Bulimia is a complicated disorder fraught with competing medical, emotional and social factors that make recovery on one’s own challenging. Recovery is possible through a specialized course of treatment that may include behavioral therapy, nutrition consultations, lifestyle changes, medication, family therapy, group therapy or support groups, and in the most severe cases inpatient rehabilitation.
Therapy for Bulimia
Therapy for bulimia will range from intensive inpatient programs for severe cases to weekly talk therapy for those in a milder recovery phase. Engaging in therapy means making a weekly commitment to gain perspective by focusing on one’s self. The relationship with a therapist provides an unbiased, open-minded space to explore anything that may be impacting an individual’s recovery. Therapy is not always easy and comfortable, but it will ideally provide the safest space possible to work through these challenging and uncomfortable feelings.
The most common and effective treatments for bulimia are often covered by insurance. Inpatient rehabilitation or hospitalization would typically require pre-authorization by one’s insurance company providing documented proof and attestation that other less invasive methods did not achieve desired outcomes.
Cognitive Behavioral Therapy
CBT is one of the few evidence-based approaches to treatment. This short-term, 6- to 12-week regimen has a 50% success rate for individuals with bulimia (success being the cessation of binging and purging). The idea is to uncover the irrational, repressed thoughts which trigger unwanted behaviors (binging and purging). The individual will meet with a CBT (or CBT-E) certified therapist to complete logs, workbooks and worksheets (often referred to as “homework”).6,8,10,12
Psychoanalysis
Psychoanalysis is considered long term treatment with no set timeline or parameters. Sessions are typically once or twice per week. While there is qualitative and anecdotal evidence of success, it is not considered an evidence-based practice. The goal is to uncover the root of the eating issues through delicate and gradual probing of the subconscious psyche.
This is an important process since those with bulimia are especially prone to experience deep insecurities and self-loathing. Ideally this is done with a Certified Eating Disorder Specialist (CEDS) who has gone through extensive training with the International Association of Eating Disorders Professionals Foundation.6,12
Psychoeducation
Psychoeducation would include teaching the individual about their disorder, causes and effects. It can also include nutritional information and consequences of the bingeing and purging behavior. For some the idea of loss of tooth enamel and acid reflux can be enough of a deterrent to alter their behavior. Additional techniques like delay, distraction, or parroting are helpful tools in psychoeducation.6
Delay
Delay means to allow oneself to engage in the unwanted binge and purge behavior but delay the initiation of it. With time and practice, episodes become more sporadic.6
Distraction
Distraction is a technique where individuals will get other coping tools and engage in an activity rather than unwanted binge and purge behavior. Tools will be determined by the patient and include, but are not limited to going for a walk, reading, writing, drawing or listening to music.6
Parroting
Parroting means repeating helpful mantras to oneself like “food will not hurt me,” “food is part of recovery,” and “purging now will only continue the cycle.”6
Group Therapy
Individuals struggling with bulimia often have difficulty socializing, relating to others and asserting themselves in conflict. Because of this social component, group therapy led by a trained facilitator can be extremely effective. Besides just learning to relate, those with bulimia will benefit greatly from knowing they are not alone through feeling seen and genuinely understood.6
Family Therapy
The source of an eating disorder is often in the home. There is a strong genetic component and higher incidence in those with a parent exhibiting disordered eating. Bulimia usually develops in teenage years, so environmental stressors of the family must be considered. Addressing these issues in family therapy can provide relief and also resolution.
