Management issues
Treatment of bulimia
nervosa and binge eating
disorder
Frederique Van den Eynde
Ulrike Schmidt
Abstract
Bulimia nervosa and binge eating disorder are complex eating disorders
with a major impact on the life of the patient and that of their family. Over
the past two decades, increasing prevalence and incidence rates have
confronted primary care and mental health services with high ­demands for
treatment for these disorders that are difficult to meet. Psychotherapeutic
interventions are the first-choice treatment. ­Cognitive–behavioural therapy
(CBT) is efficacious in both bulimia nervosa and binge eating disorder, but
there is a need to improve outcomes further. Interpersonal psychotherapy
(IPT) has also been shown to have bene­fits, although in bulimia nervosa
the response has been slower than with CBT. In general, delivering psycho-
therapy is costly and is often hampered by limited availability. Self-help
versions of CBT may help to overcome these difficulties. Although prom-
ising, further exploration is required as to whether self-help strategies
are an alternative to or can reduce therapist involvement. Alternatively,
pharmacotherapy is a potential treatment option for bulimia nervosa and
binge eating disorder, with evidence predominantly on antidepressants.
Fluoxetine in a higher dose has been recommended because it is relatively
better tolerated than antidepressants of other classes. Overall, combined
psychotherapy and pharmacotherapy in patients with bulimia nervosa
produces somewhat better outcomes than pharmacotherapy alone, but is
not clearly superior to psychotherapy alone. Data on combination treat-
ment in binge eating disorder are less conclusive. Although the therapeu-
tic arsenal for the treatment of bulimia nervosa and binge eating disorder
is expanding, several domains required further investigation.
Keywords antidepressant; binge eating disorder; bulimia nervosa;
­cognitive–behavioural therapy; interpersonal therapy; treatment
Introduction
Bulimia nervosa (BN) was first described by Gerald Russell in
1979, binge eating disorder (BED) was conceptualized a decade
later, and purging disorder (PD)1 has recently gained attention.
Despite the very recent recognition of these disorders, and in
stark contrast to anorexia nervosa, a major body of research into
the treatment of these conditions has been produced and has
been summarized in several high-quality systematic reviews. It is
Frederique Van den Eynde MD is a Marie Curie Research Fellow at
the Section of Eating Disorders, Institute of Psychiatry, London, UK.
Conflicts of interest: none declared.
Ulrike Schmidt MRCPysch PhD is Head of the Section of Eating Disorders,
Institute of Psychiatry, London, UK. Conflicts of interest: none declared.
PSYCHIATRY 7:4
likely that these research efforts were driven by the considerable
public interest in these disorders, fuelled by ‘celebrity cases’, but
also by the increasing incidence and prevalence rates of bulimia
during the last two decades of the 20th century.2
Psychological treatment of bulimia nervosa
Cognitive–behavioural therapy and interpersonal therapy
A specific form of cognitive–behavioural therapy (CBT) was
developed by Fairburn et al. (1993)3 and focuses on address-
ing bulimic behaviours and cognitions, such as overvalued
beliefs about weight, shape and appearance. A schematic form
of the model underlying this treatment is presented in Figure 1.
­Currently, this form of CBT is considered the first-choice treat-
ment for adults with bulimia nervosa.4,5 With 16 to 20 sessions of
this treatment, about 30–40% of people are symptom free at the
end of treatment, and these gains are usually maintained in the
longer term. CBT has been found to be superior to remaining on
the waiting list and to a range of comparison treatments.4 Several
trials have compared CBT to interpersonal psychotherapy (IPT).6,7
People with BN often present with interpersonal difficulties, thus
a treatment such as IPT, which focuses on these, appears highly
relevant. CBT has been found to be superior to IPT in terms of
reducing bulimic symptoms and achieving remission,8,9 but this
difference disappears over time and longer-term outcomes are
similar.7,9 A recent systematic review has confirmed that CBT
yields a faster reduction of bulimic symptoms, whereas IPT is
equally efficacious in the longer term.4
Modifications to cognitive–behavioural therapy, and what if it
fails?
Attempts to dismantle CBT and determine the ‘active ingredients’
led to identification of the ‘cognitive component’ as critical to
Cognitive–behavioural model of the maintenance of
bulimia nervosa
Over-evaluation eating, shape
and weight and their control
Strict dieting and other
weight-control behaviour
Binge eating
Compensatory
vomiting/laxative misuse
Adapted with permission from Fairburn CG, Cooper Z, Shafran R. Cognitive
behaviour therapy for eating disorders: a ‘transdiagnostic’ theory and
treatment. Behav Res Ther 2003; 41: 509–28.16
Figure 1
161 © 2008 Elsevier Ltd. All rights reserved.
