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NEDA TOOLKIT for Parents C — If the patient with anorexia nervosa and those with parental responsibility refuse treatment, and treatment is deemed to be essential, legal advice should be sought in order to consider proceedings under the Children Act 1989. C — Selective serotonin reuptake inhibitors (SSRIs) (specifically fluoxetine) are the drugs of first choice for the treatment of bulimia nervosa in terms of acceptability, tolerability, and reduction of symptoms. Psychological Interventions for Bulimia Nervosa C — For people with bulimia nervosa, the effective dose of fluoxetine is higher than for depression (60 mg daily). B — As a possible first step, patients with bulimia nervosa should be encouraged to follow an evidence- based self-help program. B — No drugs, other than antidepressants, are recommended for the treatment of bulimia nervosa. B — Health care professionals should consider providing direct encouragement and support to patients undertaking an evidence based self-help program, as this may improve outcomes. This may be sufficient treatment for a limited subset of patients. A — Cognitive behavior therapy for bulimia nervosa (CBT-BN), a specifically adapted form of CBT, should be offered to adults with bulimia nervosa. The course of treatment should be for 16 to 20 sessions over 4 to 5 months. C — Adolescents with bulimia nervosa may be treated with CBT-BN adapted as needed to suit their age, circumstances, and level of development, and including the family as appropriate. B — When people with bulimia nervosa have not responded to or do not want CBT, other psychological treatments should be considered. B — Interpersonal psychotherapy should be considered as an alternative to CBT, but patients should be informed it takes 8-12 months to achieve results comparable with CBT. Pharmacological Interventions for Bulimia Nervosa B — As an alternative or additional first step to using an evidence-based self-help program, adults with bulimia nervosa may be offered a trial of an antidepressant drug. B — Patients should be informed that antidepressant drugs can reduce the frequency of binge eating and purging, but the longterm effects are unknown. Any beneficial effects will be rapidly apparent. Management of Physical Aspects of Bulimia Nervosa Patients with bulimia nervosa can experience considerable physical problems as a result of a range of behaviors associated with the condition. Awareness of the risks and careful monitoring should be a concern of all health care professionals working with people with this disorder. C — Patients with bulimia nervosa who are vomiting frequently or taking large quantities of laxatives (especially if they are also underweight) should have their fluid and electrolyte balance assessed. C — When electrolyte disturbance is detected, it is usually sufficient to focus on eliminating the behavior responsible. In the small proportion of cases where supplementation is required to restore electrolyte balance, oral rather than intravenous administration is recommended, unless there are problems with gastrointestinal absorption. Service Interventions for Bulimia Nervosa The great majority of patients with bulimia nervosa can be treated as outpatients. There is a very limited role for the inpatient treatment of bulimia nervosa. This is primarily concerned with the management of suicide risk or severe self-harm. C — The great majority of patients with bulimia nervosa should be treated in an outpatient setting. C — For patients with bulimia nervosa who are at risk of suicide or severe self-harm, admission as an inpatient or day patient, or the provision of more intensive outpatient care, should be considered. Page | 40