Psychotherapy is generally the first-line for treatment for bulimia nervosa before psychiatric medication is prescribed. Cognitive behavioral therapy is the standard treatment, however research has indicated promise for other forms of therapy such as guided cognitive behavioral self-help and individual cognitive behavioral therapy for eating disorders in inducing remission of bulimia nervosa symptomatology.

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Depending on the severity of the case of bulimia nervosa, treatment methods may vary, but often include the following: 

- Purging cessation
- Nutritional support
- Monitoring 
- Medical treatment for complications
- Psychotherapy
- Psychiatric medication

Bulimia Nervosa Treatment

Nitsch, A., Dlugosz, H., Gibson, D., & Mehler, P. S. (2021). Medical complications of bulimia nervosa. Cleveland Clinic Journal of Medicine, 88(6), 333-343.

Medical Complications of Bulimia Nervosa

Though cognitive behavior therapy is generally considered the treatment of choice for bulimia nervosa, dialectical behavior therapy (DBT) may be particularly effective in treating bulimia nervosa due to its targeting of emotional dysregulation problems, which often underlie the eating disorder. One study has shown a significant decrease in binge/purging behaviors in patients with bulimia nervosa who underwent DBT with a focus on emotional regulation, though more research into this area is necessary.

Dialectical Behavior Therapy for treating Bulimia Nervosa

Numerous factors have been found to be associated with poorer outcomes and increased vulnerability to relapse following treatment for bulimia nervosa, although the exact rates of remission versus relapse are unclear:

- Severe global function impairment
- Later initial treatment 
- Less follow-up time
- Greater desire for thinness
- Severe weight and body image concerns

Predictors of Relapse in Bulimia Nervosa

No drug exists that is specifically designed to treat bulimia nervosa, but 60mg of fluoxetine per day is FDA-approved as a treatment if psychotherapy is ineffectual. If fluoxetine fails to manage comorbid depressive or anxiety disorder, sertraline or escitalopram may be effective second options. Other SSRIs, in addition to topiramate, an antiepileptic, have demonstrated some efficacy, and stimulants may similarly be prescribed to treat continued binge-eating after purging cessation or to manage comorbid conditions. However, treatment with such drugs are considered off-label usages and are not FDA-approved. Certain psychiatric medications should also be avoided among bulimia nervosa patients. Bupropion should not be prescribed due to the increased risk of seizure. Similarly, citalopram should not be used due to increased risk of QT prolongation, and paroxetine should not be prescribed since it often leads to weight gain which may prompt purging relapses.

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