Approach Considerations
Most individuals with eating disorders do not receive treatment for their ED. The "treatment gap" may involve individuals' attitudes about accessing various types of treatment, as well as perceived barriers to seeking treatment. [81] A study of people diagnosed or undiagnosed with eating disorders showed that undiagnosed individuals have more positive attitudes towards novel Internet- and smartphone-delivered treatments than diagnosed individuals. The strongest barriers to seeking treatment were fear of losing control, fear of change, and finding motivation to change. When adjusting for past experiences of treatment, ED symptoms were positively associated with the strength of most treatment barriers.
Specifically, the most prominent perceived barriers to help-seeking were stigma and shame, denial of and failure to perceive the severity of the illness, and practical barriers (eg, cost of treatment); some cite lack of encouragement from others to seek help and lack of knowledge about help resources. [82] Therefore, programs targeting prevention and early intervention for EDs should focus on reducing stigma and shame, educating individuals about the severity of eating disorders, and increasing knowledge around help-seeking pathways for eating disorders. Mental health literacy, overall, may offer pathways into treatment. Not surprisingly, common themes reported by participants describe the process of recovery from anorexia nervosa (AN) include dealing with a fragmented sense of self, a turning point where insight and commitment to recovery is developed, and, in recovery, a reclamation of self through meaningful relationships, rebuilding identity, and self-acceptance. [83]
A range of psychotherapies and pharmacotherapies are efficacious for bulimia nervosa (BN), [33] as are a range of nutrition-based and self-help interventions. A meta-analysis of 79 RCTs included 19 different interventions, with primary outcome measures of abstinence from binge eating episodes, compensatory behaviors, and reduction of symptom severity; reduction of self-reported eating pathology and depression served as secondary outcome variables. Retrieved RCTs were meta-analyzed using fixed and random effects models. Overall, slightly reduced effects were obtained for self-help and moderate effects for pharmacotherapy. Similarly, psychotherapy yielded large-to-very-large effects in regard to secondary outcome variables, while moderate-to-large effects were observed for self-help, pharmacotherapy, and combined therapies. Follow-up analyses revealed the sustainability of psychotherapies in terms of large effects in primary outcome criteria, while these effects were moderate for self-help, pharmacotherapy, and combined therapies. The authors concluded that CBT can be recommended as the best intervention for the initial treatment of BN.
Regarding binge eating disorder (BED), a meta-analysis of 45 studies found only moderate support for the efficacy of CBT and CBT guided self-help, and modest support for interpersonal psychotherapy (IPT), selective serotonin reuptake inhibitors (SSRI), and lisdexamfetamine in the treatment of adults with BED in terms of cessation of or reduction in the frequency of binge eating. [11]
Medical Care
Triage of care
Initial care for bulimia nervosa (BN) is usually provided in outpatient settings. Factors that may indicate a need for inpatient care include significant metabolic abnormalities, medical complications, risk of suicide, failed outpatient treatment, and inability to care for self. For guidelines regarding patient level of care, refer to the table from the APA Practice Guidelines for Eating Disorders. [8]
Interdisciplinary approach
BN is best managed using an interdisciplinary approach. Care providers who should be involved include the primary care provider, psychiatrist, psychotherapist, and nutritionist/dietitian. If the psychiatrist is not skilled in this area, involvement of a psychotherapist with expertise in the management of eating disorders is strongly recommended. Dietary review and nutritional rehabilitation counseling should be provided by a nutritionist/registered dietitian. Dental care merits attention. Depending on complications, those with bulimia nervosa may also require the services of other specialists. The goals of treatment are as follows: [84]
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Reduce and, where possible, eliminate binge eating and purging.
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Treat physical complications and restore nutritional health.
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Enhance patients' motivation to cooperate in the restoration of healthy eating patterns and participate in treatment.
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Provide education regarding healthy nutrition and eating patterns.
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Help patients reassess and change core dysfunctional thoughts, attitudes, motives, conflicts, and feelings related to bulimia nervosa.
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Treat associated psychiatric conditions and psychological difficulties, including deficits in mood and impulse regulation, and factors contributing to poor self-esteem.
