Treatments

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Treatment for bulimia nervosa typically involves several therapy approaches. It is, however, complicated by several factors.

First, patients diagnosed with bulimia nervosa frequently have coexisting psychiatric disorders that typically include major depression, dysthymic disorder, anxiety disorders, substance abuse disorders, or personality disorders. In the case of depression, the mood disorder may either precede or follow the onset of bulimia, and, with bulimia, the prevalence of depression is 40%-70%. With regard to substance abuse, about 30% of patients diagnosed with bulimia nervosa abuse either alcohol or stimulants over the course of the eating disorder. The personality disorders most often diagnosed in bulimics are the so-called Cluster B disorders— borderline, narcissistic, histrionic, and antisocial. Borderline personality disorder is a disorder characterized by stormy interpersonal relationships, unstable self-image, and impulsive behavior. People with narcissistic personality disorder believe that they are extremely important and are unable to have empathy for others. Individuals with histrionic personality disorder seek attention almost constantly and are very emotional. Antisocial personality disorder is characterized by a behavior pattern of a disregard for others' rights— people with this disorder often deceive and mainpulate others. A number of clinicians have noted that patients with bulimia tend to develop impulsive and unstable personality disturbances whereas patients with anorexia tend to be more obsessional and perfectionistic. Estimates of the prevalence of personality disorders among patients with bulimia range between 2% and 50%. The clinician must then decide whether to treat the eating disorder and the comorbid conditions concurrently or sequentially. It is generally agreed, however, that a substance abuse disorder, if present, must be treated before the bulimia can be effectively managed. It is also generally agreed that mood disorders and bulimia can be treated concurrently, often using antidepressant medication along with therapy.

Second, the limitations on treatment imposed by managed care complicate the treatment of bulimia nervosa. When the disorder first received attention in the 1970s, patients with bulimia were often hospitalized until the most significant physical symptoms of the disorder could be treated. As of 2002, however, few patients with bulimia are hospitalized, with the exception of medical emergencies related to electrolyte imbalances and gas trointestinal injuries associated with the eating disorder. Most treatment protocols for bulimia nervosa now reflect cost-containment measures.

Medications

The most common medications given to patients are antidepressants, because bulimia is so closely associated with depression. Short-term medication trials have reported that tricyclic antidepressants— desipramine, imipramine, and amitriptyline — reduce episodes of binge eating by 47%-91% and vomiting by 45%-78%. The monoamine oxidase inhibitors are not recommended as initial medications for patients diagnosed with bulimia because of their side effects. The most promising results have been obtained with the selective serotonin reuptake inhibitors, or SSRIs. Fluoxetine (Prozac) was approved in 1998 by the Food and Drug Administration (FDA) for the treatment of bulimia nervosa. Effective dosages of fluoxetine are higher for the treatment of bulimia than they are for the treatment of depression. Although a combination of medication and cognitive-behavioral therapy is more effective in treating most patients with bulimia than medication alone, one team of researchers reported success in treating some bulimics who had not responded to psychotherapy with fluoxe-tine by itself.

A newer type of medication that shows promise in the treatment of bulimia nervosa is ondansetron, a drug that was originally developed to control nausea from chemotherapy and radiation therapy for cancer. Ondansetron acts to control the transmission of signals in nerves leading to the vagus nerve, which in turn governs feelings of fullness and the vomiting reflex. A British study reported that ondansetron normalized several aspects of eating behaviors in all the patients who received it during the study.

In addition to antidepressant or antinausea medications, such acid-reducing medications as cimetidine and ranitidine, or antacids, may be given to patients with bulimia to relieve discomfort in the digestive tract associated with irritation caused by stomach acid.

Psychotherapy

Cognitive-behavioral therapy (CBT) is regarded as the most successful psychotherapeutic approach to bulimia nervosa. CBT is intended to interrupt the faulty thinking processes associated with bulimia, such as preoccupations with food and weight, black-white thinking ("all or nothing" thinking, or thinking thoughts only at extreme ends of a spectrum) and low self-esteem, as well as such behaviors as the binge-purge cycle. Patients are first helped to regain control over their food intake by keeping food diaries and receiving feedback about their meal plans, symptom triggers, nutritional balance, etc. They are then taught to challenge rigid thought patterns as well as receiving assertiveness training and practice in identifying and expressing their feelings in words rather than through distorted eating patterns. About 50% of bulimic patients treated with CBT are able to stop bingeing and purging. Of the remaining half, some show partial improvement and a small minority do not respond at all.

Family therapy is sometimes recommended as an additional mode of treatment for patients with bulimia who come from severely troubled or food-obsessed families that increase their risk of relapsing.

Other mainstream therapies

Medical nutrition therapy, or MNT, is a recognized component of the treatment of eating disorders. Effective MNT for patients with bulimia involves an understanding of cognitive-behavioral therapy as well as the registered dietitian's usual role of assisting the physician with monitoring the patient's physical symptoms, laboratory values, and vital signs. In the treatment of bulimia, the dietitian's specialized knowledge of nutrition may be quite helpful in dealing with the myths about food and fad diets that many bulimic patients believe. The dietitian's most important task, however, is helping the patient to normalize her or his eating patterns in order to break the deprivation/bingeing cycle that is characteristic of bulimia nervosa. Calorie intake is usually based on retaining the patient's weight in order to prevent hunger, since hunger increases susceptibility to bingeing.

Recent studies in upstate New York have found that bright light therapy, of the type frequently prescribed for seasonal affective disorder (SAD), appears to be effective in reducing binge eating in patients diagnosed with bulimia. It also significantly relieved depressive symptoms, as measured by the patients' scores on the Beck Depression Inventory.

Alternative and complementary treatments

Alternative therapies that have been shown to be helpful for some patients in relieving the anxiety and muscular soreness associated with bulimia nervosa include acupuncture, massage therapy, hydrotherapy, and shiatsu.

Herbal remedies that have been used to calm digestive upsets in bulimic patients include teas made from chamomile or peppermint. Peppermint helps to soothe the intestines by slowing down the rate of smooth muscle contractions (peristalsis). Chamomile has been used to help expel gas from the digestive tract, a common complaint of bulimics. Both herbs have a wide margin of safety.

Some bulimic patients have responded well to yoga u because its emphasis on focused breathing and medita- m tion calls attention to and challenges the distorted 5' thought patterns that characterize bulimia. In addition, e the stretching and bending movements that are part of a vo yoga practice help to displace negative thoughts focused sa on the body's outward appearance with positive appreciation of its strength and agility. Lastly, since yoga is non-competitive, it allows bulimics to explore the uniqueness of their bodies rather than constantly comparing themselves to other people.

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