Treatment of Bulimia Nervosa

Therapy for bulimia nervosa, as for anorexia nervosa, requires a team of experienced clinicians. These patients are less likely than those with anorexia to enter treatment in a state of semistarvation. However, if a bulimic patient has lost significant weight, this must be treated before psychological treatment begins. Although clinicians have yet to agree on the best therapy for bulimia nervosa, they generally agree that treatment should last at least 16 weeks. Hospitalization may be indicated in cases of extreme laxative abuse, regular vomiting, substance abuse, and depression, especially if physical harm is evident.
The first goal of treatment for bulimia nervosa is to decrease the amount of food consumed in a binge session in order to decrease the risk of esophageal tears from related purging by vomiting. A decrease in the number of this type of purges will also decrease damage to the teeth.
The primary aim of psychotherapy is to improve patients' self-acceptance and help them to be less concerned about body weight. Cognitive behavior therapy is generally used. Psychotherapy helps correct the all-or-none thinking typical of bulimic persons— "If I eat one cookie, I'm a failure and might as well binge." A patient may be asked to analyze the statement as a scientist would do when testing assumptions. In this way, patient and therapist together examine the validity of food and weight beliefs. The premise of this therapy is that, if abnormal attitudes and beliefs can be altered, normal eating will follow. In addition, the therapist guides the person in establishing food habits that will minimize bingeing: avoiding fasting, eating regular meals, and using alternative methods—other than eating—to cope with stressful situations. Group therapy is often useful to foster strong social support. One goal of therapy is to help bulimic persons accept as normal some depression and self-doubt.
Although pharmacological agents should not be used as the sole treatment for bulimia nervosa, studies indicate that some medications may be beneficial in conjunction with other therapies. Fluoxetine (Prozac) is the only antidepressant that has been approved by PDA for use in the treatment of bulimia nervosa, but physicians also may prescribe other forms of antidepressants and related medications.
Nutritional counseling has two main goals: correcting misconceptions about food and re-establishing regular eating habits. Patients are given information about bulimia nervosa and its consequences. Avoiding binge foods and not constantly stepping on a scale may be recommended early in treatment. The primary goal, however, is to develop a normal eating pattern. To achieve this goal, some specialists encourage patients to develop daily meal plans and keep a food diary in which they record food intake, internal sensations of hunger, environmental factors that precipitate binges, and thoughts and feelings that accompany binge-purge cycles. Keeping a food diary not only is an accurate way to monitor food intake but also may help identify situations that seem to trigger binge episodes. With the help of a therapist, patients can develop alternative coping strategies.
In general, the focus is not on stopping bingeing and purging per se but on developing regular eating habits. Once this is achieved, the binge-purge cycle should stop by itself. Patients are discouraged from following strict rules about healthy food choices, because this simply mimics the typical obsessive attitudes associated with bulimia nervosa. Rather, encouraging a mature perspective on nutrient intake—that is, regular consumption of moderate amounts of a variety of foods balanced among the food groups—helps patients overcome this disorder.
Setting time limits for the completion of meals and snacks is important for people with eating disorders. Many bulimic persons eat very quickly, reflecting their difficulties with satiety. Suggesting that the patient put his or her utensil down after each bite is a behavioral technique that a therapist might try with a recovering bulimic person. (In comparison, many anorexic persons eat in an excessively slow manner—for example, taking 1 hour to eat a muffin because it was cut into tiny, bite-size pieces.)
People with bulimia nervosa must recognize that it is a serious disorder that canhave grave medical complications if not treated. Because relapse is likely, therapyshould be long term. Note that those with bulimia nervosa need professional help because they can be very depressed and are at a high risk for suicide. About 50% of people with bulimia nervosa recover completely from the disorder. Others continue tostruggle with it to varying degrees for the rest of their lives. This fact underscores theneed for prevention because treatment is difficult.