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Enlist family support and provide family counseling and therapy where appropriate.
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Prevent relapse.
Most authorities agree that patients with BN who have benefited from CBT are likely to benefit from a program of relapse prevention as well, lasting usually 1–2 years. Since simply telling patients with bulimia nervosa who have achieved abstinence following a course of CBT to return for additional sessions if they fear relapse has been ineffective for preventing relapse, planned visits or regularly scheduled phone calls might be used. [85]
Nonpharmacologic Interventions
Treatment should be comprehensive and generally requires an interdisciplinary approach with many of the components described below. [8]
Core nonpharmacologic interventions
Individual therapies
Two systemic reviews have evaluated psychotherapy, psychopharmacology, and other treatment interventions. The first focused on 21 studies in the United Kingdom and the outcome analyzed was full remission at the end of treatment. [86] The study included 12 treatments, including wait list, and found individual cognitive behavioral therapy (CBT) was most effective in achieving remission at the end of treatment compared with wait list (OR 3.89, 95% CrI 1.19–14.02), followed by guided cognitive behavioural self-help (OR 3.81, 95% CrI 1.51–10.90). The other meta-analysis of 79 randomized-controlled trials (RCTs) with 19 interventions revealed moderate-to-large intervention effects for psychotherapy, primarily CBT and substantial sustainability of psychotherapies compared to self-help, pharmacotherapy, and combined treatments. [33]
CBT is an evidence-based, effective treatment for bulimia nervosa (BN). Behavioral approaches to avoiding undesirable eating habits are used, including diary keeping; behavioral analyses of the antecedents, behaviors, and consequences (so-called ABCs) associated with binge eating and purging episodes; and exposure to food paired with progressive response prevention regarding binge eating and purging. Distorted or maladaptive thoughts regarding weight and shape are identified, examined, and addressed, and other dysfunctional irrational beliefs are explored and confronted to allow better understanding, enhanced self-control, and improved body image. The cognitive component of CBT appears to be an essential active ingredient for change, as behavioral interventions alone are often not as effective. [84]
CBT is indicated as first-line treatment. Patients with other comorbid personality disorders, specifically borderline personality disorder, may not respond to conventional CBT to the same degree as those without these comorbidities. The more complex patients have better experiences with “enhanced” versions of CBT (specifically CBT-E) consisting of CBT augmented with techniques taken from interpersonal psychotherapy and other forms of psychotherapy. [87] CBT may help to reduce binge eating and purging behavior, but is generally not effective alone for producing weight loss. [88]
A systematic review of CBT-enhanced (CBT-E) RCTs and open trials for BN, binge eating disorder (BED), and transdiagnostic samples found seven effectiveness studies (five randomized and two open trials). [89] Substantial differences in posttreatment remission rates were found (range: 22.2–67.6%) due, in part, to differences in samples and operationalization of clinical significant change, though more studies on differential effects and working mechanisms are required to establish the specificity of CBT-E.
Interpersonal psychotherapy
Interpersonal psychotherapy (IPT) addresses specific issues in the interpersonal arena that create the context for and stimulate dynamic tensions that spur the patient's symptoms; these generally encompass such processes as grief, role transitions, role conflicts or disputes, and interpersonal deficits. Brief focused therapy in these areas can be effective in producing improvements in mood disturbance and low self-esteem, which may trigger and maintain the symptoms of BN. The efficacy of IPT is roughly similar to CBT in reducing binge eating, but it may be somewhat less effective in curbing purging.
A systematic review of 15 studies (RCTs and long-term, follow-up studies derived from the RCTs) revealed six main findings: 1) no significant differences between IPT and cognitive-behavioral therapy (CBT) were found when administered as monotherapy to patients with anorexia nervosa (AN); 2) when administered as monotherapy to patients with BN, IPT had lower outcomes than CBT and its enhanced version; 3) patients with BN who remitted with IPT showed a prolonged time spent in clinical remission, when followed up on the long term; 4) IPT and CBT, with different timings and methods, have both shown efficacy in the mid-term/long-term period in patients with BN; 5) CBT and its enhanced version produced rapid changes in the acute phase. IPT led to improvements occurring later, with slower changes that tended to maintain efficacy in the long term; and 6) abstinence from binge eating with group IPT for binge eating disorder is stable and maintained (or further improved) in the long term. [90] IPT is a reasonable, cost-effective alternative to CBT for the overall ED spectrum.
