Clinical Therapeutics/Volume 43, Number 1, 2021
State of the Art: The Therapeutic Approaches to
Bulimia Nervosa
Kelsey E. Hagan, PhD1,2; and B. Timothy Walsh, MD1,2
1
Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, USA;
and 2New York State Psychiatric Institute, New York, NY, USA
ABSTRACT
Purpose: Bulimia nervosa (BN) is an eating disorder
characterized by binge eating, inappropriate
compensatory behaviors, and body image concerns in
persons at or above a healthy weight. BN is a serious
disorder with medical sequelae and marked
psychosocial impairment. To reduce and eliminate
symptoms of BN, psychological and pharmacologic
treatments for BN have been developed. We review
the current state-of-the-art treatments for BN.
Methods: We conducted a narrative review of the
BN treatment literature to synthesize the current
evidence base, provide recommendations, and
propose future directions for BN treatment research.
Findings: Currently, the first-line, state-of-the-art
treatment for adults with BN is cognitive-behavioral
therapy (CBT). Interpersonal therapy is a second-line
evidence-based treatment for adults with BN, and
dialectical behavior therapy and integrative cognitive-
affective therapy are also promising. For BN in
adolescents, family-based treatment for BN or CBT are
evidence-based approaches. Pharmacotherapy is best
considered adjunctive to psychotherapy in adults with
BN but may be helpful, depending on the type of
psychotherapy and whether psychotherapy is ineffective
or unavailable. Fluoxetine 60 mg/d is the medication of
choice for adults with BN. Little is known with respect
to pharmacologic treatment of BN in adolescents,
although fluoxetine 60 mg/d holds promise.
Implications: Despite decades of treatment-
development research in BN, there is room for
improvement because nearly 60% of those with BN do
not achieve remission with specialty treatment and
strikingly few randomized controlled trials for BN in
adolescents exist. Moreover, the field should address
issues related to treatment dissemination, access, and
cost. (Clin Ther. 2021;43:40e49) © 2020 Elsevier Inc.
40
Key words: bulimia nervosa, pharmacotherapy,
psychotherapy, randomized controlled trials.
Bulimia nervosa (BN) is an eating disorder characterized
by recurrent binge eating, inappropriate compensatory
behavior, and body image concern in persons who are
at or above a healthy weight.1 BN is associated with
functional impairment and medical and psychiatric
comorbidities.2 Lifetime prevalence of BN is
approximately 0.5% among women,3 and the
disorder typically begins in late adolescence.4,5 To
reduce the symptoms of BN, psychotherapies and
pharmacotherapies have been developed and tested in
adults with the disorder. Despite the fact that BN
typically begins in late adolescence, few treatments
have been developed and evaluated for BN in this age
group. We describe the current evidence-based
psychotherapeutic and pharmacologic approaches to
the treatment of BN. We synthesize the current
literature, provide recommendations, and highlight
areas for future study.
PSYCHOTHERAPIES FOR ADULTS
Dozens of randomized controlled trials of
psychotherapies have been conducted for adults with
BN. We detail the psychotherapeutic approaches with
the greatest evidence base for adults with BN.
Cognitive-Behavioral Therapy
Cognitive-behavioral therapy for BN (CBT-BN) is a
brief, present-oriented approach that is the treatment
of choice for BN.6,7 The cognitive-behavioral model
of BN provides the theoretical framework for CBT-
Accepted for publication October 29, 2020
https://doi.org/10.1016/j.clinthera.2020.10.012
0149-2918/$ - see front matter
© 2020 Elsevier Inc.
Volume 43 Number 1

BN8 and has been supported by empirical research.9
This model hypothesizes that dieting begins as a
consequence of body shape and weight concerns.
Dieting eventually leads to binge eating, which, in
turn, prompts engagement of inappropriate
compensatory behaviors (eg, self-induced vomiting,
laxative and/or diuretic misuse, and excessive
exercise), reinforces body image concerns, and renews
dieting attempts. Thus, the cognitive-behavioral
model of BN hypothesizes that weight and shape
concerns and eating disorder behaviors are mutually
reinforcing and perpetuate a vicious cycle that
maintains BN.
CBT-BN uses a staged approach to introduce
behavioral techniques and cognitive strategies to
target symptoms delineated in the cognitive-
behavioral model of BN. The treatment is delivered
in approximately 20 sessions during approximately 6
months. The initial focus of CBT-BN is behavioral
because the clinician helps the patient regulate eating
patterns and self-weighing behavior. After
management of eating disorder behaviors, the focus
of CBT-BN pivots toward cognitive restructuring to
address shape and weight concerns. An enhanced
form of CBT (CBT-E) was later developed for the
transdiagnostic treatment of eating disorders,
including BN.6 A focused form and a broad form of
CBT-E exist. The focused form is similar to CBT;
however, the broad form incorporates additional,
optional modules to address problems associated
with eating disorders, including perfectionism, low
self-esteem, mood intolerance, and interpersonal stress.
An individualized formulation is a foundational
component of CBT-BN and is completed during or
before the first treatment session. The formulation is
a collaboration between the clinician and patient in
which the patient's eating disorder behaviors and
thoughts are visually diagramed. For example, the
clinician may begin the formulation by asking the
patient to identify precipitants of binge eating, and
the formulation is expanded from this starting point.
One goal of the formulation is to increase the
patient's awareness of the factors that maintain the
disorder. Another goal is to help the patient
understand the rationale behind targeting behaviors
and thoughts in CBT-BN; thus, the formulation may
promote patient buy-in. The formulation is meant to
be revisited and modified throughout treatment.
