How to Treat Bulimia Nervosa: From Inpatient to Outpatient

How to Treat Bulimia

Jennifer Huddy, MS, RD, LD

Registered Dietitian and Nutrition Writer

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Bulimia nervosa is an eating disorder characterized by recurrent binging and purging behaviors. It can lead to serious health complications if left untreated. People who have been diagnosed with bulimia must seek treatment. Remission can be achieved with the proper treatment methods.

Levels of care

There are different levels of care used to define bulimia treatment options, and these include inpatient, residential, partial hospitalization (PHP), intensive outpatient (IOP), and outpatient. The level of care for bulimia ranges from hospitalization to visiting an eating disorder center multiple days per week to virtual outpatient treatment.

The best treatment option will depend on the medical and psychiatric stability of the patient, with the highest level of care being inpatient hospitalization and the lowest level of care being outpatient counseling.

Research shows a multidisciplinary team is valuable in the treatment of bulimia when compared to individuals who receive treatment from a single healthcare provider. At a minimum, this team should involve a doctor, a therapist, and a registered dietitian to address the eating disorder thoughts and behaviors.

Types of Treatment

Treatment for bulimia is most effective when the following spheres are addressed: medical, nutritional, and psychiatric.

Medical treatment

From a medical standpoint, inpatient treatment of bulimia is indicated when an individual exhibits any of the following signs and symptoms: low serum potassium, severe dehydration, cardiac issues, suicidal ideation, tears in the esophagus or vomiting blood, or lack of improvement with outpatient treatment.

The initial goal of medical treatment is to correct electrolyte imbalance and achieve rehydration. This process must be closely monitored because drastic fluid and electrolyte shifts can be very dangerous. Patients who present with low serum potassium (hypokalemia) are at a higher risk of experiencing repeat electrolyte imbalances.

Edema can also occur as a result of restoring the body’s fluid balance, which can lead to weight gain and fuel the individual’s eating disorder thoughts and behaviors.

Medications

There has been some success in identifying medications that can assist in treating bulimia. The most common medication used is Fluoxetine (Prozac). Research shows that in patients treated with a combination of psychotherapy and Fluoxetine, there was a significant reduction in both the frequency of binge eating and purging episodes.

Some treatment models for medically stable patients with bulimia involve initial Fluoxetine therapy prescribed by a primary care physician and cognitive behavioral therapy done with a therapist.

Further, medications used for treating alcohol dependency and attention deficit hyperactivity disorder (ADHD) also show some benefits in treating bulimia as well as binge eating disorder.

Many co-occurring disorders can happen alongside bulimia. Substance abuse and mood disorders are most common, and there are medications that can help treat these concerns.

Nutritional treatment

Once the patient is medically stable, the focus shifts to breaking the pattern of binging and purging, which are the hallmarks of bulimia. A registered dietitian on the treatment team will develop a meal plan that meets the individual's nutritional needs.

The meal plan will involve regular meals and snacks throughout the day to prevent long gaps between eating. The goal is to develop a normal meal pattern that helps minimize the binge eating that tends to follow fasting or skipped meals in bulimia.

People with bulimia can present as underweight, average-weight, or overweight. If the patient is underweight, the dietitian will develop a meal plan to meet the goal of weight restoration.

The dietitian also plays a role in helping the patient identify how their previous eating pattern was contributing to binging and purging behavior. Along with the patient’s therapist, identifying these triggers is essential for maintaining progress outside treatment.

In addition to minimizing risk factors for binge eating, restricting access to purging and other compensatory methods is a significant component of bulimia treatment. With the most common compensatory method in bulimia being purging, or self-induced vomiting, there will often be restricted access to bathrooms following meal times.

Psychological treatment

The most utilized psychotherapy type in bulimia is cognitive behavioral therapy (CBT). This individual counseling method targets the person’s thoughts and behaviors related to the binging and purging behaviors.

CBT focuses on creating routine eating habits, avoiding compensatory methods, and addressing concerns about body image and self-worth. Between a third and a half of patients with bulimia who receive CBT will achieve remission.

Popularized as a treatment option for anorexia, family-based therapy (FBT) is another treatment option used in children and adolescents with bulimia. It involves the parents and family of the individual in the treatment process. It encourages family members to eat meals together at regular times throughout the day and gives them tools to stop compensatory behaviors before they happen.

Interpersonal therapy is another method that is effective in treating bulimia. It focuses on tools and strategies to improve interpersonal relationships and social interactions. This is particularly effective in bulimia since social isolation is a common symptom of binging and purging behaviors.

Prognosis

On average, almost half of people diagnosed with bulimia achieve remission, and close to 30% experience an improvement in their eating disorder symptoms. Individuals diagnosed at a younger age and who have had bulimia for a shorter period upon treatment tend to have better remission outcomes.

The presence of co-occurring conditions, such as personality disorder, and the presence of self-harm behaviors and suicidal ideation can make treating bulimia more complicated. The most common cause of mortality in bulimia is suicide. If you are experiencing suicidal thoughts, don’t wait to seek help.

Why Nourish?

Nourish matches you with registered dietitians who are experts in treating bulimia. Our dietitians work with you and your healthcare team to help you identify triggers and develop normal eating habits. The sessions are covered by insurance and completely remote, making it easy to access the care you need. Start with Nourish today.