Nutritional rehabilitation counseling
A structured meal plan provides a concrete means to help reduce episodes of dietary restriction and, consequently, urges to binge and purge. Adequate nutritional intake can prevent craving and promote satiety. Assessing nutritional intake for all patients, even those with a normal body weight (and normal BMI), is important because normal weight per se does not ensure appropriate nutritional intake or normal body composition. Nutritional counseling may not only help reduce food restriction, but may also help patients increase the variety of foods eaten and promote healthy but not compulsive exercise patterns.
Family therapy
Family therapy explores family attitudes and dynamics, dysfunctional relationships, communication and behavior patterns, and other factors that may precipitate or perpetuate abnormal eating behaviors in the family setting. This perspective often views eating difficulties as a form of communication within a family. Family therapy should be considered especially for adolescent patients still living with their parents or older patients with ongoing conflicted interactions with parents. A specific form of family intervention, the so-called Maudsley model, where parents are authorized to take an active and specified role in helping their child to eat, has been shown to be effective for treating anorexia nervosa in adolescents.
For adolescents, a randomized controlled trial showed family-based treatment to be more effective for achieving abstinence than cognitive-behavioral therapy at the end of 6 months of treatment. However, little difference was seen between these two treatments at the end of one year. [91]
Adjunctive nonpharmacologic treatments
Individual therapy
Psychodynamic psychotherapy: Some patients, particularly those with concurrent developmental and personality pathology or other co-occurring disorders, require lengthy individual treatment. Clinical reports suggest that psychodynamic and at times psychoanalytic approaches in individual or group format may help to improve overall coping once bingeing and purging improve. Supportive-expressive psychotherapy (SEP) in individual or group therapy formats may be helpful for patients with BN.
Couples therapy
Patients with marital discord may benefit from couples therapy. Although research concerning marital and cohabitation relationships in patients with BN is limited, many patients with BN are thought to experience problematic relationships with impaired intimacy, including sexuality and suboptimal communication skills. Self-consciousness and self-silencing associated with sexual activity, and anxious attachment may be associated with bulimic symptoms. [92]
Group therapy
Dialectical behavior therapy and integrative cognitive-affective therapy may have an emerging role in treatment, especially for patients with severe emotional dysregulation and impulsivity. [93]
Virtual reality
Virtual reality (VR) is a technology with a variety of uses including clinical research, education/training, and assessment and treatment of several medical and psychological conditions. A colloquial definition is that it is a human–computer interface that allows the user to interact with and become immersed in a computer-generated environment, which produces the feeling of “being there.” A review of 19 studies on the use of VR in BN and BED found nine studies on assessment and 10 on treatment. [94] Though the research is at an early stage, the use of VR in the assessment of those conditions showed some promise in identifying: 1) how those patients experienced their body image; and 2) environments or specific kinds of foods that may trigger binge–purging cycle. Some studies using VR-based environments associated to CBT showed their potential utility in improving motivation for change, self-esteem, body image disturbances, and in reducing binge eating and purging behavior.
Self-help and support groups
Support groups and 12-step programs such as Overeaters Anonymous may be helpful as adjuncts in initial treatment and for subsequent relapse prevention, but they are not recommended as the sole initial treatment approach for bulimia nervosa. In the most recent update of the Self-help and guided self-help for eating disorders in the Cochrane Database of Systematic Reviews [95] , efficacies of pure self-help (PSH) and guided self-help (GSH) were mixed. PSH/GSH did not significantly differ from waiting list in abstinence from bingeing or purging, although PSH/GSH produced greater improvement on other eating disorder symptoms, psychiatric symptomatology, and interpersonal functioning, but not depression. In addition to face-to-face interventions, self-help support may be available through books and online. See the APA's complete list of Self-Help Books and Internet Resources in the Patient Education section.