 Management issues
therapeutic outcome (for review see Shapiro et al., 2007).10 Modi­
fications to CBT such as the addition of exposure and response
prevention did not enhance its efficacy.11 In contrast, translating
CBT into self-help modalities is promising (see below). Several
recent efficacy studies (e.g. reference 12) have compared group
with individual CBT, motivated by the notion that group treat-
ment might be more cost effective. These studies suggest a slight
advantage for individual over group treatment in terms of clinical
outcomes. However, these findings are not clear-cut, as these
studies are likely to have been underpowered.
In the management of CBT non-responders, several possible
strategies can be applied, such as switching from CBT to admin-
istration of antidepressants, or another form of psychotherapy.
However, Mitchell et al. (2002)13 found that an augmentation
strategy with either IPT or antidepressants in CBT non-­responders
did not significantly improve response rates. This led the authors
to suggest that offering lengthy sequential treatments to people
with BN may be of little value.13 This needs further exploration,
as others have reported a beneficial effect for augmentation of
CBT with antidepressants.14
Another approach is to alter or add to CBT to make it more
effective.15 For example, Fairburn and colleagues (2003)16 have
described a new model of eating disorders, the so-called trans-
diagnostic model. This model and the treatment based on it, in
addition to addressing symptoms of the eating disorder, tackle
other areas in which these patients commonly experience prob-
lems. These include clinical perfectionism, core low self-esteem,
affective instability, and interpersonal problems. Other research-
ers, such as Cooper and co-workers (2004)17 and Waller et al.
(2007),18 have also developed promising additions and adapta-
tions to CBT-BN, although to date there have been no compari-
sons of CBT-BN with these more sophisticated approaches.
Interventions for adolescents
The majority of treatment trials in BN have focused on adults, and
the National Institute for Health and Clinical Excellence (NICE)
guideline identified the need for trials on adolescents as a research
priority.4 Since then, two randomized controlled trials (RCTs) of
the treatment of adolescents with BN have been published. Schmidt
et al. (2007)19 compared family therapy and CBT-based guided
self-help in adolescents aged 13–20 years with BN or eating disor-
der not otherwise specified (EDNOS)-BN. Guided self-help had a
slight advantage over family therapy in terms of producing a more
rapid reduction of bingeing, lower cost, and higher acceptability. A
second, US-based, trial20 compared family therapy with supportive
psychotherapy in adolescents aged 12–19 years with BN. Family
therapy was superior to supportive psychotherapy, although these
effects appeared to wane by the 6-month follow-up.
Other interventions
Dialectical behavioural therapy (DBT)21 and nutritional and stress
management22 in BN look promising as they reduce bingeing
and purging. Higher abstinence rates than for waiting list were
observed in the DBT group.21 Preliminary findings on guided
imaginary23 and light therapy24,25 are encouraging as well.
Response prediction
Early response to treatment predicts the post-treatment outcome
in BN.6,8,26,27 High frequency of bingeing and longer duration of
PSYCHIATRY 7:4
illness appear to predict a worse outcome from ­ psychological
treatments. There is no evidence for differential outcome by
sociodemographic factors.10
Psychological treatment of binge eating disorder
In BED the goals of treatment are two-fold: first, to help people
reduce or stop distressing binges and, second, as BED is often
associated with obesity, to reduce weight. CBT is the first-choice
treatment in BED as its efficacy in terms of binge reduction has
been well documented.28,29 However, CBT does not usually
lead to a significant weight loss in these patients. Modifications
such as additional spousal involvement28 and body exposure/
cognitive restructuring of negative body cognitions29 were not
­beneficial.
Apart from CBT, IPT has also been shown to improve binge-
ing symptoms.30 Other promising results that need further
investigation have come from a RCT with DBT,31 and virtual
reality and psychonutritional control.32 It remains unclear
whether behavioural weight loss treatments are efficacious
for weight loss in obese patients with BED.33 Compared with
guided self-help CBT, behavioural weight loss treatment was
less efficacious in improving BED symptomatology, but resulted
in similar weight reduction.34 Overall, a systematic review35
considered the evidence for the efficacy of behavioural inter-
ventions in BED to be moderate, but weak for self-help and
other interventions. Again, no consist­ency on predictive factors
was reached.
