Eating Disorders - Bulimia Nervosa
Bulimia Nervosa (BN) (1) is characterised by frequent, recurrent episodes of binge eating (e.g., once a week or more over a period of at least one month), accompanied by compensatory behaviours intended to offset the calorific impact of binges (e.g., excessive exercise, vomiting). Individuals with BN are often preoccupied with body shape or weight as central means of self-evaluation, and there is marked distress or significant impairment related to the pattern of eating and compensatory behaviours (1). BN is distinct from Anorexia Nervosa primarily due to the absence of extremely low weight as a necessary feature, and distinct from Binge Eating Disorder due to the regular use of compensatory ’purging’ strategies (1).
BN can commonly co-exist with other mental health disorders, including depression, anxiety, substance misuse, obsessive-compulsive disorder and trauma related presentations (2). Hence, co-existing mental health disorders should be identified, and a treatment plan should address patients’ mental health needs (2). Physical health consequences of BN should also be considered. These include organ damage from electrolyte imbalance; gradual erosion of tooth enamel caused by frequent initiation of vomiting; stomach pain, bloating, diarrhoea and dehydration from the use of laxatives; as well as growth and developmental impacts on children (2). Health care professionals should therefore assess the physical impact of BN on the patient and provide necessary treatment, support and advice (2). Family members of people with BN may also be involved in the care of the patient, and should be provided with emotional, practical and social support (2).
The peak age of onset for BN is estimated to be in later adolescence and early adulthood (15-25 years) (3). World-wide estimates show higher prevalence in women than men, with point prevalence of 1.5% vs 0.1%, and lifetime prevalence of 1.9% vs 0.6% for women and men respectively (4). Among women in mid-life in the UK, the lifetime prevalence of BN is estimated to be 2.2% (5). BN is estimated to persist for about 6.5 years (6).
This information is for commissioners, managers, trainers, and practitioners to consider the evidence base for the delivery of psychological interventions for people with Bulimia Nervosa. This information is also for people diagnosed with Bulimia Nervosa, their families, and carers.
This topic introduction page covers evidence-based psychological interventions used to treat Bulimia Nervosa in children, young people, and adults, and the psychological practice/settings in which these interventions can be delivered.
Exclusions for topic: This topic does not cover pharmacological interventions or interventions which are not informed by psychological theory. There are a wider range of non-psychological interventions and supports that are beyond the scope of this topic and full guidance on identifying, assessing and managing BN can be found in the SIGN guidance (2). This topic does not cover the management of anorexia nervosa or binge eating disorder and further information on these topics is available in other pages of The Matrix.
Overview of Evidence for Children and Young People
There are two forms of therapy that are consistently reported to be highly effective in the treatment of bulimia with children and young people. These are Family-Based Treatment (FBT) and models of cognitive-behavioural therapy that are specifically tailored to address bulimia. These approaches are recommended by SIGN guidelines (2). The evidence indicates that these approaches are equally effective in the long-term for children and young people who have bulimia (7). However, if there is a high level of conflict within the family, then a family-based approach is less likely to be helpful and, in such circumstances, Cognitive-Behavioural Therapy is more effective (8).
A single randomised control trial (9) compared CBT to Psychodynamic Therapy in girls aged 14-20 with BN or partial BN. At the end of treatment, rates of remission were stable and equal at 12-month follow-up. Therefore, SIGN recommends that if CBT or FBT-BN are not acceptable, Psychodynamic Therapy could be considered for adolescents with bulimia nervosa, and it is included as an alternative intervention in the evidence table.
Children and young people are often ambivalent about engaging in psychological treatment for bulimia and attempting therapeutic change. Clinicians should therefore assess, monitor and seek to improve motivation where necessary throughout the treatment process. Whereas evidence exists to support the delivery of Motivation-Focused Therapy for adults with bulimia, evidence is not available for its delivery with children and young people at this stage. It is important that the child and the family are fully supported throughout the process by eating disorders specialist staff, and therefore when a child is engaged in one-to-one therapy, their family should receive concurrent direct support from the eating disorders team (10,11).
