bulimia nervosa case study

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CASE STUDY Sage (bulimia nervosa)

Case study details.

Sage is a 26-year-old doctoral candidate in English literature at the local university. She is in good standing in her program and has plans to enter the job market in the fall. In your intake, she tells you she thinks she is “fat” and has been self-conscious about her body since the sixth grade, at which time she began menstruating and developing breasts earlier than the other girls in her class. She was teased for needing a bra and remembers feeling “chubby, too big, and just wanting to be small like [her] younger sister.” She started dieting in the seventh grade, following strict rules for weeks (e.g., she recalls the grapefruit only diet), then transitioning into what she called “bad” weeks.  During these times, she would stock up on candy bars and other snack foods and eat them, often in her bedroom late at night. Her parents became concerned and tried to strictly limit her dieting.  This led to eating “normal” during the day and binging on those candy bars she kept hidden in her bedroom at night if she felt sad, scared, or mad. She grew into a habit of eating to feel better – relief that was only temporary, as she would feel ashamed about what she had done and resolve to not do it again. In college, her pattern of emotional eating continued, which felt more distressing to her because of the pressure to look “as pretty and thin as the other girls.” In spring of her freshman year she experimented with throwing up after the late-night eating and found that, at least in the minutes that followed, she felt like she had much more control and believed this would help her to prevent the weight gain she so dreaded. She fell into a vicious cycle of late-night binges (typically consuming about 7 candy bars in 15 minutes, during which times Sage described feeling very out of control) followed by making herself throw up. In college, she engaged in these binge-purge episodes about 6 nights/week. At present, she is having a harder time hiding the episodes because she lives with her boyfriend; she estimates that they occur about 4 nights per week. The times when she feels the most compelled to binge and purge are when she has a major presentation coming up in her doctoral program and when she gets in a fight with her boyfriend. Her BMI is in the normal range, but she says she needs to lose weight. She wants to stop binging and purging because she does not want her boyfriend to find out, but she is also afraid that if she stops, she will gain weight.

• Binges and Purging
• Emotion Dysregulation
• Disordered Eating

Diagnoses and Related Treatments

1. bulimia nervosa.

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CASE REPORT article

Case report: unexpected remission from extreme and enduring bulimia nervosa with repeated ketamine assisted psychotherapy.

• 1 Department of Psychology, University of Utah, Salt Lake City, UT, United States
• 2 Behavioral Science Department, Utah Valley University, Orem, UT, United States
• 3 Division of Public Health, University of Utah School of Medicine, Salt Lake City, UT, United States
• 4 Marriage and Family Therapy Program, Capella University, Minneapolis, MN, United States
• 5 Riverwoods Behavioral Health, Provo, UT, United States
• 6 Department of Educational Psychology, University of Utah, Salt Lake City, UT, United States

Background: Bulimia nervosa is a disabling psychiatric disorder that considerably impairs physical health, disrupts psychosocial functioning, and reduces overall quality of life. Despite available treatment, less than half of sufferers achieve recovery and approximately a third become chronically ill. Extreme and enduring cases are particularly resistant to first-line treatment, namely antidepressants and cognitive behavioral therapy, and have the highest rate of premature mortality. Here, we demonstrate that in such cases, repeated sessions of ketamine assisted psychotherapy (KAP) is an effective treatment alternative for improving symptoms.

Case Presentation: A 21-year-old woman presented with extreme and enduring bulimia nervosa. She reported recurrent binge-eating and purging by self-induced vomiting 40 episodes per day, which proved refractory to both pharmacological and behavioral treatment at the outpatient, residential, and inpatient level. Provided this, her physician recommended repeated KAP as an exploratory and off-label intervention for her eating disorder. The patient underwent three courses of KAP over 3 months, with each course consisting of six sessions scheduled twice weekly. She showed dramatic reductions in binge-eating and purging following the first course of treatment that continued with the second and third. Complete cessation of behavioral symptoms was achieved 3 months post-treatment. Her remission has sustained for over 1 year to date.

Conclusions: To our knowledge, this is the first report of repeated KAP used to treat bulimia nervosa that led to complete and sustained remission, a rare outcome for severe and enduring cases, let alone extreme ones. Additionally, it highlights the degree to which KAP can be tailored at the individual level based on symptom severity and treatment response. While its mechanism of action is unclear, repeated KAP is a promising intervention for bulimia nervosa that warrants future research and clinical practice consideration.

Introduction

Bulimia nervosa (BN) is a disabling psychiatric disorder characterized by recurrent binge-eating (consuming objectively large amounts of food with a sense of lost control) and inappropriate compensatory behaviors (self-induced vomiting; laxative, diuretic, or medication misuse; and fasting or excessive exercise) aimed at preventing weight gain ( 1 , 2 ). Overtime, the severity of these patterns significantly disrupts physical health and psychosocial functioning, as well as impacts families and communities at large ( 3 ). Approximately 50 million people worldwide will develop BN at some point in their life ( 4 ). Moreover, studies have found BN to be associated with concomitant psychiatric comorbidity [e.g., mood disorders and substance abuse; ( 5 , 6 )] in addition to premature mortality due to medical complications ( 7 – 9 ). Death by suicide is also eight times more likely to occur among individuals with BN compared to the general population, with more than a third experiencing lifetime rates of non-suicidal self-injury ( 10 , 11 ).