January 2021
K.E. Hagan and B.T. Walsh
Self-monitoring is prescribed in the first session of
CBT-BN and is a cornerstone of the treatment.
Patients are asked to keep daily logs of food and
drink and contextual factors (eg, time, place,
thoughts, and emotions) around consumption.
Patients are also asked to indicate the presence of
binge eating and inappropriate compensatory
behaviors. The purpose of self-monitoring is to help
the patient increase awareness of eating behaviors as
well as cognitive and emotional antecedents and
consequences of eating behaviors. The clinician
assesses the patient's prior experiences with self-
monitoring and highlights that the purpose of self-
monitoring in CBT-BN is not to count calories and/
or macronutrients, as patients may have done in the
past, but to collect data and to help generate
hypotheses about factors that maintain BN. Self-
monitoring logs are reviewed in detail at the
beginning of each treatment session; thus, it is
important for the patient to regularly complete logs.
Self-monitoring may be completed with paper-and-
pencil logs, smartphone applications (apps), or
websites. The clinician should assess patient concerns
around and/or resistance to self-monitoring that may
interfere with the completion of logs. Common
concerns about self-monitoring include shame around
logging binge episodes, inconvenience, and
forgetfulness. Supporting the patient in problem-
solving ways to successfully and regularly complete
self-monitoring logs is important because self-
monitoring continues throughout CBT-BN.
Once-weekly weighing with the clinician is
instituted in the first session of CBT-BN and
continues throughout treatment. Patients often desire
to weigh themselves more frequently; however, the
clinician provides psychoeducation that more
frequent weighing will capture fluctuations in weight
that are physiologically not meaningful and will
contribute to worry about weight and shape. After
in-session weighing, the clinician informs the patient
of his/her weight and plots the patient's weight over
time to establish a trend. Alongside this prescription
of once-weekly weighing, the clinician provides
psychoeducation around typical weight fluctuations
and the relative ineffectiveness of weight control
behaviors, such as self-induced vomiting. There are
several purposes of once-weekly weighing. One
purpose is to encourage healthy self-weighing
41
 Clinical Therapeutics
behaviors in patients with BN; individuals with BN
may compulsively self-weigh or may habitually avoid
self-weighing. Another purpose is to track how the
patient's weight fluctuates with treatment and the
prescription of regular eating (described in the
following paragraph). Clinicians may discuss with
patients that a goal weight is one that does not
necessitate dietary restriction or use of other
compensatory behaviors.
Once the patient achieves regular self-monitoring,
the clinician prescribes regular eating, which typically
consists of 3 meals and 2 to 3 snacks per day and
going no more than 4 h without eating. Patients are
encouraged to plan ahead what and when they will
eat. If a patient deviates from their plan by
overeating or undereating, the clinician encourages
the patient to return to the plan with the next meal
or snack rather than attempting to compensate via
restriction. At this stage, the clinician may also
introduce strategies for helping the patient prevent
binge eating and compensatory behaviors, such as
stimulus control or engagement in alternative
behaviors that are incompatible with binge eating
and purging, such as taking a bath.
With successful implementation of behavioral
techniques and management of eating disorder
behaviors, CBT-BN shifts to target cognitive
distortions theorized to underpin BN. Cognitive
distortions related to eating behaviors and food rules
are first targeted; self-monitoring forms may provide
clues to target distortions. One strategy may be to
consume foods during CBT-BN sessions that the
patient believes will make him/her fat. A second step
is identifying triggers and targeting behaviors that
lead to body image concerns, such as body checking
and comparisons to others. Patients are encouraged
to increase participation in activities that are not
eating disorder related to expand self-evaluation into
other domains and decrease the impact of weight and
shape on self-worth. If the clinician is practicing
broad CBT-E, the clinician may elect to include
optional modules, such as mood intolerance and
interpersonal difficulties, at this phase.
CBT-BN concludes with a discussion of progress,
realistic expectations with respect to continued
progress, relapse prevention, and planning ahead. In
this discussion, the clinician helps the patient to
identify (1) strategies they will continue to use to
42
minimize the likelihood of a relapse, (2) warning
signs of a relapse, and (3) plans to address a relapse.
The clinician may help the patient to create a coping
card that details a plan to address a relapse of eating
disorder behaviors and thoughts.
The evidence for CBT-BN is robust. For instance,
recent meta-analyses of randomized controlled trials
for BN treatment found that therapist-led CBT-BN
was more significantly efficacious than inactive
comparisons (ie, no treatment or waitlist control)10,11
and other active psychotherapies (eg, interpersonal
therapy [IPT] or supportive psychotherapy [SPT])10,12
but not pharmacotherapy in promoting abstinence of
symptoms at the end of treatment. These meta-
analyses also suggest that self-help CBT-BN is
significantly more efficacious than inactive
comparisons (such as being assigned to a waiting list)
in promoting abstinence of symptoms at the end of
treatment.10,11 Current clinical guidelines recommend
the use of therapist-led CBT as first-line treatments
for BN but highlight that guided self-help CBT is
cost-effective and may be useful when specialized
eating disorder services are not available.7
There is yet limited evidence with respect to whether
CBT-E is superior to CBT-BN. One trial randomized
individuals with BN and comorbid borderline
personality disorder to receive broad CBT-E or
focused CBT-E (similar to CBT-BN) and found no
statistically significant differences in abstinence of
symptoms at the end of treatment and 6-month
follow-up.13 However, moderator analysis suggested
that those with greater affective/interpersonal
problems fared better with the broad form versus the
focused form of CBT-E. Thus, the broad form of
CBT-E may be indicated when elevated affective
comorbidity is present.