Overview of Evidence for Adults
A number of psychological interventions have consistent support from the literature as being effective in addressing BN among adults. However, when treatments with the most established evidence-base do not lead to remission for adults with BN, second-line or adjunctive therapeutic models can be offered. First line treatments include models of cognitive-behavioural therapy specifically tailored to addressing bulimia (12-23), including guided self-help (based on Cognitive-Behavioural Therapy specific to bulimia) (12,14,15,24). Alternative or adjunctive treatments include Interpersonal Psychotherapy (IPT) (14,19,25,26) Schema Therapy, Dialectical Behavioural Therapy (DBT), Mentalisation-based Therapy for eating disorders (MBT) and Psychodynamic/Psychoanalytical Therapy. The quality of the evidence and estimates of effectiveness vary for these interventions and this is reviewed further below. When offering alternative treatment models with preliminary evidence, is recommended that clinicians undertake evaluation/research to evaluate their efficacy and that they are delivered in line with local governance arrangements. Finally, as the literature on the effectiveness of Family-Based Treatment for bulimia that has been previously cited extends to late adolescence, this therapy approach is included as a recommendation for adult services to make available for the younger adults (> 19-year-olds only) on their caseloads.
First-line psychological therapies
Guided Self Help based on a form of Cognitive Behavioural Therapy that is specific to BN
Guided Self Help (GSH) approaches have been delivered as part of a stepped care model (27) for BN. GSH varies in format and duration, including internet delivery, chat-based therapist support and support with bibliotherapy. One trial found CBT guided self-help led to abstinence in almost 20% of patients with BN (28). Findings vary considerably across randomised control trials (RCT), with posttreatment remission rates ranging from 22.2–67.6%, and attrition rates ranging from 22.2-50% (13,29).
Cognitive Behavioural Therapy for BN
The majority of research on psychological interventions for BN have been centred around CBT tailored to eating disorders. Evidence suggests that CBT is effective in the reduction of bulimic symptoms in comparison with usual treatment or waiting list control (12). Evidence suggests that CBT-BN is equally effective whether delivered in-person or via videoconferencing (30). There are few studies comparing CBT with other therapies. However, preliminary findings indicate that outcomes appear to be equivalent to those of Interpersonal Psychotherapy (IPT) (31); Dialectical Behavioural Therapy (DBT) (32); Emotional and Social Mind Training (ESM) (33); Integrative Cognitive-Affective Therapy (ICAT) (34) and Schema Therapy (35).
Second-line psychological therapies
Interpersonal Psychotherapy (IPT)
An RCT found that IPT was equally effective as CBT in reducing BN symptoms and comorbid depression at 60-week follow-up, although CBT led to faster reduction in symptoms (31).
Schema Therapy
A single RCT of women with BN or BED found schema therapy was equally effective as CBT and appetite-focused CBT. At post treatment and 1-year follow-up, all three conditions were associated with reductions in binge frequency. Retention levels were high in all modalities, at 85%. Across all modalities, clinically significant change was found for over 60% of patients by end of treatment, with improvements in binge eating, purging and global functioning showing large effect sizes. Improvements were maintained at 12-month follow up (35).
Integrative Cognitive Affective Therapy (ICAT)
An RCT indicated that ICAT was equally effective as eating disorder focused CBT with both treatments resulting in significant improvements in bulimic symptoms, mood measurements and emotion regulation (34).
Psychoanalytic/Psychodynamic Therapy
Psychodynamic Therapy has randomised controlled trials indicating its effectiveness, though estimates of its effectiveness are slightly less than those reported for Cognitive-Behavioural Therapy and Interpersonal Psychotherapy. Two RCTs have compared Psychodynamic Therapy with CBT for BN. Steinert et al., (36) found both treatment modalities were associated with improvement in BN symptoms, with changes occurring earlier in treatment for the CBT condition. By 2-year follow-up, 15% of the Psychoanalytic Therapy group and 44% of the CBT participants were abstaining from bingeing and purging (36).
