Given the large number of patients with bulimia nervosa and the scarcity of therapists with training in the treatment of eating disorders, a 'stepped care' approach to management has been advocated. With such an approach a simple treatment is used first and only if this proves insufficient is a more complex and specialized intervention provided. Four steps may be distinguished.
Having established the diagnosis, the first decision is whether the patient may be treated on an outpatient basis. The great majority (over 95 per cent of referrals to non-specialist centres) may be managed this way. Exceptions are patients whose level of depression is so severe that they cannot make use of psychological treatment, significant risk of suicide, and physical complications necessitating inpatient or day patient care. Severe substance abuse requires treatment in its own right, although this can sometimes be integrated with the treatment of the eating disorder. For example, it is possible to adapt cognitive-behavioural therapy for bulimia nervosa so that it addresses at the same time the patient's substance abuse.
If the patient is suitable for outpatient treatment, guided cognitive-behavioural self-help is the next step. In this context, this involves following a cognitive-behavioural self-help programme under the guidance of a 'facilitator' (a non-specialist therapist). Three cognitive-behavioural self-help books are available, (6 6 and 68> two of which are direct translations of cognitive-behavioural therapy for bulimia nervosa. There is evidence to support the use of all three books and it is a matter of preference which is used. All three provide information about bulimia nervosa together with a self-help programme. The role of the facilitator is not to provide treatment as such, as in a conventional 'therapist-led' treatment, but rather to support and encourage the patient to follow the programme. Thus, this is a 'programme-led' form of treatment, and it is this characteristic that makes it suitable for dissemination. The treatment generally takes about 4 months and involves 8 to 10 meetings with the facilitator, each lasting up to 30min. It is best if the first few appointments are weekly.
Step 2 may take place in a variety of settings including primary care. A third to a half of patients show substantial change, and their progress appears to be well maintained. No consistent predictors of outcome have been identified. Patients who obtain little benefit (and usually this is obvious within 4 to 6 weeks) need to move on to step 3, although it would not be inappropriate to recommend as an interim step a brief trial of an antidepressant drug with those patients who are willing to consider drug treatment (see step3).
Research on the treatment of binge eating disorder suggests that there may be a subgroup of patients who will respond to 'pure self-help', that is following a cognitive-behavioural self-help programme with no outside support. (69> In clinical situations in which there will be a delay before therapist/facilitator-led treatment can be provided, pure self-help may have a role. At the very least it provides patients with sound information about the disorder. No adverse effects of pure or guided self-help have been identified, and failure to respond does not seem to affect response to subsequent treatment.
Patients who do not benefit from cognitive-behavioural self-help should receive full cognitive-behavioural therapy (see Chapter.B.^.^.^). In most cases this should be provided on its own, but it may be worthwhile adding an antidepressant drug under any one of the following three circumstances: if significant depressive symptoms are interfering with compliance, if depressive symptoms are persisting despite an improvement in eating habits, and if progress is limited. The drug of choice is fluoxetine (60mg). This can be started without intermediate lower doses and it should be taken in the morning.
The fourth step is essentially pragmatic since there are few research findings of relevance. To guide the choice of treatment, reasons for non-response need to be carefully considered. Explanations include failure of cognitive-behavioural therapy, poorly administered cognitive-behavioural therapy, poor patient compliance (which itself needs to be explained), and the influence of outside events.
There are a number of different treatment options under these circumstances, the choice of which depends upon the outcome of the reassessment and the resources available. They include the following.
• Stop treatment and arrange to re-evaluate the patient after an interval of some months. This can be justified on at least two grounds. First, bulimia nervosa has a general tendency to improve over time (see below). Spontaneous improvement may therefore occur. Second, patients and therapists can show 'burn-out' after sustained periods of therapeutic work. A break can often be helpful. Deciding to stop treatment should be a joint decision and it is not appropriate with patients who are distressed or with those whose physical or psychological well being is a cause for concern.
• Change antidepressant drug. As noted above, there is evidence that some patients respond to a change in antidepressant drug. If there is going to be a response to a second-line drug, it is likely to be rapid (within a few weeks). No guidelines are available to govern the choice of drug.
• Embark upon a new psychological treatment. While one obvious choice is interpersonal psychotherapy, there are no grounds for supposing that patients who fail to respond to cognitive-behavioural therapy will respond to interpersonal psychotherapy. Indeed, there is emerging evidence that this is not the case. An alternative strategy is to change the form of cognitive-behavioural therapy. The re-evaluation of the patient may have resulted in the identification of problems that might be amenable to cognitive-behavioural procedures outside the realm of mainstream cognitive-behavioural therapy for bulimia nervosa. For example, those with extreme concerns about shape might benefit from more emphasis on body image(70) and those with markedly low self-esteem might respond to an approach which focuses on negative self-evaluation.(71.)
• Arrange for day patient or inpatient treatment. In a small minority of cases outpatient treatment proves not to be sufficient, either because the disorder is resistant to treatment or because the patient's life circumstances are interfering with progress. In such cases day patient or inpatient treatment can be useful. Generally this involves a combination of approaches including elements of cognitive-behavioural therapy. Both day patient treatment and inpatient treatment should be followed by treatment on an outpatient basis designed to ensure that progress is maintained.
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