Bulimia relates to stuffing feelings and therefore learning to express difficult emotions, while confronting and communicating with family can be most effective. Family Therapy is an evidence-based intervention for adolescents and has the best outcomes for those with mild or moderate cases of bulimia.8,9
Other Types Therapy You May Encounter
The following are other types of therapy that may be used to treat bulimia:
Brief Strategic Treatment (BST)
Like CBT, this is short-term and effective treatment for bulimia, utilizing what’s called the dysfunctional perceptive-reactive system. BST does not require identifying the root causes of a problem (as in CBT), but rather on un-doing dysfunctional approaches to problems and learning new, effective solutions. The therapist may use the miracle question (i.e. What would need to happen in your life for you to be able to say, “My problem has been resolved?”).13
Gender Roles
Integrating societal pressures around gender roles and the individual’s experience of their own body may be a viable treatment option. Those with bulimia tend to strive for perfection including obtaining a body size or shape that may not be realistic.6
Food Journal and Meal Planning
A tool that’s utilized in many self-help groups, bulimic individuals will review their meal plan and food journal with a sponsor or trusted peer.6
Positive-Mood Video Induction
Based on research findings that a negative mood is strongly associated with bulimia in particular, one trial found that compulsive over-eating and thus subsequent purging was drastically reduced following a positive mood vodcast. More research needs to be done in this area.5
Internet/Teletherapy
Shown to be an effective form of continuity of care following an inpatient rehabilitation stay, more research is being done to incorporate technology, like teletherapy, in to healing treatments.3
Residential Treatment for Bulimia
Some may find the criteria for entering intensive residential treatment burdensome. Individuals who are interested must be stable enough to live on their own in dormitories (contrary to hospitalization under a constant watch), however their condition must impact functioning enough that it warrants putting their life on hold for 3-4 weeks away from friends, family and work to focus solely on their recovery.
Once admitted, patients will spend their days in various educational and recovery groups such as: Psychoeducation group, eating group to review meals from the day prior, body image group, group and individual psychotherapy, family therapy, and educational seminars. In their free time, they will be responsible for their own self-care and hygiene. In general, the intensity of a Residential Program has a good prognosis for recovery, however for long-term recovery to be sustained, outpatient treatment will be necessary.6
Medication for Bulimia
Bulimia is not always treated with medication, but when indicated patients would likely be prescribed either an antidepressant to address underlying mood issues or an appetite suppressant to control binges that lead to the inevitable purge session. To obtain a prescription, the patient will need a routine physical, a psychiatric evaluation and a prescription. Depending on one’s insurance benefits a referral may be needed to see a psychiatrist. Some common medications that treat bulimia are as follows:
SSRIs
In a recent study, use of Prozac reduced binge eating episodes by 45% and purging by 29%. At its most therapeutic dose of 60mg in this same study, Prozac showed a 67% reduction in binge eating and a 56% reduction in vomiting. Prozac is often a first line of defense in treating bulimia with such promising results. The U.S. Food and Drug Administration has recently approved the use of fluoxetine for the treatment of bulimia nervosa.2,12
Buproprion/Wellbutrin
This antidepressant seems to help with a range of addictive behaviors, including smoking and alcohol use. This medication has been shown to improve mood and energy levels, while also reducing binge eating episodes. In one study, seizures increased for treatment of bulimia, so this drug would not be the first choice for prescribers,12 and would likely not be used in patients with ongoing purging.
Tetracyclic Antidepressant Trazodone
Trazodone is a tetracyclic antidepressant used to treat depression and anxiety. In one recent study, binge eating was reduced by 31% in patients treated with trazodone 400 to 650 mg per day.12
Tricyclic Antidepressants
The tricyclic antidepressants desipramine, imipramine, and amitriptyline reduced binge eating 72% versus 52% in placebo, and reduced vomiting 78% versus 53% in placebo. Overall, short-term placebo-controlled trials in patients with bulimia nervosa have reported that tricyclic antidepressants reduce binge eating by 47 to 91% and vomiting by 45 to 78%.12
MAOIs
MAOIs like phenelzine and isocarboxazid have been found to be more effective than placebo in reducing binge eating up to about 64%, however due to some necessary dietary restrictions when they are taken, the MAOIs are often not prescribed first.12
Mood Stabilizer Topirimate/Topimax
Topimax is originally a seizure and headache medication, but has been found to help elevate the mood, relieve anxiety, and control appetite. There are various side effects, notably fatigue and grogginess so this medication should be taken in the evening.
Lifestyle Changes & Self Help Strategies for Bulimia
Bulimia is a chronic condition that will require ongoing monitoring and alongside a built in support system. Relapse is common and some days will feel like a struggle, even with prolonged recovery. Be proactive about developing healthy lifestyle routines, a healthy relationship with food and your body, and a strong support system. Recognize that it is okay to feed your body and take pleasure in food, no matter what your size.
Studies show deprivation is more likely to lead to a binge and purge session. Keep track of your binges and purges, so you can identify any emotional triggers and binge foods. You can quickly connect that reaching for that food is more an indicator of an emotional issue than a hunger issue. Educate yourself on the concept of body positivity so you can approach recovery from a compassionate place of self-love and gratification.
