Treatment for Bulimia
Bulimia nervosa is characterized by recurrent episodes of binge eating and purging. That is, individuals with bulimia eat an amount of food that’s larger than most people would eat in a similar amount of time in similar circumstances. Individuals with bulimia feel like they can’t stop eating and have zero control. Afterward, they throw up; use laxatives, diuretics, or other medication; fast; or excessively exercise in order to prevent weight gain.
Bulimia can cause severe and life-threatening medical complications, such as electrolyte imbalance, heart problems (from irregular heartbeat to heart failure), tooth decay, gum disease, gastroesophageal reflux, and digestive issues.
Bulimia also commonly co-occurs with depressive disorders and anxiety disorders. It can co-occur with substance use and personality disorders, too. And there’s an elevated risk for suicide.
However, even though bulimia is a serious illness, it can be successfully treated, and individuals do fully recover. The treatment of choice for kids and adults is psychotherapy. Medication may be helpful, but should never be offered as the sole intervention. While outpatient treatment is typically preferred, some individuals with bulimia may require more intensive interventions.
Psychotherapy is the foundation of bulimia treatment. For kids and teens with bulimia, eating disorder treatment guidelines and research recommend using family-based treatment for adolescent bulimia nervosa (FBT-BN). This typically includes 18 to 20 sessions over 6 months. In FBT-BN, parents are a significant part of treatment. The therapist helps the parents and child establish a collaborative relationship to create regular eating patterns and reduce compensatory behavior. In later phases of FBT-BN, the therapist and parents support the child in establishing more independence, as appropriate. In the final phase, the therapist focuses on any concerns the parents or child has about ending treatment, along with creating a plan for relapse prevention.
If FBT-BN doesn’t help or parents don’t want to have such a large role in treatment, the next step can be individual CBT, which is specifically tailored to eating disorders in adolescents. This kind of CBT focuses on reducing dieting, along with changing disordered behaviors and thoughts related to weight and shape. Treatment also focuses on developmental challenges and includes several sessions with parents.
For adults, according to most eating disorder treatment guidelines and the latest research, enhanced cognitive behavioral therapy (CBT-E) has the best evidence for bulimia. CBT-E is considered to be the first-line treatment, and outperforms other treatments in studies.
CBT-E generally consists of 20 sessions over 20 weeks, and the initial sessions are typically twice a week. It is a highly individualized therapy, meaning that the therapist creates a specific treatment for each person, depending on their symptoms. CBT-E features four stages: In stage one, the therapist and client gain an understanding of the bulimia, stabilize eating, and address weight concerns. In stage two, the therapist focuses on “taking stock,” or reviewing progress and coming up with treatment for the next stage. In stage three, the therapist focuses on the processes that maintain the illness, which typically involves eliminating dieting, reducing concerns about shape and eating, and dealing with day-to-day events and moods. In the last stage, therapist and client focus on navigating setbacks and maintaining the positive changes they’ve made.
Most treatment guidelines also recommend interpersonal therapy (IPT) as an alternative to CBT. Research that has compared CBT to IPT has found that CBT tends to act quicker but IPT catches up and leads to substantial improvement and durable, long-lasting effects.
IPT is based on the idea that interpersonal problems cause low self-esteem, negative mood, and anxiety, which causes individuals to binge eat and engage in other eating disorder symptoms. This becomes a never-ending cycle because eating disorder behaviors can further fracture relationships and social interactions, and trigger symptoms. IPT lasts about 6 to 20 sessions and has three phases.
In the first phase, the therapist and client gain a comprehensive history of the person’s relationships and symptoms, and how they affect each other. In the second phase, the therapist and client focus on one problem area and on treatment goals (which are set together). IPT includes four problem areas: grief, interpersonal role disputes, role transitions, and interpersonal deficits. For example, the therapist and clinician might focus on a conflict with a close friend and how to resolve it, or focus on navigating the transition of starting college. In the third phase, therapists and clients discuss ending treatment, review progress, and identify how to maintain that progress after therapy.