Interpersonal Therapy
IPT is a brief treatment that links interpersonal
difficulties and social skills deficits to eating disorder
symptoms.14 IPT was initially developed for the
treatment of depression15 and was adapted for the
treatment of BN because of links between
interpersonal functioning and bulimic behaviors.14,16
The interpersonal theory of binge eating provides the
theoretic framework for IPT.17 This model posits that
interpersonal difficulties cause low self-esteem and
negative affect, which, in turn, lead to eating disorder
Volume 43 Number 1

behaviors. Engagement in eating disorder behaviors
may further contribute to interpersonal difficulties,
thereby maintaining BN.
IPT for BN is typically delivered in 6e20 sessions
during 3 phases and focuses on addressing
interpersonal problems as an indirect means to
reduce eating disorder symptoms. In the initial phase
of IPT, the patient's eating disorder symptoms and
interpersonal problem areas are assessed. The
clinician provides the patient with a formal eating
disorder diagnosis and psychoeducation about BN.
The clinician assigns the patient to the sick role in
which the clinician emphasizes that the patient is ill
with BN and stresses the importance of focusing on
treatment and recovery from BN, as would happen
with a medical illness. At the same time, the clinician
instills hope that IPT can help to reduce or eliminate
BN symptoms.
Interpersonal problems are assessed using an
interpersonal inventory, a cornerstone of IPT. The
interpersonal inventory determines the interpersonal
problem area that will be the focus of treatment and
connects interpersonal problems to eating disorder
symptoms. Interpersonal problem areas include
interpersonal deficits, role transitions, role disputes,
and grief. Interpersonal deficits are characterized by
longstanding difficulties with making and maintaining
friendships. Role transitions are major life transitions
that affect interpersonal relationships, such as
graduating from school, becoming a parent, or
starting a new job. Role disputes are characterized by
discrepant expectations about the role someone plays
in a relationship and often result in disagreement.
Grief involves the loss of someone significant to the
patient. The interpersonal assessment is also used to
collaboratively develop an interpersonal case
formulation that links interpersonal problem areas to
the onset and maintenance of the eating disorder.
The interpersonal case formulation pinpoints which
problem area will be the focus of treatment; one
problem area is selected as a treatment target, even
though a patient may have difficulties in 2 areas.
In the intermediate phase of IPT, the clinician helps
the patient work toward interpersonal goals and keeps
the patient focused on the interpersonal problem area.
Techniques to address interpersonal problem areas
include communication analysis, role playing, and
clinician modeling of good verbal and nonverbal
communication. The patient also completes weekly
January 2021
K.E. Hagan and B.T. Walsh
eating disorder symptom assessments, and the
clinician repeatedly connects eating disorder
behaviors to interpersonal problem areas, which
reinforces the importance of addressing interpersonal
problem to reduce eating disorder symptoms.
Clinicians also connect reductions in eating disorder
behaviors to improvements in interpersonal problem
areas. IPT concludes with a termination phase in
which the clinician and patient review the patient's
progress, discuss remaining interpersonal work, and
identify potential warning signs and relapse
prevention strategies.
IPT is an efficacious treatment for BN, as evidenced
by results from 2 randomized controlled trials. One
trial randomized 220 adults with BN to receive IPT
or CBT and found that CBT was statistically superior
to IPT with respect to end-of-treatment abstinence
from eating disorder behaviors (29% for CBT-BN vs
6% for IPT).18 Similarly, another trial randomized 75
women to receive CBT, IPT, or behavior therapy and
found that CBT was superior to IPT in facilitating
end-of-treatment symptom reductions.16 However,
both trials found no statistically significant
differences in those who received IPT versus CBT at
1-year follow-up.18,19 Thus, it seems that IPT may
have a slower effect on reducing eating disorder
symptoms than CBT, perhaps by virtue of its indirect
treatment of the eating disorder via interpersonal
behaviors. Together, data suggest that IPT is an
efficacious second-line treatment for BN.
Dialectical Behavior Therapy
Dialectical behavior therapy (DBT) for BN is a
present-focused approach that enhances skills in
interpersonal effectiveness, distress tolerance, emotion
regulation, and mindfulness domains to reduce
affective lability and eating disorder behaviors.20
DBT for BN is rooted in the biopsychosocial theory,
which hypothesizes that the combination of an
individual's biological temperament and an
invalidating environment cause affective lability that
triggers eating disorder symptoms.21 DBT was
originally developed for individuals with chronic
suicidality22 and was adapted for BN based on
evidence that emotion dysregulation triggers eating
disorder behaviors and vice versa.23,24
DBT is a structured treatment that is composed of
individual therapy, coaching calls (described below),
a skills group, and a consultation group for DBT
43
 Clinical Therapeutics
clinicians (described below); DBT for BN may not
include some components of traditional DBT
treatment. Individual therapy helps patients apply
skills to certain targets, which are addressed in order
of importance as established by the DBT model.
Level 1 targets are life-threatening behaviors (eg,
nonsuicidal self-injury, purging with syrup of ipecac,
or insulin omission by persons with insulin-dependent
diabetes), level 2 targets are therapy-interfering
behaviors (eg, not completing diary cards or arriving
late to session), and level 3 targets are those that
interfere with quality of life (eg, eating disorder
behaviors). Outside sessions, patients are encouraged
to use brief, skills-focused coaching calls to connect
with a clinician and receive help in applying skills to
challenging real-world situations, such as when urges
to binge eat or purge are high. Groups teach
interpersonal effectiveness, distress tolerance, emotion
regulation, and mindfulness skills in a didactic format
to individuals participating in DBT. Finally, DBT
clinicians participate in weekly consultation groups to
promote adherence to the DBT model through
practicing skills and reviewing the DBT manual. In
addition, consultation groups are used to provide
group supervision. Clinician consultation groups
promote adherence to the DBT model and assist with
burnout.
