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NEDA TOOLKIT for Parents Among patients of normal weight, nutritional counseling is a useful part of treatment and helps reduce food restriction, increase the variety of foods eaten, and promote healthy but not compulsive exercise patterns [I]. b. Psychosocial Interventions It is recommended that psychosocial interventions be chosen on the basis of a comprehensive evaluation of the individual patient that takes into consideration the patient’s cognitive and psychological development, psychodynamic issues, cognitive style, comorbid psychopathology, and preferences as well as patient age and family situation [I]. For treating acute episodes of bulimia nervosa in adults, the evidence strongly supports the value of CBT as the most effective single intervention [I]. Some patients who do not respond initially to CBT may respond when switched to either interpersonal therapy (IPT) or fluoxetine [II] or other modes of treatment such as family and group psychotherapies [III]. Controlled trials have also shown the utility of IPT in some cases [II]. In clinical practice, many practitioners combine elements of CBT, IPT, and other psychotherapeutic techniques. Compared with psychodynamic or interpersonal therapy, CBT is associated with more rapid remission of eating symptoms [I], but using psychodynamic interventions in conjunction with CBT and other psychotherapies may yield better global outcomes [II]. Some patients, particularly those with concurrent personality pathology or other co- occurring disorders, require lengthy treatment [II]. Clinical reports suggest that psychodynamic and psychoanalytic approaches in individual or group format are useful once bingeing and purging improve [III]. Family therapy should be considered whenever possible, especially for adolescent patients still living with their parents [II] or older patients with ongoing conflicted interactions with parents [III]. Patients with marital discord may benefit from couples therapy [II]. A variety of self-help and professionally guided self- help programs have been effective for some patients with bulimia nervosa [I]. Several innovative online programs are currently under investigation and may be recommended in the absence of alternative treatments [III]. Support groups and 12-step programs such as Overeaters Anonymous may be helpful as adjuncts in the initial treatment of bulimia nervosa and for subsequent relapse prevention, but they are not recommended as the sole initial treatment approach for bulimia nervosa [I]. Issues of countertransference, discussed above with respect to the treatment of patients with anorexia nervosa, also apply to the treatment of patients with bulimia nervosa [I]. c. Medications i. Initial Treatment Antidepressants are effective as one component of an initial treatment program for most bulimia nervosa patients [I], with SSRI treatment having the most evidence for efficacy and the fewest difficulties with adverse effects [I]. To date, fluoxetine is the best studied of these and is the only FDA-approved medication for bulimia nervosa. Sertraline is the only other SSRI that has been shown to be effective, as demonstrated in a small, randomized controlled trial. In the absence of therapists qualified to treat bulimia nervosa with CBT, fluoxetine is recommended as an initial treatment [I]. Dosages of SSRIs higher than those used for depression (e.g., fluoxetine 60 mg/day) are more effective in treating bulimic symptoms [I]. Evidence from a small open trial suggests fluoxetine may be useful for adolescents with bulimia [II]. Antidepressants may be helpful for patients with substantial concurrent symptoms of depression, anxiety, obsessions, or certain impulse disorder symptoms or for patients who have not benefited from or had only a suboptimal response to appropriate psychosocial therapy [I]. Tricyclic antidepressants and MAOIs have been rarely used with bulimic patients and are not recommended as initial treatments [I]. Page | 53