Bulimia Nervosa
Finding The Right Treatment
Treatment
Several types of therapy can be helpful for BN including:
Cognitive Behavioral Therapy - uses techniques to replace negative thoughts and all or nothing thinking, such as feelings about your body along with changing behaviors.
Dialectical Behavior Therapy – brings in skills to manage emotions around stressful situations and building positive relationships in order to have social supports.
Acceptance and Commitment Therapy – offers competencies to accept thoughts and feelings, stay in the present moment, and choose a valued direction in the recovery process.
Mindfulness-Based Cognitive Therapy - uses mindful meditation to understand one’s thought process and how the mind become entangled by emotions and feelings.
Body-Centered Therapies - integrates talk therapy with techniques that bring the body into counseling as a therapeutic resource to increase awareness of body sensations, behaviors, emotions, and thoughts so to learn the relationships between them. Body centered therapies may include yoga therapy, dance, breath work, and meditation.
Depending on the severity of one's condition, a higher level of care may be warranted such as inpatient hospitalization for medical stabilization; residential treatment for excessive and daily behaviors that undermine health; partial hospitalization for those with daily behaviors but are able to function in normal social, educational, or vocational situations; or intensive outpatient therapy for those who are psychiatrically stable and have symptoms under sufficient control to be able to function in normal social, educational, or vocational situations, while continuing to make progress in recovery.
The decision to start therapy
Many people try to cope with their distress on their own, then feel disappointed when they find that this is very difficult to do. Deciding to start therapy can be hard; it takes courage.
For some people, it can take time to warm up to the idea of sharing one’s intimate thoughts or disclosing details of one’s life, especially for those who grew up in a culture where seeking psychological help was frowned upon.
Psychotherapy is increasingly accepted as not only a way to improve mental health symptoms, but also a means for self exploration and personal growth. No problem is too small for a trained therapist: an individual need not worry that others may have it worse. The willingness to reach out for help is increasing: in 2020, one out of every six Americans (men and women) reported seeing a therapist.
Seeing a therapist with whom one feels comfortable, and a sense of connection, and who also participates in their insurance network, is essential. It may take a couple tries to find a therapist who feels like the right fit. If therapy didn't help the first time around, it can be helpful to give another therapist a try because therapeutic styles vary so much from therapist to therapist.
Where to start
Requesting one’s physician to make a referral is often a good place to start. Many health insurance cards have websites or 1-800 numbers to call for a list of in-network providers.
To find a therapist who takes your insurance, the National Institute of Mental Health offers a comprehensive list of resources.
Psychology Today also lists therapists by type, location and insurance.
Stepping up or down with therapy
Treatment protocols for BN often call for a “stepwise-therapy,” approach or hospitalization or residential treatment in a specialized facility for the person who is very ill with bulimia nervosa. In the early stages of BN treatment, intensive inpatient therapy may be needed, but as the person begins to recover, then therapy can be “stepped down” to an intensive outpatient therapy usually 4-5 times a week or at the level the treatment team believes is needed.
With further improvements come fewer therapy sessions, but with the understanding that therapy can always be stepped back up or down again, if and when it is needed. Progress does not always come in a straight line and people with BN may have a few setbacks along the way.
Determining whether medications will play a role in treatment
Many people with BN also struggle with depression, anxiety, and other psychiatric disorders, and improving other psychiatric illnesses may help the person with BN resolve underlying problems or concerns. Medications often play a central role in the lives of people with BN, depression and anxiety.
There are multiple categories, or classes, of medications that the Food & Drug Administration (FDA) has approved to treat depression. Each class is often prescribed for a different scenario or type of depression.
First-line treatment
Fluoxetine (Prozac), an antidepressant, is the only medication that is approved by the Food and Drug Administration (FDA) for the treatment of bulimia nervosa. The normal starting dose for fluoxetine is 20 mg; however, the dose that is considered efficacious for bulimia nervosa is 60 mg. Most physicians who prescribe fluoxetine for BN start at 20 mg and gradually increase the dosage over time.
As a class of medications, antidepressants often take 10 days to two weeks to begin working. The full effect of the medication is not realized for two months.
If fluoxetine does not initially work, a prescriber has other options. For example, other medications in the selective serotonin reuptake inhibitor class may be tried, such as citalopram (Celexa), escitalopram (Lexapro), or sertraline (Zoloft).
Second-Line medications
When fluoxetine and other SSRIs do not help the person with BN, then the doctor may try other categories of medications, including the off-label use of the anticonvulsant topiramate (Topamax). This medication has many problematic aspects associated with it and should be considered very carefully before taking it.
FDA warning about suicide risk with antidepressants
Some research exists that, occasionally, newly initiated anti-depressants may increase the risk of suicide. If an individual begins to have these thoughts after starting an anti-depressant, please stop this medicine and contact a prescriber immediately. This risk is more evident in children, adolescents, and young adults.
Healthcare providers that can prescribe medications
Psychiatrists, psychiatric nurse practitioners, and physician assistants are practitioners who are trained to diagnose and treat mental health conditions by prescribing medications. Sometimes it's hard to find a psychiatric provider because there are so many people who need them. So, individuals often choose to see a different kind of provider who can prescribe. This could be a doctor they already see, like a primary care doctor, family doctor or OB/GYN, or a new primary doctor.