DBT for BN commences with commitment and
orientation during which the patient commits to
ceasing bulimic behaviors. After commitment, DBT
uses skills, diary cards, and behavior chain analyses
as core techniques to reduce affective lability and
eliminate eating disorder behaviors. Skills are taught
in group and individual therapy sessions and are
meant to provide concrete ways to address urges to
restrict, binge eat, and/or engage in inappropriate
compensatory behaviors. The diary card is
introduced at the onset of treatment and is used
throughout treatment to track skills use and eating
disorder behaviors outside sessions. Similar to CBT,
diary cards are reviewed at the beginning of each
DBT session. Behavior chain analyses are a
collaboration between clinicians and patients and
used in session to visually diagram the antecedents
and consequences of eating disorder behaviors. The
purpose of the behavior chain analysis is to increase
the patient's awareness of the affective and
behavioral correlates of eating disorder behavioral
urges and actions.
44
Preliminary evidence suggests that the treatment of
BN with DBT holds promise. In 1 randomized
controlled trial, 31 women with BN were randomized
to receive DBT for BN or waitlist control.21 At the
end of treatment, 28.6% of women with BN who
received DBT were abstinent from binge eating and
purging compared with no women with BN in the
waitlist group, and this difference was statistically
significant. More recently, a randomized controlled
trial tested the efficacy of an adapted form of DBT
for BN that integrates satiety awareness training
relative to a waitlist comparison condition in 31
women with BN.25 At the end of treatment, 26.9%
of women who received DBT were abstinent relative
to the waitlist control group, a statistically significant
difference.
Integrative Cognitive-affective Therapy
Integrative cognitive-affective therapy for BN
(ICAT-BN) is a newer psychotherapy that emphasizes
emotion regulation and coping, intrapersonal factors
(self-discrepancy and nutrition), and interpersonal
relationships.26 ICAT-BN was developed from the
ICAT model of BN, which hypothesizes that self-
discrepancy (mismatch between the actual and ideal
self) leads to negative affect.27 Negative affect leads
to self-directed coping strategies, such as self-
criticism, and subsequent bulimic behaviors, which
reinforce negative affect and cause an inexorable
cycle of negative affect, self-directed coping, and
bulimic behavior.
ICAT-BN is delivered in 21 sessions during 4
phases. In phase 1, motivational interviewing is used
to address ambivalence and psychoeducation about
the role of emotions in bulimic symptoms is
provided. Phase 2 centers on introduction and
implementation of coping strategies and meal
planning. In phase 3, treatment is personalized to
address factors that may maintain the individual's
bulimic symptoms according to the ICAT-BN model;
personalized targets include self-directed coping (eg,
self-neglect and self-criticism), interpersonal problems
(eg, withdrawal and submissiveness), and/or self-
discrepancy. Phase 4 focuses on planning and relapse
prevention. Although similar to CBT, ICAT-BN is
distinct with respect to its use of motivational
interviewing at the onset of treatment, use of
cognitive interventions that target self-discrepancies,
and lack of use of cognitive restructuring.
Volume 43 Number 1

Evidence for ICAT-BN is preliminary and is
composed of 1 randomized controlled trial.
Wonderlich et al28 randomized 81 adults with BN to
receive ICAT-BN or CBT-E. ICAT-BN and CBT-E
did not significantly differ in abstinence rates at the
end of treatment (37.5% for ICAT-BN vs 22.5% for
CBT-E) or 4-month follow-up (32.5% for ICAT-BN
vs 22.5% for CBT-E).
PSYCHOTHERAPIES FOR CHILDREN AND
ADOLESCENTS
Despite the fact that BN typically begins in late
adolescence, only 4 randomized controlled trials have
evaluated the efficacy of psychotherapies for BN in
adolescents. We review the limited evidence base for
psychotherapies for BN in adolescents.
Family-based Treatment
Family-based treatment for BN (FBT-BN) in
adolescents is an outpatient behavioral approach that
centers on parental empowerment, normalization of
adolescent eating patterns, and a return to normal
adolescent development.29 The core tenants of FBT-
BN include agnosticism with respect to the cause of
BN, the philosophy that parents hold the knowledge
and resources necessary to facilitate their child's
recovery from BN, and externalization of the illness
from the adolescent.
FBT-BN consists of 3 phases delivered in 20 sessions
for approximately 6 months. In the first phase of FBT-
BN, parents are tasked with disrupting their
adolescent's eating disorder behaviors by providing
regular meals and snacks and monitoring their child
after meals and snacks to prevent inappropriate
compensatory behaviors. With the resolution of eating
disorder behaviors, in the second phase,
developmentally appropriate autonomy over meals and
snacks is gradually returned to the adolescent. Phase 3
commences once the adolescent has achieved
developmentally appropriate autonomy in feeding
themselves and focuses on addressing typical adolescent
development issues and helping the adolescent to build
an identity outside BN. Throughout FBT-BN, the
adolescent is weighed at the beginning of each session.
Of importance, FBT-BN is contraindicated when FBT-
BN is unacceptable (parents do not accept the FBT
model and/or desire an individual approach), parents
are unavailable to participate in treatment, or there is a
history of abuse or neglect within the family.
