Treatment of bulimia nervosa: when CBT fails

Controlled studies have established manual-based cognitive-behavioral therapy (CBT) is the first-line treatment of choice for bulimia nervosa. Nevertheless, its effectiveness is limited. On average, only 50% of patients cease being eating and purging. Of the remainder, some show partial improvement, whereas a small number derive no benefit at all. In treating nonresponders to CBT one option would be to use antidepressant medication. A second would be to adopt interpersonal psychotherapy (IPT), an alternative psychological therapy with empirical support. However, both options have failed to reduce binge eating following unsuccessful CBT. Treating nonresponders is hampered by the lack of treatment-specific predictor variables. Comorbid personality disorder is associated with a poorer response not only to CBT but also alternative therapies. There is no evidence that psychodynamic therapy is effective with complex cases with associated psychopathology. A third option is to use more expanded or intensive CBT. An example of the latter would be concentrated exposure within an inpatient setting. The relative merits of adhering to manual-based treatment versus allowing therapists free reign in individual case formulation are discussed.