Dialectical Behavioural Therapy
DBT led to reduction in symptoms of Borderline Personality Disorder (BPD) (but not dysfunctional eating) in a small naturalistic study of patients with BN and comorbid BPD (32). Two small follow up studies found that DBT was found to be more effective than waiting list controls in reducing bingeing, purging and eating disordered attitudes (32).
Mentalisation-Based Therapy for Eating Disorders (MBT-ED)
A single RCT of MBT-ED for people with a range of (unspecified) ED diagnoses and comorbid BPD found higher reductions in shape and weight concerns compared with those receiving Specialist Supportive Clinical Management (SSCM-ED). At 6-, 12- and 18-month follow-up, both ED and BPD symptoms had deteriorated across both conditions (37).
DBT, MBT and Schema Therapy all have a robust evidence base for Personality Disorder and therefore may be considered in the treatment of BN with comorbid PD.
Recommendation Summary for Adults with BN:
- Cognitive Behavioural Therapy for BN (CBT-BN) should be the first line treatment for BN.
- When CBT is not effective, acceptable or suitable, other treatments with Level A evidence should be considered: Interpersonal Psychotherapy, Integrative Cognitive-Affective Therapy, or Schema Therapy.
- In eating disorders with comorbid borderline personality disorder, therapeutic approaches with evidence in both areas of presentation should be considered, such as Mentalisation-Based Therapy (MBT) Dialectical Behaviour Therapy (DBT) and Schema Therapy.
Overview of evidence for Older People
The information available on the specific treatment of eating disorders in people over the age of 65 years is limited (38). The quality of case reports to date makes it difficult to suggest specific assessment or treatment guidelines for this population and therefore clinicians should follow the guidance for adults. Clinicians are advised that there are differences in presentation of psychological problems in later life and to consult Delivering Effective Psychological Therapies and Interventions to Older People for further information on factors relevant to practice.
| Recommendation | Who for? | What Intervention? | Type of Psychological Practice | Level of Evidence | Level of Efficacy |
| First line | Adolescents diagnosed with BN or partial BN from families without high levels of conflict. | Family-Based Treatment for bulimia (8,39-44) | Specialist | A | High |
| First line | Adolescents diagnosed with BN or partial BN | Individual CBT for adolescents (CBT-A) (8,9,45) | Specialist | A | High |
| Alternative (evidence less established) | Adolescents diagnosed with BN or partial BN | Psychodynamic Therapy (9) | Specialist | B | High |
| Recommendation | Who for? | What intervention? | Type of Psychological Practice | Level of evidence | Level of efficacy |
| First line | Adults (≥18 years) diagnosed with BN | Cognitive Behavioural Therapy (CBT) for eating disorders (in person or videoconferencing) (12,13,30-35,46) | Specialist | A | High |
| First line | Adults (≥18 years) diagnosed with BN or partial BN | CBT guided self-help (28) | Enhanced | A | High |
| Alternative/second line | Adults (≥18 years) diagnosed with BN and co-morbid depression | Interpersonal Psychotherapy (IPT) (31) | Specialist | A | High |
| Alternative/second line | Adults (≥18 years) diagnosed with BN | Integrative Cognitive-Affective Therapy (34) | Specialist | A | High |
| Alternative /second line | Adults (≥18 years) diagnosed with BN | Schema Therapy (35) | Specialist | A | High |
| Alternative (lower efficacy) | Adults (≥18 years) diagnosed with BN | Psychodynamic Therapy (36) | Specialist | A | Low-medium |
| Alternative (with co-occurring difficulties) | Adults (≥18 years) diagnosed with BN and comorbid borderline personality disorder | Mentalisation-Based Therapy (37) | Specialist | A | High |
| Alternative (with co-occurring difficulties) | Adults (≥18 years) diagnosed with full or some symptoms of BN and comorbid borderline personality disorder | Dialectical Behavioural Therapy (47) | Specialist | B | High |
With thanks to the Matrix Cymru team for sharing the results of their evidence review.
Advisory Group: BEAT
Technical Group: Sandra Ferguson, Anne Joice, Leeanne Nicklas, Susan Simpson, Paula Collin, Vicki Dunbar
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