Bulimia nervosa is generally treated in an outpatient setting. Both psychotherapy and medication have been shown to be efficacious in the treatment of bulimia nervosa.
1 Cognitive-Behavioral Psychotherapy (CBT)
CBT is the most well-studied psychological treatment for bulimia nervosa and is generally considered first-line treatment for this disorder (96,97). Originally adapted for use in eating disorders by Fairburn, CBT is based on the premise that central to the disorder are maladaptive cognitions regarding the fundamental importance of weight and shape. In this model, the extremes of dietary restraint that are used to control weight lead to compensatory binge eating. Thus, the modification of these abnormal attitudes and behaviors of weight and shape may be expected to ameliorate the consequent dietary restriction, binge eating, and purging. While modifications of the technique are frequent, the original program consisted of time-limited, individual treatment given over 20 weeks (98).
Studies of treatment efficacy show very good short-term outcomes for CBT. Reviews have shown mean reductions in binge eating and purging of from 40% to 97%, with about half of patients, on average, ''abstinent'' from binge eating or purging at the end of treatment (97). CBT has also been show to produce more rapid improvement in symptoms than nonspecific supportive psychotherapy (99).
2 Interpersonal Psychotherapy (IPT)
IPT has also been shown to improve symptoms in bulimia nervosa. This type of psychotherapy, originally developed for the treatment of depression, has been adapted for the treatment of eating disorders. In contrast to CBT, which focuses on the elimination of dietary restriction and distorted cognitions about weight and shape, IPT focuses on improving negative moods and low self-esteem that may trigger binge eating, through the mastery of social and interpersonal relationships (100). Research suggests that CBT is superior to IPT at 1 year in some measures of treatment effectiveness, including percentage recovered or remitted, or with improved eating attitudes and behaviors (101,102). At longer-term follow-up, however, IPT and CBT appear to have similar effectiveness (102-104).
Antidepressants, including tricyclics, monoamine oxidase (MAO) inhibitors, atypical antidepressants, and selective serotonin reuptake inhibitors (SSRIs), are frequently used in the treatment of bulimia nervosa and have been proven effective in numerous studies (97). MAO inhibitors have the disadvantage of requiring restriction of certain foods, which may be difficult for some bulimic patients. SSRIs, such as fluoxetine, have fewer adverse effects than tricyclics and MAO inhibitors. While some SSRIs, such as fluoxetine and sertra-line, don't cause weight gain, and may even cause weight loss, over the short term, weight generally returns to baseline with longer-term (i.e., > 6 months) treatment (105). Fluoxetine is currently FDA approved for the treatment of bulimia nervosa. Bupropion is contraindi-cated in patients with anorexia or bulimia nervosa because of an increased incidence of seizures (106). While trials with a variety of antidepressant agents of different classes have shown short-term efficacy in reduction of binge eating, there are a number of limitations to these studies. Most were conducted using fixed dosages over relatively short periods of time and involved populations of normal-weight, purging women. Thus, the optimal dose ranges, duration of treatment, and treatment response in the nonpurging bulimic patient are not clear. In a dose response study of fluo-xetine for bulimia nervosa, the most effective dose was 60 mg/d, significantly higher than that usually used for depression (107). Both patients with and without a history of depression appear to show similar improvement in bulimic symptoms with antidepressant treatment (97,108).
Antidepressant treatment, while more effective than placebo, is not a ''magic bullet.'' Although antidepres-sant medications reduce frequency of binge eating in bulimic patients, only ~25% respond with complete abstinence from binge eating/purging (109). In addition, many patients who show initial improvement later relapse, despite continued use of the drug (108,109). Most experts do not recommend medication alone in the treatment of bulimia nervosa (97,108). There is some support for switching antidepressant medications if a patient fails to respond to one drug (109,110).
Other pharmacotherapeutic agents that have been evaluated for bulimia nervosa include anticonvulsants, lith ium carbonate, L-tryptophan, and naltrexone. However, none of these agents has been consistently shown to be useful for treatment of this disorder (97,108). One trial evaluating the efficacy of fenfluramine versus desipra-mine in 22 patients with bulimia nervosa found decreases in binge eating and improvement in depression over the 15-week trial period with both agents (111). Although both drugs reduced binge eating and vomiting, only fenfluramine produced a small weight loss. However, a larger placebo-controlled study of dexfen-fluramine in 42 patients found no antidepressant effect for dexfenfluramine and a slight weight gain (112). In addition, patients who experienced the most symptomatic improvement in binge eating/purging showed a paradoxical tendency to drop out of the study. Another controlled trial of dexfenfluramine versus placebo found no advantage over brief psychotherapy alone in the treatment of bulimia nervosa (113). A recent double-blind placebo-controlled trial found that short-term treatment with the serotonin receptor antagonist ondansetron significantly reduced binge eating/purging in patients with bulimia nervosa (114).
Medications and psychotherapy are often used in combination. Studies have found that CBT added to medication is more efficacious than medication alone (108, 115). While one study found that medication added to CBT provided little additional benefit (102,116) to study patients who received state-of the-art CBT in an intensive outpatient setting, the results may not be applicable to patients receiving less intensive psychotherapeutic treatment. Another study did find a small additional benefit to adding antidepressant medication to CBT (115). In addition, fluoxetine was shown in one study to be helpful in patients who had either not responded to, or had relapsed after, a course of CBT or IPT (117). It is reasonable to add an antidepressant medication (such as an SSRI or tricyclic) to psychotherapy if a patient does not have an adequate response to psychotherapy.
6 Support/Self-Help Groups
Support/self-help groups are commonly used in bulimia nervosa. These may be led by professionals or laypersons. Twelve-step programs, such as Overeaters Anonymous, are helpful for some patients, although controlled studies of their efficacy are not available. There is increasing interest in developing and evaluating stepped-care approaches, in which guided or unguided self-help manuals are used initially, supplemented by medication if needed, within the primary care setting
(108). Referral for more intensive psychotherapy would be reserved for those who failed to respond to initial interventions. A supervised cognitive-behavioral self-help approach, using a manual, has been shown to reduce bulimic symptoms in carefully selected patients (118,119).
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