Other
Bright light therapy has been shown to reduce binge frequency in several controlled trials of patients whose binge eating follows a seasonal pattern (akin to seasonal affective disorder) and may be used as an adjunct when CBT and antidepressant therapy have not been effective in reducing bingeing symptoms in such patients. [96]
One study provided some support for guided imagery compared to journaling. However, long-term maintenance of treatment effects is unknown. [97]
Recent research has shown Web-based CBT to improve psychopathology, decrease body dissatisfaction, and benefit other problems related to eating disorders. Overall, technology-based interventions (using computers, the Internet, and mobile resources) have been efficacious both in preventing and treating eating disorders. [98, 99]
Pharmacologic Treatments
Food and Drug Administration (FDA) approved treatments
Fluoxetine (Prozac): Initial dose 20 mg/d with advance over 1–2 weeks to 60 mg/d in the morning as tolerated. Some patients may need to begin at a lower dose if side effects are intolerable. A maximum dose of 80 mg/d may be used in some cases.
Other evidence-based pharmacologic treatments
Antidepressants
Antidepressants as a group – particularly selective serotonin reuptake inhibitors (SSRIs) – are the mainstay of pharmacotherapy for bulimia nervosa (BN). [8] These may be helpful for patients with substantial concurrent symptoms of depression, anxiety, obsessions, or certain impulse disorder symptoms. They may be particularly good for patients who have not benefited from or had suboptimal response to suitable psychosocial therapy or who have a chronic, difficult course in combination with other treatments.
Among the antidepressants, the strongest evidence for efficacy with the fewest adverse effects has been associated with SSRIs. [100, 8] As mentioned above, only fluoxetine (Prozac) is approved by the FDA for the treatment of BN. Sertraline (Zoloft) at 100 mg or higher dose/day is the only other SSRI shown to be effective, as demonstrated in a small, randomized controlled trial. Fluvoxamine [101] and citalopram [102] have also shown benefit. However, recent current FDA guidance advises that citalopram not be prescribed in doses more than 40 mg/d, which may be suboptimal for many patients. The exact mechanisms underlying the efficacy of antidepressants in BN are unclear, but the effects are presumed to be mediated through their salutary impact on cerebral serotonin systems. Higher doses of SSRIs require more vigilance regarding side effects, though they appear to be well tolerated in this population.
Bupropion (Wellbutrin) is relatively contraindicated in the treatment of BN because of a higher risk of seizures in patients with eating disorders associated with this medication. [8]
Tricyclic antidepressants (TCAs) [103] and monoamine oxidase inhibitors (MAOIs) have been shown to be effective in small randomized controlled trials in patients with BN, but due to higher risks of adverse effects and toxicity in overdose they are not recommended as initial treatments. [8]
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Desipramine and imipramine (up to 300mg/d)
The most recent update of Antidepressants versus placebo for people with bulimia nervosa in the Cochrane Database of Systematic Reviews included TCAs, SSRIs, MAOIs, and other classes of drugs (mianserin, trazodone, bupropion). Similar results were obtained in terms of efficacy for the different groups of drugs. Patients with TCAs dropped out due to any cause more frequently than patients with placebo, and the opposite was found for fluoxetine. [104]
Mood stabilizers
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Topiramate: Small controlled trials have demonstrated efficacy of this anticonvulsant medication, but since adverse reactions are common, topiramate should be used only when other medications have proven ineffective. Since patients tend to lose weight on topiramate, its use is problematic for normal or underweight patients. [8, 105] Topiramate is useful for short-term treatment of binge eating disorder as it improves binge frequency and decreases weight. Open label studies also suggest that topiramate may be efficacious in the long term, but this remains to be conclusively demonstrated. [106]
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Lithium: Lithium has not been demonstrated to be effective for BN per se. In patients with co-occurring bipolar disorder and BN, lithium treatment is particularly difficult to manage because of the risk of frequent and major fluid shifts and associated toxicity. As well, some patients have weight gain with lithium, which would have to be aggressively managed if the patients stay on the medication.