January 2021
K.E. Hagan and B.T. Walsh
Current clinical guidelines recommend FBT-BN for
BN in adolescents,7,30 and 3 randomized controlled
trials have evaluated the efficacy of FBT-BN to date. In
1 trial, 80 adolescents with BN were randomized to
receive FBT-BN or individual SPT, a nonspecific and
nondirective approach.31 At the end of treatment and
12-month follow-up, adolescents who received FBT-
BN had statistically significantly greater rates of
abstinence from eating disorder behaviors than those
who received SPT (39% for FBT-BN vs 18% for SPT
at the end of treatment; 29% for FBT-BN vs 10% for
SPT at 12-month follow-up). In a second trial, 85
adolescents with BN were randomized to undergo a
Maudsley model of family therapy or guided self-help
CBT-BN. A significantly greater proportion of
adolescents who received guided self-help CBT-BN
were abstinent from eating disorder behaviors than
adolescents who received family therapy at the end of
treatment; however, at 6-month follow-up, there were
no statistically significant differences between groups
with respect to abstinence from eating disorder
behaviors. In a third trial, 130 adolescents with BN
were randomized to receive FBT-BN or CBT adapted
for adolescents (CBT-A, reviewed in detail below), a
modified version of CBT-BN that includes collateral
sessions with parents and integration of developmental
elements.32 At the end of treatment and 6-month
follow-up, adolescents who received FBT-BN had
statistically significantly greater rates of abstinence
from eating disorder behaviors than adolescents who
received CBT-A (39.4% for FBT-BN vs 19.7% for
CBT-A at the end of treatment; 44% for FBT-BN vs
25.4% for CBT-A at 6-month follow-up). A 12-month
follow-up analysis found that abstinence rates did not
statistically differ between groups. Together, results
provide preliminary evidence that FBT-BN is an
efficacious treatment for BN; however, additional
study is needed to understand the long-term efficacy of
FBT-BN relative to other treatments.
CBT-A
CBT-A incorporates parent collateral sessions into
CBT-BN and addresses adolescent developmental
considerations.33 CBT-A uses the same staged approach
as CBT-BN to introduce behavioral and cognitive
techniques to address bulimic symptoms in adolescents
with BN. In CBT-A, parent collateral sessions are
scheduled throughout treatment, and parents may be
actively involved in the treatment at the discretion of
45
 Clinical Therapeutics
the adolescent. In the initial behavioral phase of CBT-A,
parents are oriented to the BN diagnosis, provided
psychoeducation about regular eating and self-
monitoring, and encouraged to structure the home to
support recovery. If the adolescent desires, parents may
assist with meal and snack planning as well as
monitoring to prevent compensatory behaviors after
eating. Parents are encouraged to reinforce adolescent
behaviors that are incompatible with bulimic behaviors.
In the second cognitively focused phase of CBT-A,
parents help to identify socioemotional triggers for
bulimic symptoms and may assist the adolescent in
problem solving and cognitive restructuring. In the
maintenance and relapse prevention phase of CBT-A,
parents consider developmental transitions that may
increase risk of relapse, such as leaving for college, and
identify strategies to support their adolescent and
prevent a relapse.
One randomized controlled trial of CBT-A has been
performed. This previously described trial randomized
adolescents with BN to receive CBT-A or FBT-BN and
found that FBT-BN was statistically superior in
promoting abstinence of binge eating and purging
behavior at the end of treatment and 6-month
follow-up.32 However, the abstinence rates for FBT-
BN and CBT-A did not statistically differ at 1-year
follow-up (49% for FBT-BN vs 33% for CBT-A).
Two other trials have examined the efficacy of CBT-
BN in adolescents to date. One previously mentioned
trial randomized adolescents with BN to receive
guided self-help CBT-BN or family therapy and
found that guided self-help CBT was statistically
superior to family therapy in promoting abstinence of
eating disorder behaviors at the end of treatment but
not at 6-month follow-up.34 The second is a recent
trial that randomized 81 adolescent girls with BN to
receive CBT-BN or psychodynamic therapy for BN.35
No significant differences in remission were found
(defined as no longer meeting criteria for an eating
disorder) between CBT-BN and psychodynamic
therapy at the end of treatment (33.3% for CBT-BN
vs 31% for psychodynamic therapy) and 1-year
follow-up (38.5% for CBT-BN vs 31% for
psychodynamic therapy). Outcomes from these trials
suggest that CBT is a suitable treatment for
adolescent BN, although more research is warranted.
In addition, CBT could be considered when FBT-BN
is unacceptable or contraindicated.7
46
Pharmacotherapy
Psychotherapy is typically considered the treatment
of choice for BN. However, pharmacotherapy may
be considered as a standalone treatment for BN if
psychotherapy is unavailable or ineffective36 and may
depend on the type of psychotherapy.12 For instance,
a randomized controlled trial of 120 women with BN
examined the efficacy of combined psychotherapy
(CBT or SPT) and medication relative to medication
alone.12 Results suggest that a combination of CBT
and medication was superior to medication alone in
promoting reductions in BN symptoms, whereas
combined SPT and medication did not outperform
medication alone. Thus, medication may be
considered as a standalone treatment if CBT-BN is
unavailable.
To date, no psychotropic medications have been
developed to specifically treat BN. Rather,
medications developed for other conditions, namely
antidepressants and antiepileptics, have been
examined in adults with BN with moderate efficacy
relative to placebo.37 Strikingly, only 1 open trial of
pharmacotherapy for BN in adolescents has been
conducted.38 Overall, there are relatively few ongoing
pharmacotherapy trials in BN and few new
developments, perhaps because of the established
efficacy of current medications (described below).37
Antidepressant Medications
Soon after BN was first clearly described in 1979,39
it was recognized that many patients with BN
experienced significant depression and anxiety. This
finding led to initial trials in the early 1980s to
examine the potential utility of antidepressant
medication.40,41 Subsequently, multiple controlled
trials of a range of antidepressant medications
documented their efficacy compared with placebo.
