Further Outpatient Care
The 2 standard approaches to outpatient care are counseling and medication; these are not mutually exclusive. A combination of these methods has been found to be most effective in patients with bulimia nervosa (BN).
The most studied form of outpatient care for patients with bulimia is CBT. A specific form of CBT has been created for patients with bulimia and is termed CBT-BN. CBT has been shown to have significantly better results in patients with bulimia nervosa than other forms of psychotherapy.
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This form of therapy is usually short-term (4-6 mo).
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CBT focuses on patients' preoccupation with body shape and weight, persistent dieting, and binge eating and purging.
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Patients are asked to monitor thoughts, feelings, and circumstances surrounding binge-purge episodes. Patients may be asked to keep a food diary and record feelings and urges to binge or purge along with foods the patient consumed during the day. By examining the cues that lead patients to binge, patients can learn to avoid these cues or to redirect their feelings when the cues emerge. These strategies can also help patients challenge their fears of loss of control.
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Patients are also instructed to cease dieting and begin regular eating. By quitting dieting and removing the feeling of being restricted in what one can eat, patients are less likely to binge on "forbidden foods."
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Patients are also asked to systematically challenge their assumptions linking weight to self-esteem.
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Therapy is focused on building trust and developing a treatment alliance.
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Patients are involved in setting the treatment goals.
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Some patients benefit from self-help groups. Family involvement in treatment is welcomed and encouraged.
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The goal of care is to focus on the overall well being of the patient.
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CBT is a highly effective treatment. A recent study of 78 adult women showed that over half achieved remission by the completion of CBT treatment. In addition to decreased frequency of binging and purging behaviors, subjects also showed improvement in mood and attitudes regarding feeding. [37] CBT is equally effective for both the purging type and nonpurging type of bulimia. [38]
Other staples of outpatient care include nutritional counseling and meal planning. Relaxation strategies are helpful for some, such as prolonged breathing and progressive muscle relaxation.
Other forms of therapy with unclear benefit include interpersonal psychotherapy, hypnobehavioral therapy, dialectical behavior therapy, and motivational enhancement therapy. These therapies have not been adequately studied in patients with bulimia nervosa.
Current research suggests that family therapy is as effective as CBT after 1 year of treatment; however, CBT shows improvement of symptoms within 6 months of initiation and improvement is seen as early as CBT session 3 in 50% of patients. [4, 21, 31, 39, 40, 41]
The second approach to treatment is the use of medications. The use of antidepressant medications, such as fluoxetine or a TCA, was initially based on an association between bulimia nervosa and mood disturbance. More than 12 double-blind placebo-controlled trials have shown that antidepressants help patients reduce binge frequency.
Deterrence/Prevention
Prevention efforts have centered on counseling to encourage rational attitudes about weight, moderation of overly high self-expectations, enhancement of self-esteem, and alleviation of stress and stimulating a healthy body image.
Prevention efforts can be pursued in primary care physicians' offices during health supervision visits.
Complications
Many complications to bulimia are possible, including the following: [14, 10, 13, 9]
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CNS - Seizures
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Cardiac - Cardiac arrhythmias secondary to hypokalemia; can lead to cardiac arrest, cardiac rupture, and cardiomyopathy secondary to ipecac abuse
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Pulmonary - Pulmonary aspiration of gastric contents, pneumomediastinum
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GI - Esophageal rupture, esophagitis, delayed gastric emptying, pancreatitis
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Musculoskeletal - Muscle weakness secondary to ipecac abuse and potassium irregularities, tetany
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Renal - Impaired renal function
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Psychiatric - Depression, suicide attempts, substance abuse
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Reproductive - Increased risk of induced abortion [42]
Prognosis
CBT has been shown to benefit patients. Evidence suggests persistent benefit 4 years after treatment; however, treatment benefit greatly depends on accessibility to CBT-trained therapists. Therapists with expertise in CBT may be difficult to find outside of established centers.
Medication therapy has also been shown to benefit patients; however, only a minority of patients achieve full remission on medication alone. Limited data suggest that a considerable rate of relapse is observed once medications are discontinued.
Studies have shown that patients who receive treatment (CBT or medication) demonstrate benefit. One study compared treated versus nontreated patients 6 months after initial presentation. Follow-up studies reported that 28-33% women without treatment were in remission, and follow-up studies of treated women reported 21–75% successful remissions.
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After one year, follow-up studies reported 28–33% of patients without treatment were in remission, and 5–83% of women in treatment were in remission.
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Follow-up studies reported a range of 13–69% of patients still in remission without ongoing treatment 2–4 years after initial remission. These data were compared to data pertaining to women who were still in treatment; these women had remission ranges of 46-50%. Over 5 years of follow-up, untreated women had maintained remission rates around 31–60%. This was compared to women who were still in treatment, who had an average remission rate of 54%. Women in treatment outcome studies had higher rates of remission than women in studies who did not receive treatment.
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Overall, 5–10 years following presentation, approximately 50% of all women with bulimia nervosa fully recover, and 20% still have full bulimia nervosa.
Given that eating disorders only have been defined and studied as diseases for 20 years, limited long-term data on prognosis exist. The imprecise, inconsistent, and often confusing data on remission rates and percentages available for patient follow-up are evidence that more research and follow-up are needed.
Lower weight (less than 75% of MBW mean body weight) and longer duration (more than 19 months) of symptoms were predictors of poorer outcomes in a 2011 study of 11 sites of 267 adolescents with eating disorders. [43, 44] There was a slight benefit to family therapy with the Maudsley Model; however, all adolescent medicine-based treatments were effective in helping adolescents to gain weight.
Overall, despite advances in medical care and therapy, the prognosis for patients with bulimia remains guarded. Even in the best of hands, both medications and therapy fail in 33–50% of patients. The relapse rate remains around 30%, and patient crossover to anorexia nervosa from bulimia nervosa ranges from 0–7%.
Studies have shown that patients with bulimia who have a previous diagnosis of anorexia nervosa are more likely to have a protracted illness or relapse into anorexia nervosa during follow up compared with patients with bulimia with no history of anorexia nervosa. [45]
Patient Education
Education of patients and families involves teaching the seriousness and consequences of bulimic behavior.
Information about complications and physiologic changes that can occur as a result of bulimia is important to convey to patients and families.
Information on proper nutrition and metabolic balance is also helpful.
For excellent patient education resources, see eMedicineHealth's patient education article Bulimia.
The National Eating Disorder Association is dedicated to providing education, resources, and support to those affected by eating disorders. Their Web site includes information for patients, families, and health care providers. [46]
