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The treatment of bulimia nervosa is challenging. Bulimic patients are characteristically secretive about their symptoms and ambivalent about seeking and maintaining treatment. Moreover, bulimia nervosa is associated with significant co-morbidity and frequently coexists with other Axis I and Axis II disorders. Although bulimia nervosa, in an uncomplicated form, may respond well to cognitive, interpersonal, or psychodynamic psychotherapy or psychopharmacotherapy, this paper will focus on the refractory bulimic patient who requires an integrated multimodal treatment approach.
DSM-III-R criteria for the diagnosis of bulimia nervosa (formerly designated as bulimia in DSM-III) include at least two binge eating episodes per week for three months, a feeling of being out of control during a binge, the regular use of vomiting, laxatives, diuretics, dieting, or exercise to counteract the effect of a binge, and preoccupation with weight or body. Although bulimia nervosa can occur in individuals who are obese or underweight, most bulimics are normal weight. According to the DSM-III-R, bulimia nervosa can coexist with the diagnosis of anorexia nervosa.
The onset of this disorder frequently precedes presentation for treatment by several years. In the Eating Disorders Unit at Massachusetts General Hospital the mean duration of symptoms prior to presentation is almost six years. Typically the bulimic is ashamed of her disordered eating behaviors and has kept it a secret. Approximately 10% of the patients we see in our clinic are in ongoing psychotherapy but have not been able to inform their therapist of their disordered eating behaviors out of shame or guilt. While the bulimic is often accepting of treatment initially, she may have a low