Miscellaneous
In small studies, ondansetron [108] , baclofen [109] , and an antiandrogenic oral contraceptive [110] have been shown to have some use as alternative pharmacotherapeutic options in the management of BN. Trials investigating naltrexone (ReVia) have shown mixed results, and venlafaxine has not been shown to be beneficial.
Clinicians must be aware of the black box warnings relating to antidepressants and other medications to discuss the potential benefits and risks as part of the consent process with patients and families if such medications are to be prescribed. See the statement on Antidepressant Use in Children, Adolescents, and Adults by the Food and Drug Administration.
Case reports indicate that methylphenidate may be helpful for patients with BN and concurrent ADHD. [8]
Trials of traditional and nontraditional medication treatments have to be weighed in terms of potential for drug interactions, the medical complications of BN, and the medical comorbidities of BN.
Combination treatment
Patients with BN often benefit more from combinations of psychotherapy and pharmacotherapy than from either treatment alone, particularly in the presence of a comorbid depressive disorder, which is seen in the majority of cases. For uncomplicated bulimia nervosa, CBT alone is superior to pharmacotherapy alone. [111]
Follow-up
Treatment outcomes
CBT is the single most well-studied and effective treatment for bulimia nervosa. Some studies have reported that the combination of antidepressant therapy and CBT results in the highest remission rates. This combination is recommended initially when qualified CBT therapists are available. In addition, when CBT alone does not result in a substantial reduction in symptoms after 10 sessions, addition of fluoxetine is ordinarily recommended. [8] However, a major study found that when excellent manual-based CBT is administered, the addition of fluoxetine may not offer additional benefit. How best to treat individuals who do not respond to CBT and/or antidepressant medications remains an unsettled question. [97]
Limited evidence supports the use of fluoxetine for relapse prevention, but substantial rates of relapse occur even with treatment. The optimal duration of treatment and the optimal strategies for maintaining treatment gains are unknown. In the absence of adequate data, most clinicians recommend continuing antidepressant therapy for a minimum of 9 months and probably for at least 1 year in most patients. [8] Other medications have not been studied long term in bulimia nervosa.
With CBT and maintenance treatment, as many as 50% of patients with bulimia nervosa are asymptomatic at follow-up 2-10 years after completing treatment. Rates of persistent long-term improvement following other forms of psychotherapy (eg, IPT, supportive-expressive psychotherapy) are unknown.
In an update of Psychotherapy for bulimia nervosa and binging in the Cochrane Database of Systematic Reviews, CBT, particularly CBT-BN (a specific modification of CBT to address bulimia nervosa), noted efficacy in decreasing binge eating. However, these conclusions are limited by the fact that the clinical trials were highly variable and small sample sizes. Long-term interpersonal psychotherapy was also demonstrated to be efficacious. Self-help, alongside highly structured CBT, appeared to be promising. However, exposure and response prevention did not appear to enhance the efficacy of CBT. Psychotherapy alone was unlikely to change body weight. [112]
According to the most recent update of Antidepressants versus psychological treatments and their combination for bulimia nervosa in the Cochrane Database of Systematic Reviews, combination treatments of medications plus psychotherapy were superior to psychotherapy alone. Psychotherapy appeared to be more acceptable to patients. When antidepressants were combined with psychological treatments, acceptability of the latter was significantly reduced. [113]
Technology-based interventions, such as Internet prevention programs, Internet-assisted CBT, online consulting, and text messaging have shown promise in assisting in the treatment of eating disorders. [114, 115, 116]
Surgical Care
Major medical treatment requiring surgical intervention is rare, but medical care providers should be familiar with potential serious complications.
Patients may develop an acute gastric obstruction and/or gastric dilatation [117] (rarely resulting in gastric perforation leading to acute peritonitis), which presents with severe, continuous projectile vomiting that occurs soon after any oral intake. This possibility should be considered in individuals with known bulimia nervosa who present complaining of uncontrollable vomiting. When the potential for gastric dilatation, outlet obstruction, or both is of concern, an urgent surgical consultation is indicated.
