How Bulimia Is Treated

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Bulimia (also called bulimia nervosa) is an eating disorder that can be life threatening. It is characterized by repeated episodes of binge eating (eating a large amount of food in a relatively short amount of time) followed by purging (compensatory) behaviors such as self-induced vomiting, fasting, misuse of medications (laxatives, diuretics, diet pills, etc.), or excessive exercise.

Bulimia is primarily treated with nutrition therapy, psychotherapy (talk therapy), and in some cases medications.

This article covers the various treatment options for bulimia.

A young woman stands speaking in front of a group of seated people in a group therapy setting.

KatarzynaBialasiewicz / Getty Images

In-Patient Hospital Care

While bulimia is usually treated in outpatient programs, in some cases people with eating disorders such as bulimia may need to be placed in in-patient care within the hospital.

Reasons a person with an eating disorder such as bulimia may need hospitalization include:

  • Their weight is less than 75% of the estimated healthy weight for their age and height
  • A persistent, rapid decline in food intake or weight despite exercising all available outpatient treatments
  • An individual history of needing medical attention at a certain weight
  • Serious physical problems
  • Electrolyte or metabolic abnormalities
  • Hematemesis (vomiting blood)
  • Vital sign changes including orthostatic hypotension (a sudden drop in blood pressure when standing up from sitting or laying down) and bradycardia (a persistently low heart rate) or other abnormalities of heart rhythm
  • Problems with thermoregulation (inability to sustain body core temperature)
  • Psychiatric illness that needs acute care (suicidality, depression, inability to care for themselves)

Therapies

Therapy, particularly cognitive-behavioral therapy (CBT), is the leading evidence-based treatment for bulimia.

Multiple therapies can be used concurrently, such as CBT and nutrition therapy, and may be combined with medication if necessary.

Team members that might be involved in treatment for bulimia may include a:

  • Psychiatrist
  • Psychologist
  • Dietitian
  • Family therapist
  • Social worker

Nutrition Therapy

Nutrition therapy is usually led by registered dietitians who have specialized training and experience in treating eating and feeding disorders.

The goals of nutrition therapy for bulimia include:

  • Stabilization of weight
  • Decreasing the cycles of binge eating and compensation behaviors
  • Developing neutral feelings toward food
  • Re-learning intuitive understandings of hunger, fullness, and satiety
  • Reestablishment of blood-sugar levels (through portion redistribution)
  • Regulation and maintenance of potassium levels

Nutritional counseling may explore topics such as:

  • Food and drinks needed to keep the body healthy
  • What vitamins and minerals are, how the body uses them, and why they are important
  • How nutrients in food are used by the body
  • The role that emotions play in eating behaviors
  • Planning and preparing healthy meals and snacks
  • Fears about certain food groups and why even “feared” foods are important for health

The goal of a healthy diet is to eat a variety of nutritious foods from different food groups, without deprivation. What constitutes a “balanced diet” varies between studies, experts, and the individual.

One sample guideline to follow is to break down food consumption into thirds:

  • 1/3 starchy carbohydrates: Especially whole grains
  • 1/3 fruit and vegetables: Five portions of fruit and vegetables each day as snacks or incorporated into meals
  • 1/3 dairy and protein: Can include milk, cream, cheese, meat, fish, nuts, beans, and eggs

Avoid excessive consumption of saturated fats from processed foods.

Beware of “Fad” Diets

The diet industry is booming, but just because a diet is popular doesn’t mean it’s healthy.

Whether it is a complex diet with lots of “rules,” or one that seems balanced and appears to be backed by registered dietitians, always check with your healthcare provider before starting a nutrition plan.

Cognitive Behavioral Therapy (CBT)

CBT is a type of psychotherapy (talk therapy) that involves a person facing their own fears, learning to understand their personal behaviors and those of other people, and learning how to use problem solving to help manage difficult situations. CBT focuses on changing thought patterns that are distorted, problematic, and unhealthy into healthier, productive ones.

CBT treatments aimed toward eating and feeding disorders have been developed and continue to evolve.

In 2004, the National Institute for Health and Care Excellence (NICE) recommended that an adaptation of CBT—called CBT-BN—be used for the treatment of bulimia. This treatment targeted bulimia specifically.

From there, a more comprehensive approach to treating eating and feeding disorders was developed. Instead of focusing on individual diagnoses like bulimia alone, enhanced cognitive behavior therapy (CBT-E) addresses the psychopathology of all eating disorders.

CBT-E was designed for use with adults in an outpatient setting, but it can be adapted to suit younger people and different therapy types such as day-patient or in-patient therapy.

CBT-E treats the eating disorder as part of the person, and the person with bulimia takes an active role in all areas of the treatment. They are kept fully informed and have the final say on all decisions regarding their treatment. While suggestions and encouragement are offered, they are never asked to do anything they do not want to do.

During CBT-E, people with bulimia learn how to identify the thought processes and behaviors that contribute to their eating disorder, and how those play out in their lives. They are given help examining their concerns about shape, weight and eating, and other harmful behavior surrounding their disorder.

Changes to thinking and actions can lead to healthier outcomes.

CBT-E occurs in four stages:

Stage 1:

  • 50-minute-long sessions, twice a week
  • Focused on developing a mutual understanding of the person’s eating problem
  • Focused on helping them to modify and stabilize their pattern of eating
  • Emphasizes personalized education
  • Addresses concerns about weight

Stage 2:

  • Brief “taking stock” stage
  • Progress is systematically reviewed
  • Plans are made for the main body of treatment

Stage 3:

  • Weekly 50-minute-long sessions
  • Focused on the processes that are maintaining the person’s eating problem
  • Addresses concerns about shape and eating
  • Focused on enhancing the ability to deal with day-to-day events and moods
  • Addresses extreme dietary restraint

Stage 4:

  • Future oriented
  • Focused on dealing with setbacks and maintaining the positive changes that have been achieved

If the person with bulimia is underweight, treatment begins with encouraging the person to choose to regain the weight back to an expected range and helping them to do so. Once a weight necessary for health has been achieved, the focus shifts to healthy weight management.

A 2010 review of evidence supporting the use of CBT in treating eating and feeding disorders showed that CBT is the leading evidence-based treatment for bulimia nervosa, and suggested CBT-E is more effective than CBT or CBT-BN.

A 2013 study supports the use of CBT for the treatment of bulimia, but notes that it is not effective on its own for every person with bulimia, and suggests alternate or supplemental treatment may be necessary.

Dialectical Behavior Therapy (DBT)

While originally developed to treat borderline personality disorder, DBT has shown effectiveness in treating other mental health disorders, including bulimia.

DBT explores seemingly contradictory goals of acceptance and change. People participating in DBT are encouraged to both accept themselves as they are and be motivated to change unhealthy behaviors.

The four essential components of DBT are:

  • Mindfulness: Observation, description, and participation
  • Interpersonal effectiveness: Asking for what you need, setting boundaries (saying no), learning how to deal with interpersonal conflict
  • Distress tolerance: Distracting, self-soothing, improving the moment, and consideration of pros and cons
  • Emotion regulation: How to recognize, label, and change emotions you want to change

DBT can be conducted as part of individual therapy or group therapy.

Resources

If you or a loved one is coping with an eating disorder, contact the National Eating Disorders Association (NEDA) Helpline for support at 1-800-931-2237

For more mental health resources, see our National Helpline Database.

Family-Based Treatment (FBT)

FBT (also called the Maudsley Approach) is used mostly with adolescents and children. It involves the whole family, especially the parents, in the treatment plan.

The premise of FBT is that the adolescent with bulimia is not in control of their behavior, but rather the condition controls them. FBT takes the control and responsibility of the adolescent’s eating from the adolescent and transfers it to their parents.

With this approach, parents are seen as attacking the disorder itself without being critical of the adolescent.

As the treatment progresses, control is gradually shifted back to the adolescent.

Parent-focused treatment (PFT) is another form of therapy that is similar to FBT, except the parents and adolescent are seen separately. 