On the basis of large trials supported by Eli Lilly and
Company, the selective serotonin reuptake inhibitor
(SSRI) fluoxetine was approved by the US Food and
Drug Administration for the treatment of BN in
adults and, given its efficacy and generally low
incidence of adverse effects, is the pharmacologic
treatment of choice.42 Moreover, results suggested
that 60 mg/d of fluoxetine facilitated reductions in
binge eating and purging even in the absence of
comorbid depression.42 On the basis of this study,
fluoxetine is typically prescribed at 60 mg/d for BN,
Volume 43 Number 1

in contrast to the 20-mg/d dose typically prescribed for
depression. In addition, fluoxetine is promising
compared with placebo in adults with BN who had
poor response to psychotherapy.36 This finding
suggests that fluoxetine may be useful when
psychotherapy is ineffective.
With respect to medication in adolescents with BN,
a single open-label trial examined fluoxetine 60 mg/
d in 10 adolescent girls with BN during an 8-week
period.38 Results were encouraging and suggested
significant reductions in binge eating and purging
frequencies and that the medication was accepted and
tolerated with few adverse effects. Given the elevated
risk of suicide in adolescents with BN43 and concerns
about SSRIs increasing suicidality in youths,44 it is
important to carefully monitor adolescents with BN
who have been prescribed SSRIs.
Antiepileptic Medications
Topiramate is a medication used to treat epilepsy with
known effects on appetite regulation and weight that has
been evaluated for the treatment of adults with BN in 2
randomized controlled trials. Both trials found that
topiramate facilitated meaningful reductions in binge
eating and purging frequencies and attitudinal
measures.37 However, 1 randomized controlled trial
found that women with BN randomized to receive
topiramate lost significantly more weight than those
randomized to receive placebo.45 In addition,
topiramate is associated with troublesome adverse
effects, such as cognitive slowing, paresthesias, and
kidney stones. Thus, topiramate is not considered a
first-line treatment for BN.
SYNTHESIS AND RECOMMENDATIONS
Currently, the first-choice treatment for BN is
outpatient psychotherapy. For adults with the
disorder, clinical guidelines informed by empirical
research recommend therapist-led CBT. In addition,
guided self-help CBT may be useful for patients
without access to specialty eating disorder clinicians
or who have financial and/or insurance barriers. IPT
is a reasonable second-line, evidenced-based
psychological treatment for adults with BN and may
be particularly useful in those with marked
interpersonal difficulties. DBT and ICAT-BN have
initial promise for the treatment of BN in adults,
although more research is needed. The
pharmacotherapy of choice for BN is fluoxetine
January 2021
K.E. Hagan and B.T. Walsh
prescribed at 60 mg/d. Pharmacotherapy should
generally be considered adjunctive to psychotherapy,
but standalone pharmacotherapy may be indicated
when psychotherapy is unavailable or ineffective and
may depend on the type of psychotherapy available.
In contrast to the dozens of psychotherapy and
medication trials for adult BN, only 4
psychotherapy trials and 1 medication trial for
adolescents with BN have been published to date.
FBT-BN is recommended for adolescents, and
individual CBT is an acceptable alternative.
Fluoxetine 60 mg/d appears to have benefit and is
acceptable to adolescents with BN.
As we look forward, several important issues should
be considered to advance the treatment of BN. One issue
is that, despite decades of research, approximately 60%
of individuals with BN who receive the best available
treatments do not achieve symptom abstinence.46
Another key issue relates to the access, cost, and
dissemination of specialty BN treatments. One way
that this issue has been addressed is through guided
self-help therapies, such as CBT.10 It might also be
useful to identify the specific components of current
and new treatments that are beneficial, inert, or
harmful through the multiphasic optimization
strategy.47 The multiphasic optimization strategy
offers a way to isolate and efficiently test treatment
components and may ultimately help to streamline
treatments by removing components that offer little
benefit. Streamlining BN treatments may be of use in
increasing their effectiveness, reducing their cost, and
improving dissemination. Finally, further study of
pharmacologic and psychological treatments for
adolescents with BN is warranted given the scant
evidence base.
FUNDING SOURCES
This work was supported by grant T32MH096679
from the National Institutes of Mental Health. The
National Institutes of Mental Health had no role in
the writing of the manuscript or the decision to
submit the manuscript for publication.
DISCLOSURES
Dr Walsh receives royalties from Up to Date, Oxford
University Press, McGraw-Hill, Guidepoint Global,
Jonhs Hopkins University Press, and BMJ. The
authors have indicated that they have no other
conflicts of interest regarding the content of this article.
47
 Clinical Therapeutics
ACKNOWLEDGMENTS
Drs Hagan and Walsh contributed to the
conceptualization and writing of the manuscript.
REFERENCES
1. American Psychiatric Association. Diagnostic and Statistical
®
Manual of Mental Disorders (DSM-5 ). American Psychiatric
Pub; 2013.
2. Fichter MM, Quadflieg N. Mortality in eating disorders - results
of a large prospective clinical longitudinal study. Int J Eat Disord.
2016;49:391e401. https://doi.org/10.1002/eat.22501.
3. Udo T, Grilo CM. Prevalence and correlates of DSM-
5edefined eating disorders in a nationally representative
sample of U.S. Adults. Biol Psychiatr. 2018;84:345e354.
https://doi.org/10.1016/j.biopsych.2018.03.014.
4. Kessler RC, Berglund PA, Chiu WT, et al. The prevalence
and correlates of binge eating disorder in the world Health
organization world mental Health surveys. Biol Psychiatr.
2013;73:904e914. https://doi.org/10.1016/
j.biopsych.2012.11.020.
5. Wade TD, Bergin JL, Tiggemann M, Bulik CM, Fairburn CG.
Prevalence and long-term course of lifetime eating disorders
in an adult Australian twin cohort. Aust N Z J Psychiatr.
2006;40:121e128. https://doi.org/10.1080/j.1440-
1614.2006.01758.x.
6. Fairburn CG. Cognitive Behavior Therapy and Eating Disorders.
The Guilford Press; 2008.
7. Jones DD, LaBouchardiere DJ, Bird MC, Richardson DJ.
NICE nuggets: NG69 eating disorders: recognition and treatment.
InnovAiT. Published online; 2020. https://doi.org/10.1177/
1755738020903757. Accessed February 13, 2020.
8. Fairburn CG, Cooper Z, Shafran R. Cognitive behaviour
therapy for eating disorders: a “transdiagnostic” theory and
treatment. Behav Res Ther. 2003;41:509e528. https://
doi.org/10.1016/S0005-7967(02)00088-8.
9. Pennesi J-L, Wade TD. A systematic review of the existing
models of disordered eating: do they inform the development
of effective interventions? Clin Psychol Rev. 2016;43:175e192.
https://doi.org/10.1016/j.cpr.2015.12.004.
10. Linardon J, Wade TD, de la Piedad Garcia X, Brennan L.
The efficacy of cognitive-behavioral therapy for eating
disorders: a systematic review and meta-analysis. J Consult
Clin Psychol. 2017;85:1080e1094. https://doi.org/
10.1037/ccp0000245.
11. Slade E, Keeney E, Mavranezouli I, et al. Treatments for bulimia
nervosa: a network meta-analysis. Psychol Med. 2018;48:
2629e2636. https://doi.org/10.1017/S0033291718001071.
12. Walsh BT, Wilson GT, Loeb KL, et al. Medication and
psychotherapy in the treatment of bulimia nervosa. Am J
Psychiatr. 1997;154:523e531. https://doi.org/10.1176/
ajp.154.4.523.
48
13. Thompson-Brenner H, Shingleton RM, Thompson DR,
et al. Focused vs. Broad enhanced cognitive behavioral
therapy for bulimia nervosa with comorbid borderline
personality: a randomized controlled trial. Int J Eat Disord.
2016;49:36e49. https://doi.org/10.1002/eat.22468.
14. Karam AM, Fitzsimmons-Craft EE, Tanofsky-Kraff M,
Wilfley DE. Interpersonal psychotherapy and the treatment
of eating disorders. Psychiatr Clin North Am. 2019;42:
205e218. https://doi.org/10.1016/j.psc.2019.01.003.
15. Markowitz JC, Weissman MM. Interpersonal
psychotherapy: principles and applications. World Psychiatr.
2004;3:136e139.
16. Fairburn CG, Jones R, Peveler RC, et al. Three psychological
treatments for bulimia nervosa: a comparative trial. Arch
Gen Psychiatr. 1991;48:463e469. https://doi.org/10.1001/
archpsyc.1991.01810290075014.
17. Wilfley DE, MacKenzie RK, Welch RR. Interpersonal
Psychotherapy for Group. Basic Books; 2000.
18. Agras WS, Walsh T, Fairburn CG, Wilson GT, Kraemer HC.
A multicenter comparison of cognitive-behavioral therapy
and interpersonal psychotherapy for bulimia nervosa. Arch
Gen Psychiatr. 2000;57:459e466. https://doi.org/10.1001/
archpsyc.57.5.459.
19. Fairburn CG, Jones R, Peveler RC, Hope RA, O'Connor M.
Psychotherapy and bulimia nervosa. Longer-term effects of
interpersonal psychotherapy, behavior therapy, and
cognitive behavior therapy. Arch Gen Psychiatr. 1993;50:
419e428. https://doi.org/10.1001/
archpsyc.1993.01820180009001.
20. Safer DL, Telch CF, Chen EY. Dialectical Behavior Therapy for
Binge Eating and Bulimia. Guilford Press; 2009.
21. Safer DL, Telch CF, Agras WS. Dialectical behavior therapy
for bulimia nervosa. Am J Psychiatr. 2001;158:632e634.
22. Linehan MM. DBT Skills Training Manual. Second. Guilford
Press; 2014.
23. Lavender JM, Wonderlich SA, Engel SG, Gordon KH,
Kaye WH, Mitchell JE. Dimensions of emotion
dysregulation in anorexia nervosa and bulimia nervosa: a
conceptual review of the empirical literature. Clin Psychol
Rev. 2015;40:111e122. https://doi.org/10.1016/
j.cpr.2015.05.010.
24. Prefit A-B, C^ andea DM, Szentagotai-T atar A. Emotion
regulation across eating pathology: a meta-analysis.
Appetite. 2019;143:104438. https://doi.org/10.1016/
j.appet.2019.104438.
25. Hill DM, Craighead LW, Safer DL. Appetite-focused
dialectical behavior therapy for the treatment of binge
eating with purging: a preliminary trial. Int J Eat Disord.
2011;44:249e261. https://doi.org/10.1002/eat.20812.
26. Wonderlich SA, Peterson CB, Smith TL. Integrative Cognitive-
Affective Therapy for Bulimia Nervosa: A Treatment Manual.
Guilford Publications; 2015.
Volume 43 Number 1

27. Wonderlich SA, Engel SG,
Peterson CB, et al. Examining the
conceptual model of integrative
cognitive-affective therapy for BN:
two assessment studies. Int J Eat
Disord. 2008;41:748e754. https://
doi.org/10.1002/eat.20551.
28. Wonderlich SA, Peterson CB,
Crosby RD, et al. A randomized
controlled comparison of integrative
cognitive-affective therapy (ICAT)
and enhanced cognitive-behavioral
therapy (CBT-E) for bulimia nervosa.
Psychol Med. 2014;44:543e553.
https://doi.org/10.1017/
s0033291713001098.
29. Le Grange D, Lock JD. Treating Bulimia
Nervosa in Adolescents: A Family-Based
Approach. Guilford Press; 2009.
30. Hilbert A, Hoek HW, Schmidt R.
Evidence-based clinical guidelines for
eating disorders: international
comparison. Curr Opin Psychiatr.
2017;30:423e437. https://doi.org/
10.1097/YCO.0000000000000360.
31. Le Grange D, Crosby RD, Rathouz PJ,
Leventhal BL. A randomized
controlled comparison of family-
based treatment and supportive
psychotherapy for adolescent
bulimia nervosa. Arch Gen Psychiatr.
2007;64:1049e1056. https://
doi.org/10.1001/
archpsyc.64.9.1049.
32. Le Grange D, Lock J, Agras WS,
Bryson SW, Jo B. Randomized
clinical trial of family-based
treatment and cognitive-behavioral
therapy for adolescent bulimia
nervosa. J Am Acad Child Adolesc
Psychiatr. 2015;54:886e894. e2.
33. Lock J. Adjusting cognitive behavior
therapy for adolescents with bulimia
nervosa: results of case series. Am J
Psychother. 2005;59:267e281.
https://doi.org/10.1176/
appi.psychotherapy.2005.59.3.267.
January 2021
34. Schmidt U, Lee S, Beecham J, et al.
A randomized controlled trial of
family therapy and cognitive behavior
therapy guided self-care for
adolescents with bulimia nervosa
and related disorders. Am J Psychiatr.
2007;164:591e598. https://doi.org/
10.1176/ajp.2007.164.4.591.
35. Stefini A, Salzer S, Reich G, et al.
Cognitive-behavioral and
psychodynamic therapy in female
adolescents with bulimia nervosa: a
randomized controlled trial. J Am
Acad Child Adolesc Psychiatr. 2017;56:
329e335. https://doi.org/10.1016/
j.jaac.2017.01.019.
36. Walsh BT, Agras WS, Devlin MJ,
et al. Fluoxetine for bulimia nervosa
following poor response to
psychotherapy. Am J Psychiatr.
2000;157:1332e1334. https://
doi.org/10.1176/
appi.ajp.157.8.1332.
37. McElroy SL, Guerdjikova AI, Mori N,
Romo-Nava F. Progress in developing
pharmacologic agents to treat
bulimia nervosa. CNS Drugs. 2019;33:
31e46. https://doi.org/10.1007/
s40263-018-0594-5.
38. Kotler LA, Devlin MJ, Davies M,
Walsh BT. An open trial of fluoxetine
for adolescents with bulimia nervosa.
J Child Adolesc Psychopharmacol.
2003;13:329e335. https://doi.org/
10.1089/104454603322572660.
39. Russell G. Bulimia nervosa: an
ominous variant of anorexia nervosa.
Psychol Med. 1979;9:429e448.
40. Pope HG, Hudson JI, Jonas JM,
Yurgelun-Todd D. Bulimia treated
with imipramine: a placebo-
controlled, double-blind study. Am J
Psychiatr. 1983;140:554e558.
https://doi.org/10.1176/
ajp.140.5.554.
41. Walsh BT, Stewart JW, Roose SP,
Gladis M, Glassman AH. Treatment
Address correspondence to: Kelsey E. Hagan, PhD, Department of
Psychiatry, Columbia University Irving Medical Center, 1051 Riverside
Drive, Unit 98, New York, NY, 10032, USA. E-mail: kh3081@cumc.
columbia.edu
K.E. Hagan and B.T. Walsh
of bulimia with phenelzine. A double-
blind, placebo-controlled study. Arch
Gen Psychiatr. 1984;41:1105e1109.
https://doi.org/10.1001/
archpsyc.1983.01790220095015.
42. Levine LR. Fluoxetine in the treatment
of bulimia nervosa. Arch Gen Psychiatr.
1992;49:139e147.
43. Crow SJ, Swanson SA, le Grange D,
Feig EH, Merikangas KR. Suicidal
behavior in adolescents and adults
with bulimia nervosa. Compr Psychiatr.
2014;55:1534e1539. https://
doi.org/10.1016/
j.comppsych.2014.05.021.
44. Morrison J, Schwartz TL. Adolescent
angst or true intent? Suicidal
behavior, risk, and neurobiological
mechanisms in depressed children
and teenagers taking
antidepressants. Int J Emerg Ment
Health. 2014;16:247e250. https://
doi.org/10.4172/1522-
4821.1000105.
45. Nickel C, Tritt K, Muehlbacher M,
et al. Topiramate treatment in
bulimia nervosa patients: a
randomized, double-blind, placebo-
controlled trial. Int J Eat Disord.
2005;38:295e300. https://doi.org/
10.1002/eat.20202.
46. Linardon J, Wade TD. How many
individuals achieve symptom
abstinence following psychological
treatments for bulimia nervosa? A
meta-analytic review. Int J Eat Disord.
2018:51287e51294. https://
doi.org/10.1002/eat.22838.
47. Collins LM. Optimization of Behavioral,
Biobehavioral, and Biomedical
Interventions: The Multiphase
Optimization Strategy (MOST). Springer
International Publishing; 2018.
https://doi.org/10.1007/978-3-319-
72206-1.
49