Q & A: Can Ritalin Be Used for Bulimia Nervosa?

Q: One of my patients with bulimia nervosa failed to respond to fluoxetine (Prozac”) and several similar antidepressants. However, her psychiatrist decided that she also had attention deficit disorder and treated her with methylphenidate (Ritalin”). Her bulimia nervosa seems to have improved after this treatment. Should methylphenidate be used to treat bulimia nervosa?

A: The extent to which women who develop bulimia nervosa (BN) have had co-morbid attention deficit disorder (ADD), either of the hyperactive or inattentive type, and the implications of concurrent ADD on the course and outcome of BN have not yet been adequately researched. It is quite plausible that some women with BN, especially those who have had concurrent so-called “cluster B” personality disorders and traits (of the “erratic and dramatic” type), and those who have concurrent alcohol and illicit substance abuse, may be more likely to have ADD. This is a reasonable conjecture because childhood ADD occurs more frequently among teenagers who develop these personality problems and/or alcoholism and substance abuse. Thus far, the literature contains only case reports concerning the stimulant treatment of ADD such as in patients with BN (Int J Eat Dis 25:233, 1999). In these reported cases, methylphenidate appears to have helped the ADD and BN. I have seen similar results in a very small number of patients in whom stimulants for ADD have been added to selective serotonin reuptake inhibitors (SSRIs) for BN. These patients seemed to develop increased capacities for sustained attention, and became less impulsive. These improvements may well have contributed to their overall improvement. However, no systematic research justifies the routine treatment of BN with methylphenidate. Studies to systematically assess BN patients for ADD and which then treat the ADD with stimulants would be very welcome. In the meantime, if careful assessment of a patient with BN reveals strong evidence for concurrent ADD, and if the patient is not responding to conventional treatment for BN, adding methylphenidate may not only improve the ADD but may coincidentally lead to improvement in the BN as well.

— J.Y.