Self help strategies that may help someone recovering from bulimia include:
- Intuitive Eating: To eat mindfully is to start eating when hungry and to stop when full. Consider this approach over tracking and counting calories.
- Coping Skills: Consider easing into hobbies and enjoyable activities again as a distraction and method of coping when triggered
- Self Help Groups: Food Addicts Anonymous and Overeaters Anonymous are long-standing, reputable support groups available for sufferers of all eating disorders
- Body Positivity: Learning to accept and love your body will reduce episodes of bulimia. Studies show body dysmorphia and self-loathing is at the core of most eating disorders.6
- Honesty and Accountability: Be honest with doctors and other care providers about your food, purging and exercise habits as well as any supplements you are taking
- Limit Environmental Stress: During this time of healing, your health and wellness should take priority over any other career, financial or aspirational stressors.
- Social Media: Re-evaluate its role in your life. Are the influences on social media negatively or positively impacting you in your recovery?
- Talk to Professionals: Consult with a registered dietician, nutritionist, and other professionals involved in your treatment prior to engaging in diets or exercise routines aimed at weight loss
- Mindfulness: Practice a meditation routine to work on distancing yourself from unhelpful thoughts that feed into your desire to binge, purge or restrict
- Stay Positive: Research also shows that an excessive negative attitude strongly correlates with disordered eating behavior5
- Proper Sleep: Consider a device that tracks sleeping patterns and learn about sleep hygiene techniques such as reducing caffeine and screen time. Studies show that poor disrupted sleep is highly correlated with Eating Disorders.1
Hospitalization for Bulimia
At the most acute and severe point, hospitalization for bulimia may be warranted. This is usually when a medical issue as a result of bulimia comes to the forefront. Medical issues from bulimia may include: Aspiration of food, respiratory distress, GERD, acid reflux, diarrhea, dehydration, electrolyte imbalance, low body weight or overweight, pneumomediastinum, cathartic colon syndrome, and heart arrhythmias that can be fatal. Bloated face (“chipmunk cheeks”) and dental issues are less severe, but typical issues caused by bulimia.11
Likewise, a co-morbidity that complicates matters, such as a substance use disorder may require hospitalization. Hospitalization will generally take place for medical purposes and immediate stabilization. Treatment would include managing vitals, regulating food intake (proper caloric intake), a one to one specialist to watch the patient and prevent self-harming and purging behaviors. In addition to nutritionists, nurses, and doctors, there will be individual and group therapy, as well as family counseling. The goal is not to cure the patient but to stabilize them enough mentally and physically for on-going treatment in an outpatient setting.
Questions to Ask About Bulimia Treatments
It is natural to be concerned or even down right skeptical before starting a new treatment. Sometimes this fear and vulnerability keeps individuals who desperately need help from reaching out. Trust that your providers are there to help you, but also be sure to ask the right questions so you can be thorough in your decision.
Ultimately if a situation seems uncomfortable or feels off, it is okay to trust your gut. A defensive or impatient provider would not be a good choice. When in the midst of a mental health crisis, our judgment and decision-making abilities can feel all out of sorts, so you can also bring a trusted friend or family member to your initial consultation.
Here is a list of questions you can ask before initiating treatment:
- How long is the process?
- How much will it cost?
- How often do I come to therapy?
- Is my information confidential?
- What are your credentials and experience in treating Bulimia?
- What is your approach, philosophy, goals in treating clients with Bulimia?
- What is the expected outcome of treatment? Will there be a full recovery or harm reduction approach?
- What’s the level of support upon discharge?
- Is this process evidence-based?
- Is it considered studied, safe, and effective?
Questions to ask about medications include:
- Are there any side effects or contraindications?
- How long will I need this medication?
- What do I do if there are unpleasant side effects?
- What do I do if I feel better and wish to taper off the medication?
Questions to ask about lifestyle changes include:
- Is this accredited and proven? Otherwise, where is the anecdotal evidence that this is effective and not harmful?
- What level of support is offered?
- What is the cost? Self-help and lifestyle changes should be free, low-cost, or sustainable on a regular basis.
- How do I best incorporate these new habits into my old life?
For Further Reading
The following are helpful resources for anyone interested in treatment for bulimia:
