What treatments are used for bulimia nervosa?

The most commonly used treatments are psychotherapy (in various forms) and prescription medications. Various psychotherapies are used one-on-one and in groups, and sometimes involve families, as deemed appropriate by the therapist. Various means are used to deliver psychotherapy, including in recent years, text, e-mail, and online. Other therapies that are often added to these treatment approaches include nutrition therapy and supportive or adjunct interventions such as yoga, art, massage, meditation, and movement therapy. Some novel treatments being researched in clinical studies include a device called a vagus nerve stimulator implanted at the base of the neck to deliver electrical stimulation intended to reduce certain feelings and behaviors. This stimulator is currently FDA-approved to treat some forms of depression and obsessive-compulsive disorder (OCD). If a person with bulimia nervosa also has a diagnosis of one of these conditions, the stimulator might be mentioned as a possible adjunct to psychotherapy and medication.

Psychotherapy and medication are delivered at various levels of inpatient and outpatient care and in various settings, depending on illness severity and the patient’s treatment plan. Bulimia nervosa can often be treated on an outpatient basis, although more severe cases may require inpatient care or residential treatment. The levels of care and types of treatment centers are discussed elsewhere on this website. The treatment plan should be developed by a multidisciplinary team that addresses both psychological and medical aspects of bulimia. The team should formulate the plan in consultation with the patient. Family members may be included as deemed appropriate by the patient and care team.

Types of prescription drug therapy

Biochemical abnormalities in the brain and body are associated with bulimia nervosa. Many types of prescription drugs have been used to treat bulimia nervosa even though they are not specifically approved for treating bulimia nervosa. This is termed “off label” use. FDA has approved only one prescription drug (fluoxetine, brand name Prozac) specifically for treating bulimia nervosa, based on data submitted to FDA that tested the medication in patients with bulimia nervosa. The medication is an antidepressant in the drug class known as selective serotonin uptake inhibitors (SSRIs) and was shown in clinical studies to help some patients with bulimia.

Most prescription drug therapy for bulimia is aimed at alleviating major depression, anxiety, or OCD, which often coexist with bulimia nervosa. Some prescription drug therapies are intended to make individuals feel full to try to prevent binge eating.

Antidepressants are intended to try to reduce a patient’s urge to binge and purge by treating depression, anxiety, and OCD. Generic and brand names of prescription drugs that have been used to treat bulimia nervosa are listed in the chart. Some of these antidepressants also can exert other effects. SSRIs may alleviate depression and may play a role in making an individual feel full and possibly prevent binge eating.

Clinicians note that they give lower preference to medications known to be associated with a high risk of fatality if an overdose occurs given the increased risk of suicide attempts in patients with bulimia nervosa. Medications that have been used in treating patients with bulimia nervosa are listed below, categorized by drug class.

Antidepressants

Tricyclics

  • Amitriptyline (Elavil)
  • Clomipramine (Anafranil)
  • Desipramine (Norpramin, Pertofrane)
  • Imipramine (Janimine, Tofranil)
  • Nortriptyline (Aventyl, Pamelor)

SSRIs

  • Citalopram (Celexa)
  • Escitalopram (Lexapro)
  • Fluoxetine (Prozac, Sarafem)
  • Fluvoxamine (Luvox)
  • Paroxetine (Paxil)
  • Sertraline (Zoloft)

Monoamine oxidase inhibitors (MAOIs)

Medications in this drug class are less favored by clinicians for treating bulimia nervosa because of concerns about following dietary restrictions to avoid serious side effects. There have been case reports of patients on MAOIs who consumed foods during binge episodes that are contraindicated and led to serious adverse events.

  • Brofaromine (Consonar)
  • Isocarboxazide (Benazide)
  • Moclobemide (Manerix)
  • Phenelzine (Nardil)
  • Tranylcypromine (Parnate)

Tetracyclics

  • Mianserin (Bolvidon)
  • Mirtazapine (Remeron)

Modified cyclic antidepressants

  • Trazodone (Desyrel)

Aminoketone

  • Bupropion (Wellbutrin, Zyban) (This drug was once used, but is now contraindicated for treatment of eating disorders because of several reports of drug-related seizures.)

Phenethylamine monoamine reuptake inhibitor

  • Venlafaxine (Effexor)

Serotonin and noradrenaline reuptake inhibitor (SNRI)

  • Duloxetine (Cymbalta)

Opioid antagonist

  • Naltrexone (Nalorex) (Intended to alleviate addictive behaviors such as the addictive drive to eat or binge eat)

Antiemetic

  • Ondansetron (Zofran) (Used to give sensation of satiety and fullness)

Anticonvulsant

  • Topiramate (Topamax) (May help regulate feeding behaviors)

Other

  • Memantine (Namenda) (May help regulate compulsive eating)
  • Lithium carbonate (Carbolith, Cibalith-S, Duralith, Eskalith, Lithane, Lithizine, Lithobid, Lithonate, Lithotabs) (Typically used as a mood stabilizer, this drug may be contraindicated for some patients with bulimia nervosa.)

Types of psychotherapy

A psychologist may use several different approaches tailored to the situation. The types of psychotherapy used are listed here and defined in the glossary on this website. Cognitive behavior therapy (CBT) and behavior therapy (BT) are first-line treatment and the most often used types of psychotherapy for bulimia nervosa.

In general, CBT has several components, each equally important to break the cycle of unhealthy thoughts and behaviors and replace them with positive, healthy behaviors. First, educating about the dangers of the behaviors and offering alternative, healthy options help people resist the urge to engage in eating-disordered behavior as a coping skill. Second, teaching people how to recognize and change their “cognitive distortions” (irrational thought patterns and beliefs that reinforce negative behavior) helps combat the triggers for behaviors such as bingeing, purging, or restriction and can help increase the regularity of eating. The final component involves teaching people relapse-prevention strategies to help prepare them for possible setbacks. A course of individual CBT for bulimia nervosa usually involves 16- to 20-hour-long sessions over 4 to 5 months. CBT is now also delivered in groups, via self-help manuals, and more recently, via telemedicine systems, e-mail, and online.

In contrast, BT focuses solely on modifying unhealthy behaviors and helping people adapt healthy coping skills by using principles of learning to increase the frequency of desired behavior and decrease the frequency of problem behavior. When used to treat bulimia nervosa, BT focuses on teaching relaxation techniques and coping strategies that individuals can use instead of binge eating and purging or excessively exercising or fasting.

Self-help groups are listed here because they may be one of few options available to people who have no insurance. However, self-help groups can also have negative effects on a person with an eating disorder if they are not well-moderated by a trained professional.

Individual psychotherapy

  • Behavior therapy
  • Exposure with response prevention
  • Hypnobehavior therapy
  • Cognitive therapy
  • Cognitive analytic therapy
  • Cognitive orientation treatment
  • Cognitive behavior therapy (all forms)
  • Scheme-based cognitive therapy
  • Self-guided cognitive behavior therapy
  • Dialectical behavior therapy
  • Integrated cognitive affective therapy
  • Psychodynamic therapy
  • Self-psychology
  • Psychoanalysis
  • Interpersonal psychotherapy
  • Motivational enhancement therapy
  • Psychoeducation
  • Supportive therapy

Family-based therapy

  • Involving family members in psychotherapy sessions with and without the patient; may be performed in the home, in residential treatment, or on an outpatient basis

Group psychotherapy

  • Cognitive behavioral therapy
  • Psychodynamic
  • Psychoeducational
  • Supportive therapy

Self-help groups

  • ANAD (Anorexia Nervosa and Associated Disorders)
  • 12-step approaches (Eating Disorders Anonymous)

Telemedicine as a psychotherapy delivery mode

In recent years, in response to the need to improve access to care in underserved regions or where treatment costs could deter people from seeking help, telemedicine (also referred to as telehealth) has become an important means of delivering mental health services. Researchers have started studying the effectiveness of CBT and other interventions delivered online or through mobile-based methods such as videoconferencing, mobile self-monitoring, text messaging, chat groups, digital coaching, and online self-help training. More studies that include longer-term assessment of outcomes need to be conducted to understand the effectiveness of these interventions. Early research has shown some promising results in treating symptoms of bulimia nervosa.

Other types of treatment

Many interventions are used as adjuncts or supportive therapy. Some people consider some of these options to be “alternative or complementary therapy.” Opinions differ about the role of many of these therapies. We identified as many treatments and interventions as possible that have been used as part of treatment for bulimia nervosa. Then we searched for clinical studies that evaluated these treatments to determine whether any evidence is available to show how well they work as part of a treatment plan for bulimia nervosa. We found few or no well-conducted clinical studies on adjunct or alternative interventions, so no one really knows what role these play in helping recovery for patients. Nonetheless, many of these adjunct therapies pose little to no risk to patients using them.

Some interventions are used alone; others are used in conjunction with medications or psychotherapy. Some may be included as activities made available at residential treatment centers; others may be used in private therapists’ offices. Definitions of these therapies can be found in the glossary.

Creative arts

  • Art therapy
  • Movement therapy
  • Psychodrama

Nutritional counseling

  • Individual, group, family, and mealtime support therapy

Other interventions

  • Biofeedback
  • Coaching
  • Eye movement desensitization and reprocessing
  • Exercise
  • Guided imagery
  • Journaling
  • Mandometer method
  • Massage
  • Meditation (various approaches)
  • Relaxation training
  • Vagus nerve stimulation
  • Yoga