In addition, there are other treatments that appear to be promising for bulimia. For example, dialectical behavior therapy (DBT) was originally developed to treat borderline personality disorder and chronically suicidal individuals. In its adaptation for eating disorders, DBT focuses on eliminating bingeing and purging, and creating a more fulfilling life. It teaches individuals healthy emotional-regulation skills and a balanced approach to eating, among other skills.
Another promising intervention is integrative cognitive-affective therapy (ICAT), which includes 21 sessions and seven primary targets. For instance, individuals with bulimia learn how to recognize and tolerate different emotional states; adopt a regular eating routine; engage in problem solving and self-soothing behaviors when they’re at risk for disordered behaviors; cultivate self-acceptance; and manage eating disorder urges and behaviors after treatment.
Fluoxetine (Prozac), a selective serotonin reuptake inhibitor (SSRI), is the only medication approved by the U.S. Food and Drug Administration to treat bulimia. The approval was primarily based on two large clinical trials, which found that fluoxetine reduced binge eating and vomiting. Doses of 60 to 80 mg of fluoxetine appear to be more effective than lower doses. However, some people with bulimia might not be able to tolerate a higher dose, so doctors typically start the medication at 20 mg, and gradually increase the dose if the medication isn’t working.
Common side effects of fluoxetine include insomnia, headaches, dizziness, drowsiness, dry mouth, sweating, and upset stomach.
Other SSRIs are considered second-line treatments, but there are some precautions. According to a 2019 article on pharmacological treatment for eating disorders, there’s some concern over prolonged QTc in individuals taking high doses of citalopram (Celexa). Again, it’s likely individuals with bulimia will need high doses, as well. (An unusually long QT interval is associated with an elevated risk of developing abnormal heart rhythms.) This limits the use of citalopram and possibly escitalopram (Lexapro).
It’s vital to never abruptly stop taking SSRIs, because doing so can produce discontinuation syndrome, which some professionals refer to as withdrawal. This can include flu-like symptoms, dizziness, and insomnia. Instead, it’s important for your doctor to help you slowly and gradually decrease the dose of the medication (and even then, these symptoms can still occur).
Medication research in adolescents has been very limited. Only one small, open label trial in 2003 looked at the efficacy of fluoxetine in 10 teens with bulimia. It found that fluoxetine was effective and well tolerated. However, this research hasn’t been replicated, and no placebo-controlled trials have been conducted. The risk for suicide may be higher with SSRIs in younger populations, so it’s critical for doctors to both discuss these risks with clients and families, and to closely monitor clients who’ve been prescribed an SSRI.
Additionally, there’s been a lot of research on tricyclic antidepressants (TCAs) in treating bulimia in adults. The best TCA for bulimia may be desipramine (Norpramin) because it has less cardiac effects, sedation, and anticholinergic side effects (e.g., dry mouth, blurred vision, constipation, lightheadedness, urine retention). Older treatment guidelines from the U.S. (2006) advise against using TCAs as an initial treatment, while the 2011 guidelines from the World Federation of Societies of Biological Psychiatry recommend TCAs.
Medication can be helpful, but it should never be prescribed as the sole treatment for bulimia. Rather, it must be accompanied by therapy.
The decision to take medication should be a collaborative one. It’s critical to discuss any concerns you might have with the doctor, including potential side effects and discontinuation syndrome (with SSRIs).
Outpatient treatment is the first-line treatment. However, if outpatient treatment doesn’t work, the person is suicidal, eating disorder behaviors have worsened, or medical complications are present, more intensive interventions might be necessary.
There are various options for intense interventions, and the decision should be made on an individual basis. In general, the specific intervention depends on severity, medical status, treatment motivation, treatment history, co-occurring conditions, and insurance coverage.
For some individuals with bulimia, staying at an eating disorder residential treatment center might be the right choice. Such facilities usually include a wide range of specialists—psychologists, medical doctors, and nutritionists—and treatments—individual therapy, group therapy, and family therapy. Individuals stay at the center 24/7, and eat supervised meals.
When a person with bulimia is severely ill or has other serious medical problems, a brief inpatient hospitalization may be necessary to help them get stabilized. If possible, it’s best to stay at a unit that specializes in treating eating disorders.