Self-help and guided self-help
As specialist psychological treatment is not always easily access­
ible, or only with considerable delays, self-help treatments might
help to bridge the gap between demands and available resources.
Self-help treatments use audiovisual materials for the purpose of
gaining understanding or solving problems relevant to a person’s
therapeutic needs.36 In guided self-help, guidance by a health-
care professional or a layperson is offered, ‘to monitor progress,
clarify procedures, to answer general questions, or to provide
general support or encouragement’.37
Is it efficacious?
Two systematic reviews have summarized the available litera-
ture on self-help treatments in BN, BED, and EDNOS in adults.
These reviews underline their utility as a first treatment step
and regard them as potential alternatives to formal therapist-
­delivered psychological therapy.38,39 In comparison with wait-
ing list, self-help, in particular with guidance, leads to a greater
improvement in eating disorder symptoms (but not bingeing or
purging), other psychiatric symptomatology, and interpersonal
functioning. There is also some evidence suggesting that guided
self-care may be as effective as other formal psychological treat-
ments,38 although others40 have cautioned that this area needs
further study.
The relative efficacy of self-help interventions compared
with pharmacological interventions remains unclear. Much is
still to be learnt about who benefits from what kind of self-
help, in what setting, and with how much and what type of
guidance.
162 © 2008 Elsevier Ltd. All rights reserved.
 Management issues
Pharmacological treatment of bulimia nervosa
Antidepressants
Efficacy: pharmacological intervention in BN has focused prim­
arily on antidepressants. The rationale for this was high co-
­morbidity between BN and affective disorders, and findings
of serotonin system dysfunctions in BN.41 According to some
authors antidepressants have antibulimic properties regardless
of the presence of mood symptoms,42 but according to others it
remains unclear whether this effect is direct or indirect by lower-
ing depressive symptoms.43
A systematic review of RCTs comparing different tricyclic
antidepressants (TCAs), a selective serotonin reuptake inhibitor
(SSRI), and monoamine oxidase inhibitors (MAOIs) concluded
that the use of a single antidepressant in patients with BN was
clinically effective and associated with an overall greater remis-
sion rate, but also higher drop-out rates than placebo.43 Differ-
ent classes of antidepressant did not differ in efficacy, although
patients taking TCAs were more likely to interrupt treatment
prematurely and fluoxetine was more acceptable. To date, only
fluoxetine has been approved by the US Food and Drug Admin-
istration in the treatment of BN. It is of note that promising find-
ings for other antidepressants (mianserin, reboxetine, sertraline,
milnacipran, and trazodone) have been published, as well as
negative findings for others (e.g. lack of efficacy for fluvoxamine
in a large multicentre randomized placebo-controlled trial).44
Dosage, side effects, and duration of treatment: TCA and MAOI
doses applied in BN are comparable to those in depression.43 For
fluoxetine, a dose–response study showed a high dose (60 mg)
to be superior to a lower dose (20 mg) and placebo.45 Data on
adolescent subjects with BN are scarce, but a high dose of fluox-
etine has been argued to be safe and effective.46 Side effects can
negatively influence compliance and increase discontinuation
rates. Fluoxetine was repeatedly reported to be the best tolerated
antidepressant with proven efficacy in BN.43 Its use is not associ-
ated with increased suicidality.47
A recurrent clinical dilemma concerns the duration for which
a treatment should be continued. The literature is inconclusive,
but high relapse rates after treatment discontinuation48 and
improved relapse prevention with treatment continuation49 sug-
gest that the effect of antidepressant treatment is most likely not
enduring. Based on these findings, the NICE guidelines4 recom-
mend that antidepressants can be tried as a first step in treat-
ment, but should be discontinued if found not to be effective
quickly.
Who is going to respond?
According to some authors, antidepressant responders can be
reliably identified in the first 2 weeks of treatment.50 However,
this does not enable clinicians to make accurate predictions on
an individual level, as there is a subgroup of people who respond
more slowly.8 The literature on predictors of treatment outcome
is inconsistent, but a high level of bulimic symptoms and a his-
tory of substance abuse/dependence were shown negatively to
influence treatment outcome, whereas a good therapeutic alli-
ance increased the likelihood of remission.8 Greater concern for
body shape and weight, higher weight, and longer duration of
illness have been associated with a more favourable outcome.48
PSYCHIATRY 7:4
Other psychotropics
Numerous pharmacological compounds have been studied in BN,
although these trials were not always clearly driven by hypoth-
eses. Mood stabilizers (phenytoin, carbamazepine, and lithium),
l-tryptophan, naltrexone, and fenfluramine have not been found
to be effective. In contrast, one small RCT found the 5-HT3 ago-
nist ondansetron to be superior to placebo in the short term,
although the feasibility of this treatment is questionable as it is
expensive and multiple daily dosing is required.51 Several RCTs
(e.g. reference 52) have suggested that topiramate reduces binge
days; this warrants further exploration.