CBT is still the preferred choice of psychotherapy for bulimia, and FBT appears to be more effective for anorexia than bulimia. Still, FBT is an option for treatment, and studies on its efficacy with bulimia are ongoing.

Support Groups

Support groups provide an opportunity to meet others who understand your experiences and feelings. They can also be a place to find contacts for other valuable resources.

To find support groups in your area or online, try checking in with:

  • Your doctor or therapist
  • Local hospitals and universities
  • Local eating disorder centers and clinics
  • Your school’s counseling center

Support groups are not a substitute for comprehensive treatment, but they can be helpful as a complement to treatment for people with bulimia.

Prescription Medications

Psychotherapy and nutrition therapy are not always enough on their own to treat bulimia, particularly with the high rates of comorbidity that come with bulimia.

One survey showed that 94.5% of people with bulimia also had at least one other mental health condition, particularly anxiety disorders.

Treating the comorbid conditions can help improve the outcome of other treatments for bulimia.

The selective serotonin reuptake inhibitor fluoxetine (Prozac) is the only medicine approved by the Food and Drug Administration (FDA) for treating bulimia, but several medications have been used off label in the treatment of bulimia.

Medications Used

  • Other selective serotonin reuptake inhibitors (SSRIs): Such as sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa)
  • Anticonvulsants: Commonly, topiramate (Topamax)
  • Tricyclic antidepressants: Imipramine (Tofranil), nortriptyline (Pamelor), desipramine (Norpramin)—although these may come with more side effects than other antidepressants
  • Serotonin-norepinephrine reuptake inhibitors (SNRIs): Venlafaxine (Effexor), duloxetine (Cymbalta)
  • Atypical neuroleptics: Olanzapine (Zyprexa)

Wellbutrin Warning

Bupropion (Wellbutrin) is not recommended, as it has been associated with seizures in patients with purging bulimia.

Lifestyle

Self-help practices can help enhance formal treatments for bulimia, increase chances of remission, and decrease chances of relapse.

Some healthy ways to deal with unpleasant emotions include:

  • Calling a friend
  • Writing in a journal
  • Watching a movie or a favorite TV show
  • Reading a good book
  • Listening to music
  • Going out into nature
  • Playing with a pet
  • Playing a game
  • Practicing random acts of kindness

Some things that can help with bulimia recovery include:

  • Get rid of rigid eating rules, and don’t diet.
  • Establish and stick to a regular eating routine.
  • Listen to your body, and look for hunger and fullness cues.
  • Choose to wear clothes you like and feel comfortable in, no one else’s opinion matters.
  • Focus on your good qualities (list all of the great things about yourself).
  • Refrain from criticizing your own body and appearance, and that of others.
  • Don’t compare yourself to others or be critical of another person’s body/weight gain.
  • Treat yourself with kindness, challenging negative self-talk.
  • Be kind to your body.
  • Pamper yourself with things that make you feel good like a massage, a pedicure, or a hot shower.

To help stay on track during treatment and prevent a relapse:

  • Keep a strong support system of people who help you in your recovery and want the best for you.
  • Identify the things that trigger your disordered eating behaviors, and learn to manage or avoid them.
  • Steer clear of anything that glorifies bulimia and eating and disorders, such as harmful groups and websites.
  • Use a journal to keep track of your thoughts, emotions, and behaviors, and watch for negative patterns that indicate you need to seek help.
  • Stick to your treatment plan, even if you are feeling better.
  • Do things you enjoy, and engage in activities that make you feel happy.
  • If you have a lapse, be kind to yourself. Just continue with your treatment and recovery plan.

Summary

Bulimia is primarily treated with nutrition therapy, psychotherapy (talk therapy), and in some cases medications.

In order to find the best bulimia treatment for you or a loved one, speak with a healthcare provider.

A Word From Verywell

With help from professionals who are experts in eating and feeding disorders, and with a good treatment plan, recovery from bulimia is possible. 

If you think you might have bulimia or another eating or feeding disorder, contact your healthcare provider to do a proper screening.

Your healthcare provider can help you understand your condition, help you make a treatment plan, and if necessary put you in touch with further resources.

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Article Sources
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