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Treatment-Resistant Bulimia Nervosa: Clinical Implications and Future Directions

Treatment-Resistant Bulimia Nervosa: Clinical Implications and Future Directions


Bulimia nervosa (BN) is a serious disorder characterized by recurrent large-volume eating episodes that are marked by a loss of control (binge eating), regular compensatory behaviors that are intended to prevent weight gain (purging), and over-valuation of body shape and weight. BN is associated with psychiatric comorbidity, significant psychosocial impairment, medical complications, and increased mortality.

Clinical guidelines for the evidence-based treatment of BN highlight first-line, outpatient psychotherapeutic and pharmacological approaches. Self-help, enhanced cognitive-behavioral therapy (CBT), and interpersonal psychotherapy are considered first-line psychotherapeutic interventions. Antidepressants, most notably SSRIs and specifically fluoxetine, which is FDA-approved for use in BN, are recommended adjunctive first-line treatments. Limited data suggest that CBT-BN alone and CBT-BN plus antidepressants are more efficacious than antidepressants alone.1 Despite these available treatment options, roughly 30% of cases are chronic and unremitting. Even for those who do initially respond to treatment, estimated rates of relapse in BN range from 25% to 63%.2



Melia is a patient with treatment-refractory, complex BN, who presents for treatment at our eating disorders program. A 20-year-old college student, she plans to attend law school after graduation.

Her eating disorder began in her freshman year, when she started “using food to cope” after a difficult breakup and domestic violence. Before admission, she was eating salads or diet frozen entrées for most meals and binge eating and purging 3 to 5 times a day. She has a history of self-harming behaviors and 2 suicide attempts.

She reports frequent shoplifting, occasional binge drinking to the point of blacking out, and recurrent unsafe sex with men she meets at bars. She previously had attempted outpatient, partial hospital, and residential treatment but had been unable to sustain recovery. She also had several trials of antidepressant medication without response for depression, anxiety, and eating-disordered symptoms.

Melia reports that she feels “very stressed” at school and has high standards for herself. She has had to withdraw from school several times to pursue treatment.


Improving outcomes for individuals with treatment-resistant BN such as Melia hinges on:

1 Developing an understanding of what factors make treatment failure or dropout more likely

2 Generating hypotheses about the mechanisms of non-response

3 Proposing and evaluating treatments that address these hypothesized mechanisms


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