Introduction
Fluoxetine
This drug is a selective serotonin reuptake inhibitor (SSRIs) that effectively reduces bulimia nervosa’s behavioral symptoms. The US Food and Drug Administration (FDA) has approved the medication for the disorder (Reas & Grilo, 2021). Fluoxetine daily dose of 60mg reduces carbohydrates cravings, depression, and pathological eating behaviors (Frank, 2020). The medication is also helpful in patients who have an inadequate response to psychotherapy. Patients tolerate fluoxetine without experiencing mood instability or weight gain.
Desipramine
This drug is classified as an antidepressant, administered orally, and has shown effectiveness in treating bulimia nervosa. According to Himmerich and Treasure (2017) the initial dose for adults is 25mg per day for three days. The dosage is then increased by 25 to 50mg every three to five days, depending on the patient’s response and tolerability. Clinical trials used the average doses of 100 to 200 mg per day.
Naltrexone
This medication reduces purging and binge eating in bulimia nervosa patients. A daily dose of 200mg Naltrexone helps manage bulimia nervosa symptoms (Stancil et al., 2019). The drug is safe, tolerable, and effective in treating the disorder in both adults and adolescents.
Topiramate
This medication is an antiepileptic drug that is effective for bulimia nervosa treatment. The average dose for this drug ranges from 100mg to 250mg per day (Consoli et al., 2019). Topiramate reduces binge frequency and purge days in bulimic patients and is also associated with lowering body weight.
Non-pharmacological (Psychotherapy) Interventions
Cognitive-Behavioral Therapy (CBT-BN)
CBT is a present-oriented treatment technique of choice for bulimia nervosa. The intervention model hypothesizes weight and body shape concerns as triggers of dieting. The CBT therapy for bulimia nervosa uses several stages to introduce patients to behavioral methods and cognitive strategies to target bulimic symptoms. Psychotherapists deliver the treatment in about 20 sessions within six months (Hagan & Walsh, 2021). They start with behavioral aspects to help patients regulate their eating patterns and self-weight their conduct. The following stage focuses on cognitive restructuring to address patients’ concerns about their weight and shape. The clinicians prescribe self-monitoring approaches during initial sessions to help patients enhance their awareness of eating behaviors and emotional and cognitive precursors (Reas & Grilo, 2021). The last phase of CBT involves a discussion of progress, expectations, and strategies to prevent relapse. The clinicians help patients to identify approaches they will continue using to alleviate the possibility of a relapse, warning signs of the latter, and plans to address it.
Brief Strategic Therapy (BST)
BST conceptualizes the complex process of recursive interactions between patients and their reality as the cause of bulimia nervosa. The intervention focuses on what perpetuates and reinforces the eating disorder, and it involves four stages (Pietrabissa et al., 2019). The first phase of BST treatment centers on establishing collaboration, engaging patients, and bypassing resistance to change. The second phase of the intervention is a paradoxical diet, where patients are asked to prepare the food they want carefully and eat as much as they can during mealtimes. This tactic helps in reducing the frequency of eating and minimizing the amount patients consume daily (Pietrabissa et al., 2019). The third stage encourages bulimic patients to eat small portions of food that they crave. The last phase of BST treatment focuses on helping patients assume enhanced responsibility for their desired changes.
Integrative Cognitive-Affective Therapy (ICAT)
ICT is the latest psychotherapy intervention for individuals with bulimia nervosa. This therapy accentuates coping, emotional regulation, interpersonal relationships, and interpersonal factors such as nutrition and self-discrepancy. The intervention involves 21 sessions, which are delivered in four phases (Hagan & Walsh, 2021; Peterson et al., 2020). Psychotherapists use motivational interviewing in the first phase to address ambivalence and educate patients about the role played by emotions in bulimic symptoms. The second phase of ICAT focuses on the introduction and implementation of meal planning and coping strategies. In the third phase, psychotherapists personalize treatment to address aspects that may be preventing the alleviation of bulimic symptoms. Targets in this stage include interpersonal problems such as submissiveness and withdrawal, self-directed coping, and self-discrepancy. The last face of ICAT concentrates on planning and preventing relapse.
Interpersonal Psychotherapy (IPT)
IPT is a brief intervention that associates social skill deficit and interpersonal challenges with bulimic symptoms. Psychotherapists deliver IPT for bulimia nervosa in three phases that comprise 6 to 20 sessions (Hagan & Walsh, 2021). The main objective for IPT is to address interpersonal issues as an indirect way of reducing bulimic symptoms. Clinicians assess interpersonal problem areas and bulimic symptoms in patients and provide a formal diagnosis as well as psychoeducation related to the disorder during the first phase. The common interpersonal problem areas evaluated during this stage are role disputes, grief, role transitions, and relational deficits. The clinicians help bulimic patients achieve interpersonal goals and focus on particular problem areas at the intermediate level (Bäck et al., 2020). The intervention ends with the termination phase, where clinicians and their clients review patients’ progress, devise strategies to complete remaining interpersonal work, and identify relapse prevention approaches as well as potential warning signs.
Family-Based Treatment (FBT-BN)
FBT-BN is an outpatient behavioral intervention that applies commonly in adolescents. The treatment focuses on empowering parents, normalizing adolescents’ eating patterns, and reestablishing normal adolescent development. The intervention comprises three phases delivered in about 20 sessions for six months (Hagan & Walsh, 2021). The first phase encourages parents to disrupt adolescents’ eating disorder behavior by giving them regular meals and snacks and monitoring them to prevent unsuitable compensatory conduct. The second phase involves helping the adolescents develop appropriate autonomy over meals. The last stage focuses on addressing patients’ development issues and helping them create identities outside bulimia nervosa.
