. The American Journal of Psychiatry. 1997;154:523-531.³¹Bacaltchuk J, Hay PJ. Antidepressants versus placebo for people with bulimia nervosa. Cochrane Database of Systematic Reviews. 2003(4)..
2. Combining antidepressants with CBT may produce the best outcomes for bulimia nervosa³²Walsh BT, Wilson GT, Loeb KL, et al. Medication and psychotherapy in the treatment of bulimia nervosa. The American Journal of Psychiatry. 1997;154:523-531..
3. Many patients experience unwanted side effects, which makes adherence to antidepressants poor³³Bacaltchuk J, Hay PJ. Antidepressants versus placebo for people with bulimia nervosa. Cochrane Database of Systematic Reviews. 2003(4)..

Conclusion

There are a number of treatments available for bulimia nervosa. The treatments reviewed here are delivered on an outpatient basis with a therapist.

However, there are also a number of inpatient and day-patient programs and self-help books that may also be effective in treating this condition. The evidence supporting these other treatment modalities, however, is less clear.

Given that a substantial percentage of people with bulimia nervosa fail to fully recover from our best available treatments, it is clear that much more research needs to be done to improve the outcomes for this debilitating condition. If you need help, view our list of services and resources here.