When it’s considered safe to do so, the person starts attending outpatient treatment. This might be partial hospitalization (PHP) or intensive outpatient treatment (IOP). PHP may be appropriate for individuals who are medically stable but still need structure and support in not engaging in eating disorder behavior. Typically, this means going to an eating disorder center for about 6 to 10 hours a day, 3 to 7 days a week; attending various therapies, such as individual and group therapy; and eating most of their meals there, but sleeping at home. IOP involves attending a treatment program, which also includes various therapies, for several hours a day, 3 to 5 days a week, and eating one meal there.
Turn to reputable resources. For instance, you might check out the books Beating Your Eating Disorder and When Your Teen Has an Eating Disorder. When choosing a resource, it’s very important to make sure that it doesn’t recommend dieting or losing weight, because engaging in either one triggers and perpetuates bulimic behavior. (Another keyword to stay away from is “weight management.”) In this Psych Central piece, eating disorder expert Jennifer Rollin shares why promising weight loss to clients is unethical. Rollin also shares more on this podcast and on this one.
Learn to effectively cope with emotions. Not being able to sit with uncomfortable emotions can lead to engaging in eating disorder behavior. Thankfully, processing emotions is a skill anyone can learn, practice, and master. You might start by reading a few articles (e.g., how to sit with painful emotions) or books on emotions (e.g., Calming the Emotional Storm).
Monitor your media. While the media doesn’t cause eating disorders, it can complicate recovery and deepen your desire to diet and lose weight. Pay attention to the people you follow on social media, the shows you watch, the magazines you read, and other kinds of information you consume. Unfollow individuals who promote detoxes, diets, “meal plans,” and in general glorify looking a certain way. Follow, instead, individuals who take an anti-diet approach and are proponents of Health at Every Size.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Anderson, L.K., Reilly, E.E., Berner, L., Wierenga, C.E., Jones, M.D., Brown, T.A., … Cusack, A. (2017). Treating eating disorders at higher levels of care: Overview and challenges. Current Psychiatry Reports, 19, 48, 1-9. DOI: 10.1007/s11920-017-0796-4.
Crow, S.J. (2019). Pharmacologic treatment of eating disorders. Psychiatric Clinics of North America, 42, 253-262. DOI: 10.1016/j.psc.2019.01.007.
Gorrell, S., Le Grange, D. (2019). Update on treatments for adolescent bulimia nervosa. Psychiatric Clinics of North America, 42, 2, 193-204. DOI: https://doi.org/10.1016/j.chc.2019.05.002.
Hilbert, A., Hoek, H.W., Schmidt, R. (2017). Evidence-based clinical guidelines for eating disorders: international comparison. Current Opinion in Psychiatry, 30, 423-437. DOI: 10.1097/YCO.0000000000000360.
Karam, A.M., Fitzsimmons-Craft, E.E., Tanofsky-Kraff, M., Wilfley, D.E. (2019). Interpersonal psychotherapy and the treatment of eating disorders. Psychiatric Clinics of North America, 42, 205-218. DOI: 10.1016/j.psc.2019.01.003.
Kotler L., Devlin M.J., Davies M., Walsh, B.T. (2003). An open trial of fluoxetine for adolescents with bulimia nervosa. Journal of Child Adolescent Psychopharmacology, 13, 3, 329–35. DOI: 10.1089/104454603322572660.
National Institute for Health and Care Excellence (NICE). (2017). Eating disorders: recognition and treatment. Retrieved from nice.org.uk/guidance/ng69.
Pisetsky, E.M., Schaefer, L.M., Wonderlich, S.A., Peterson, C.B. (2019). Emerging psychological treatments in eating disorders. Psychiatric Clinics of North America, 42, 219-229. DOI: 10.1016/j.psc.2019.01.005.
Wade, T.D. (2019). Recent research on bulimia nervosa. Psychiatric Clinics of North America, 42, 21-32. DOI: 10.1016/j.psc.2018.10.002.
Tartakovsky, M. (2020). Treatment for Bulimia. Psych Central. Retrieved on October 27, 2020, from https://psychcentral.com/eating-disorders/treatment-for-bulimia/