Pharmacological treatment of binge eating disorder
SSRIs (citalopram, sertraline, fluoxetine, and fluvoxamine) have
mainly been used as the active compound in pharmacological tri-
als of patient with BED. Overall, they generated a reduction of
binge eating behaviour and were well tolerated. However, they
were also associated with higher discontinuation rates.35 A large
case-series has also provided promising results for venlafaxine in
BED.53 Apart from antidepressants, topiramate54,55 and subitra-
mine56 reduce binge eating symptoms, but only subitramine also
improved mood symptoms and resulted in significant weight loss.
Is combination treatment the answer?
Bulimia nervosa
Findings on combined psychotherapy and antidepressant treatment
in BN are rather inconsistent and do not show a clear additive, let
alone multiplicative, effect. Furthermore, complex study designs do
not contribute to a straightforward interpretation of the literature.
Most authors have reported that addition of an antidepressant
to CBT did not amplify the efficacy of CBT alone,57–59 whereas
others found that it did.14 A further question is whether combina-
tion treatment is more efficacious than medication alone. Again,
conflicting results have been reported, with positive14,58,59 and
negative57 findings.
Other forms of psychotherapy have been poorly studied in
this respect. Neither the combination of an antidepressant and
IPT in CBT non-responders,13 nor the combination of an antide-
pressant and psychodynamically oriented supportive therapy,14
proved to be superior to medication alone. However, the anti­
depressant and supportive therapy combination was significantly
better than psychotherapy alone,14 whereas this was not the case
for a structured group therapy.60
Where combined self-help intervention and antidepressant
treatment were delivered, the active component reducing bulimic
symptoms appeared to be the antidepressant, whereas self-help
interventions had no independent effect.61,62
Kotler and Walsh (2000)46 emphasized that the modest gains
of adding medication to psychotherapy should be weighed
against the risk of side effects and the costs of medication and its
monitoring. Conversely, the gains of adding psychological treat-
ment to medication must be examined in the context of costs and
limited availability.
Binge eating disorder
The addition of antidepressants to CBT is a successful strategy in
BED63,64 and was shown to be better than medication alone.34,65
163 © 2008 Elsevier Ltd. All rights reserved.
 Management issues
Data on its ability to reduce binge eating and weight vs CBT
alone, are conflicting.34,65,66 In contrast, the addition of orlistat67
or topiramate55 to CBT increased the efficacy of the latter.
Both dietary counselling68 and behavioural therapy69 com-
bined with an antidepressant also resulted in weight reduction.
This was not the case for nutritional management.65
Conclusion
On the whole, treatment of bulimic syndromes is characterized
by low remission and high relapse rates. For both BN and BED,
CBT is the first-choice treatment, but associated costs and limited
availability are disadvantages of this. In BN, CBT and IPT appear
to be equally effective in the longer term, although CBT induces
a faster response. In BED, CBT is the best-established therapeu-
tic option, but does not reduce weight. Self-help interventions,
guided or not, have the potential to allow clinicians to overcome
the present gap between high demands for treatment and limited
resources.
Pharmacological interventions are part of the armamentarium
for treating bulimic syndromes, especially when affective symp-
toms are present.46 A higher dose of fluoxetine is considered
effective and safe in adults and adolescents. However, there is
a need for more replication studies.41 It is an advantage of anti­
depressant treatment that it can be easily and successfully imple-
mented in primary care settings.62 As to whether a combination
of psychotherapy and pharmacology is the solution, this remains
uncertain. In general, combination treatment is more effective
than medication alone, but not than psychotherapy alone.
Even if unsuccessful in the short term, engaging patients in
an active treatment seems to improve social functioning after a
decade, compared with giving no active treatment.70
Many domains in the treatment of bulimic syndromes are yet
to be explored. Generalizability of current findings is largely lim-
ited to young adult patients without severe co-morbidity. Uni-
form adequate outcome measures need to be defined, including
clear conceptualization of ‘remission’, ‘recovery’, and ‘relapse’
in bulimic syndromes.43 ◆
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