Assessment and Treatment of Bulimia Nervosa

continued

Pharmacologic Interventions

Tricyclic Antidepressants. A number of placebo-controlled, double-blind studies21-27 have examined the effectiveness of tricyclic antidepressants in patients with bulimia nervosa. Several of these studies23,25-27 found that desipramine, 150 to 300 mg per day, was clearly superior to placebo. Two parallel studies21,24 reported that imipramine, 176 to 300 mg per day, was also more beneficial than placebo. Amitriptyline, 150 mg per day, was shown to be more effective than placebo in reducing binge eating (72 percent versus 52 percent) and vomiting (78 percent versus 53 percent).22 Overall, short-term placebo-controlled trials in patients with bulimia nervosa have reported that tricyclic antidepressants reduce binge eating by 47 to 91 percent and vomiting by 45 to 78 percent.

Monoamine Oxidase Inhibitors. Phenelzine, 60 to 80 mg per day, has been found to be more effective than placebo in reducing binge eating (64 percent versus 5 percent).28 Isocarboxazid, 60 mg per day, has also been superior to placebo in controlling binge eating.29 However, the monoamine oxidase inhibitors have considerable side effects and therefore are not recommended as initial pharmacologic therapy for bulimia nervosa.

Other Antidepressants. Several atypical antidepressants have been investigated in placebo-controlled double-blind studies. Bupropion, 25 to 450 mg per day, can effectively diminish the frequency of binge eating, but an increased rate of seizures discourages the use of this medication in patients with bulimia.30 Binge eating has been reduced by 31 percent in patients treated with trazodone, 400 to 650 mg per day.31

Selective Serotonin Reuptake Inhibitors. The most promising results have been reported in studies investigating the use of fluoxetine in the treatment of bulimia nervosa.32,33 In the most comprehensive drug trial to date,33 382 patients were evaluated in a multicenter study comparing 20- and 60-mg dosage of fluoxetine with placebo. At the 20-mg dosage, fluoxetine therapy resulted in a 45 percent reduction in binge eating, compared with a 33 percent reduction with placebo. Vomiting was reduced by 29 percent in patients treated with fluoxetine and by 5 percent in those who received placebo.

Notably, the patients who received fluoxetine in a dosage of 60 mg per day showed the best treatment response, demonstrating a 67 percent reduction in binge eating and a 56 percent reduction in vomiting.33 A smaller study32 replicated these findings, reporting a 51 percent reduction of binge eating in patients treated with fluoxetine at 60 mg per day, compared with a 17 percent reduction in those who were given placebo. The U.S. Food and Drug Administration has recently approved the use of fluoxetine for the treatment of bulimia nervosa.

Other Medications. In one placebo-controlled crossover study,34 no improvement in bulimic symptoms was noted in patients treated with naltrexone, 50 mg per day. Likewise, a brief placebo-controlled trial of lithium35 resulted in no significant differences between groups in the reduction of binge eating frequency.

Psychotherapy
Despite differences in the application of techniques, the skill level of clinicians and the duration of the illness, controlled studies have clearly established the superiority of cognitive-behavioral therapy for the treatment of bulimia nervosa. Based on comparative studies, this therapy used alone or in combination with another technique has resulted in the most significant reductions of binge eating and/or purging.

Cognitive-behavioral therapy principally involves a systematic series of interventions aimed at addressing the cognitive aspects of bulimia nervosa, such as the preoccupation with body, weight and food, perfectionism, dichotomous thinking and low self-esteem. This therapy also addresses the behavioral components of the illness, such as disturbed eating habits, binge eating, purging, dieting and ritualistic exercise.

The initial goal of cognitive-behavioral therapy is to restore control over dietary intake. Caloric restriction and dieting efforts that set patients up to binge are avoided. Patients typically record their food intake and feelings. They then receive extensive feedback concerning their meal plan, symptom triggers, caloric intake and nutritional balance. Patients are also instructed in cognitive methods for challenging rigid thought patterns, methods for improving self-esteem, assertiveness training, and the identification and appropriate expression of feelings. A thorough explanation of cognitive-behavioral therapy for the treatment of bulimia nervosa is available elsewhere.36

The relative benefits of medications and cognitive-behavioral therapy have been assessed and compared. Study results indicate that cognitive-behavioral therapy is superior to medication alone and that the combination of cognitive-behavioral therapy and medication is more effective than the use of medication alone.37

Similarly, the durable effects of cognitive-behavioral therapy have been well documented. In contrast, there has been only one study of the long-term effectiveness of pharmacologic treatment. In that study, six months of desipramine therapy produced lasting improvement, even after the medication was withdrawn.38

Although cognitive-behavioral therapy is the first-line treatment of choice for bulimia nervosa, its effectiveness is limited. Approximately 50 percent of patients who receive this therapy stop binge eating and purging. The remaining patients show partial improvement, but a small number do not benefit at all.37 A comorbid personality disorder is associated with a poorer response not only to cognitive-behavioral therapy but also to alternative therapies.

The approach to take when cognitive-behavioral therapy is not effective remains unclear. Some patients may not respond to additional pharmacologic or psychologic therapy. However, the hope is that some treatment is better than no treatment at all. Thus, no patient should be dismissed as "chronic and untreatable."

The Authors

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BETH M. MCGILLEY, PH.D., is a nationally recognized specialist in eating disorders and maintains a private practice. She codirects the eating disorders clinic at the University of Kansas School of Medicine­Wichita, where she is a volunteer faculty member. Dr. McGilley is a member of the Managed Care Task Force of the Academy of Eating Disorders.

TAMARA L. PRYOR, PH.D., is clinical associate professor in the Department of Psychiatry and Behavioral Sciences at the University of Kansas School of Medicine­Wichita, where she founded and currently codirects the eating disorders clinic. Dr. Pryor also developed one of the few postdoctoral internship and fellowship programs in eating disorders accredited by the American Psychological Association. She is a member of the Managed Care Task Force of the Academy of Eating Disorders.

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Beth M. McGilley, PH.D., and Tamara L. Pryor, PH.D

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