Emergency surgical review is also required if symptoms suggestive of esophageal tear (Mallory-Weiss syndrome) develop or in case of esophageal rupture, which can precipitate acute mediastinitis. (See images below). For more information, see Medscape Reference articles Mallory-Weiss Syndrome and Esophageal Rupture.
This chest radiograph demonstrates pneumomediastinum, which can occur in association with esophageal rupture from forceful vomiting.
Water-soluble contrast esophagram from a patient with esophageal perforation after esophageal dilation shows contrast leak (arrowheads) and normal esophageal lumen (arrows).
Mallory-Weiss tear. Typical longitudinal mucosal tear with overlying fibrinous exudate extending from the distal esophagus to the gastric cardia. Courtesy of C.J. Gostout, MD.
These conditions are surgical emergencies and, although uncommon, are occasional causes of mortality related to bulimia nervosa.
Consultations
Dental consultations
Dentists and dental hygienists sometimes play a unique role in opening dialogues with patients about eating disorders. They can help with early recognition and refer patients for specialist-level eating disorders care. Similarly, dental professionals can make important contributions to recovery and long-term treatment of these patients. [118]
Diet
As described above regarding the role of the registered dietician, patient education regarding healthy, well balanced diets, exercise, and long-term maintenance of a healthy weight is important and may help reduce the risk of relapse or chronicity.
Prevention
All eating disorders appear to arise within a cultural context that places too high a value on thinness and engenders unreasonable expectations regarding physical appearance. Awareness of the cultural and social forces and education for both children and their parents regarding the attitudes and behaviors that foster eating disorders may reduce the prevalence of these syndromes. Opportunities for this kind of intervention abound in primary care, athletic, and educational settings. School-based programs that emphasize health, fitness and a range of physical and psychological competences have shown promise in being able to reduce the development of eating disorder-associated attitudes in vulnerable school-age populations. [119]
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Parotid hypertrophy. Reprinted with permission from Mandel, L and Siamak, A. Diagnosing bulimia nervosa with parotid gland swelling. J Am Dent Assoc 2004, Vol 135, No 5, 613-616.
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Dental caries. Reprinted with permission from Wolcott, RB, Yager, J, Gordon, G. Dental sequelae to the binge-purge syndrome (bulimia): report of cases. JADA. 1984; 109:723-725.
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Russell sign. Reprinted with permission from Glorio R, et al. Prevalence of cutaneous manifestations in 200 patients with eating disorders. Int J Derm, 2000, 39(5), 348-353.
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This chest radiograph demonstrates pneumomediastinum, which can occur in association with esophageal rupture from forceful vomiting.
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Water-soluble contrast esophagram from a patient with esophageal perforation after esophageal dilation shows contrast leak (arrowheads) and normal esophageal lumen (arrows).
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Mallory-Weiss tear. Typical longitudinal mucosal tear with overlying fibrinous exudate extending from the distal esophagus to the gastric cardia. Courtesy of C.J. Gostout, MD.
Tables
| Anorexia Nervosa | AN and BN | Bulimia Nervosa |
|---|---|---|
| Restriction of energy intake relative to requirement, leading to significantly low body weight in the context of age, sex, developmental trajectory, and physical health | Recurrent episodes of binge eating: a) eating in a discrete period of time, within a 2-hour period, an amount that is definitely larger than what most would eat in that time period; b) a sense of lack of control over eating | |
| Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight | Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise | |
| Disturbance in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight | The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months | |
| Two types: Restrictive and Purge/Bing-Eating type | The disturbance does not occur exclusively during episodes of AN | |
| Body Dysmorphic Disorder | BDD and BN | BN |
| Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others | Disturbance in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation | Recurrent episodes of binge eating: a) eating in a discrete period of time, within a 2-hour period, an amount that is definitely larger than what most would eat in that time period; b) a sense of lack of control over eating |
| At some point during the course of the disorder, the individual has performed repetitive behaviors or mental acts in response to the appearance concerns | The preoccupation causes significant distress or impairment in social, occupational, or other important areas of functioning | Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise |
| The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder | The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months |