Dialectical Behavior Therapy (DBT)
DBT intervention for bulimia nervosa is a present-focused that alleviates eating disorders and affective lability behaviors by enhancing patient’s skills in emotional regulation, interpersonal effectiveness, mindfulness, as well as distress tolerance. Hagan and Walsh (2021) indicate that this psychotherapy is a structured treatment comprising individual therapy, DBT clinicians’ consultation groups, coaching calls, and skills group. The individual therapy involves three levels that help patients apply skills to particular targets. The targets in level one are life-threatening behaviors such as purging with ipecac syrup and non-suicidal self-injury. While level two focuses on aspects that interfere with therapy, level three centers on factors that hamper patient’s quality of life. Coaching calls are encouraged outside sessions to allow patients connect with clinicians and get necessary assistance in applying skills in challenging situations. Skills groups teach bulimic patients distress tolerance, interpersonal effectiveness, mindfulness, and emotion regulation approaches. The DBT clinicians’ consultation groups promote adherence to therapy and help with burnout.
Level of Evidence for the Interventions
The level of evidence for all the pharmacological interventions, including fluoxetine, desipramine, naltrexone, and topiramate, is Level I because their effectiveness in treating bulimia nervosa is determined experimental study or randomized controlled trials (RCTs). Frank (2020) indicates that the largest RCT for bulimia nervosa showed that fluoxetine is 67 % and 57 % effective in reducing binge and vomiting episodes, respectively. An RCT for the disorder involving adolescents found 67 % effectiveness of naltrexone in reducing bulimic symptoms (Stancil et al., 2019). Frank (2020) adds that randomized controlled studies showed the superiority of desipramine and topiramate to placebo in reducing purge and binge days.
The non-pharmacological interventions (psychotherapies) also have a Level I level of evidence except for the BST. According to Hagan and Walsh (2021), various RCT for bulimia nervosa found that CBT-BN is significantly efficacious in treating the disorder. Additionally, CBT-BN is superior to IPT in reducing bulimic symptoms. An RCT comprising 31 women win bulimia nervosa found a 28.6% reduction of purging and binge eating among those who received DBT. Further, RCT with 81 adults and 80 adolescents found ICAT and FBT-BN to be 37.5% and 39% effective, respectively, in managing the disorder. The level of BST intervention is Level II because the study to determine its effectiveness is non-randomized.
Summary of the Knowledge Gap
While all the pharmacological interventions have been shown to manage various bulimic symptoms effectively, it is unclear what factors influence the response or non-response to the medications. Therefore, further study is necessary to evaluate these aspects to promote individualized treatment approaches for bulimia nervosa. Equally, further research about the effectiveness of BST using RCT and the larger sample is recommendable. Moreover, a study that integrates two or more psychotherapies should be conducted. The research should focus on determining whether combining two or more non-pharmacological therapies increases the rate of recovery and minimizes risks for relapses.
References
Bäck, M., Falkenström, F., Gustafsson, S., Andersson, G., & Holmqvist, R. (2020). Reduction in depressive symptoms predicts improvement in eating disorder symptoms in interpersonal psychotherapy: results from a naturalistic study. Journal of Eating Disorders, 8(1), 1-10.
Consoli, A., Çabal Berthoumieu, S., Raffin, M., Thuilleaux, D., Poitou, C., Coupaye, M. Pinto, G., Lebbah, S., Zahr, N., Tauber, M., Cohen, D., & Bonnot, O. (2019). Effect of topiramate on eating behaviours in Prader-Willi syndrome: TOPRADER double-blind randomised placebo-controlled study. Translational Psychiatry, 9(1), 1-8.
Frank, G. (2020). Is the pharmacological management of bulimia nervosa plausible?Expert Opinion on Pharmacotherapy, 21(17), 2073-2075.
Hagan, K., & Walsh, B. (2021). State of the art: The therapeutic approaches to bulimia nervosa.Clinical Therapeutics, 43(1), 40-49.
Himmerich, H., & Treasure, J. (2017). Psychopharmacological advances in eating disorders. Expert Review of Clinical Pharmacology, 11(1), 95-108.
Peterson, C., Engel, S., Crosby, R., Strauman, T., Smith, T., Klein, M., Crow, S., Mitchell, J., Erickson, A., Cao, L., Bjorlie, K., & Wonderlich, S. (2020). Comparing integrative cognitive‐affective therapy and guided self‐help cognitive‐behavioral therapy to treat binge‐eating disorder using standard and naturalistic momentary outcome measures: A randomized controlled trial. International Journal of Eating Disorders, 53(9), 1418-1427.
Pietrabissa, G., Castelnuovo, G., Jackson, J., Rossi, A., Manzoni, G., & Gibson, P. (2019). Brief strategic therapy for bulimia nervosa and binge eating disorder: A clinical and research protocol.Frontiers in Psychology, 10(373), 1-7.
Reas, D., & Grilo, C. (2021). Psychotherapy and medications for eating disorders: Better together?Clinical Therapeutics, 43(1), 17-39.
Stancil, S., Adelman, W., Dietz, A., & Abdel-Rahman, S. (2019). Naltrexone reduces binge eating and purging in adolescents in an eating disorder program. Journal of Child and Adolescent Psychopharmacology, 29(9), 721-724.