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].
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