While pharmacological (e.g., selective serotonin reuptake inhibitors) and behavioral (e.g., cognitive behavioral therapy) interventions are effective in managing BN ( 12 , 13 ), many individuals do not respond to first-line treatment, are unsuccessful in later attempts, and fail to change over protracted periods ( 14 , 15 ). Nearly 30% of sufferers become chronically ill as a result ( 16 ). For such chronic refractory cases, the paucity of evidence-based treatments has prompted paradigm shifts toward harm reduction and palliative care over recovery ( 17 , 18 ).

Ketamine, a non-competitive N-methyl-D-aspartate receptor (NMDAr) antagonist, is an emerging therapy for treatment-resistant mood disorders ( 19 , 20 ). Single-dose studies have consistently shown rapid antidepressant and anti-suicidal effects following ketamine treatment, though are relatively short-lived (1–4 weeks) ( 21 – 28 ). Ketamine assisted psychotherapy (KAP) has therefore been utilized to prolong ketamine's efficacy and maximize therapeutic outcomes ( 29 – 34 ). To date, few studies have used ketamine for the treatment of eating disorders, including one open-label study ( 35 ), two case reports ( 36 , 37 ), and one longitudinal case series ( 38 ), all of which administered ketamine without a psychotherapeutic component. Nonetheless, the results are encouraging. Here, we report the case of a young woman suffering from extreme and enduring BN, according to CARE (CAse REport) guidelines ( 39 ), who demonstrated remarkable symptom improvement following repeated sessions of KAP.

Case Presentation

A 21-year-old woman with BN of 9 years presented to the outpatient clinic, Forum Health. She was first diagnosed with BN, binge-eating/purging type, at 12.5 years of age to which the severity of her symptoms steadily increased overtime. On presentation, she reported alarming rates of binge-eating and purging by self-induced vomiting, averaging ~40 episodes per day for the last 12 months. Based on this frequency, her BN was categorized as “extreme” according to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criterion (14 or more episodes per week). Clinical assessment and scoring on the Eating Disorder Examination Questionnaire [EDE-Q; ( 40 , 41 )] additionally confirmed the severity of her illness. No laxative or diuretic abuse was reported. While not active in psychiatric treatment, the patient was taking potassium chloride 20 mEq extended-release twice daily for hypokalemia as well as trazodone 100 mg once daily in the evenings for sleep. At 161.92 cm tall and 46.26 kg in weight [body mass index (BMI) = 17.6 kg per m 2 ], the patient was amenorrheic and described body image disturbances, intense fear of gaining weight, and obsessive-compulsive tendencies around food (counting calories, binging by order of food group, and inability to discard uneaten items). She further displayed pronounced bilateral parotid sialadenosis (enlargement of the salivary glands) and pseudo-idiopathic edema, otherwise known as pseudo-bartter's syndrome (PBS): a rare and painful complication of BN characterized by hyperaldosteronism, metabolic alkalosis, and hypokalemia ( 42 ). As a University student studying cognitive neuroscience, the patient was obliged to take a medical leave due functional decline. “I lost all ability to take care of myself. I could not think clearly or show up for classes. I stopped socializing and running errands. I could hardly maintain basic hygiene.”

Her psychiatric history included an adolescent sexual assault by a treating physician (13 years of age [2011]); a suicide attempt by cut throat injury at the level of the hyoid bone, which required emergency transportation and thyroid cartilage repair as well as inpatient hospitalization (13 years of age [2011]); a second suicide attempt by drug overdose involving mixed opioids, barbiturates, and antidepressants that resulted in emergency room hospitalization (15 years of age [2013]); and a blitz rape (surprise attack) by an unknown assailant (19 years of age [2017]). The patient's history also contained reports of major depression, general anxiety, and obsessive-compulsive disorder. There was no family history of eating disorders, including BN.

As an outpatient, she was treated with various pharmacotherapies (fluoxetine 40 mg once daily, citalopram 20 mg once daily, and naltrexone 50 mg twice daily), behavioral interventions (cognitive behavioral therapy, mindfulness-based stress reduction, and eye movement desensitization and reprocessing), and nutritional counseling (dietary modification and time-based feeding). She additionally was prescribed spironolactone 25 mg twice daily, a potassium-sparing diuretic, on multiple occasions to treat PBS following attempts at purging cessation. However, the patient's binge-purge patterns continued. Finally, she received inpatient, residential, and intensive-outpatient eating disorder care (15–16 years of age [2013–2014]), which the patient described as a “traumatic experience” that resulted in immediate relapse upon discharge.

“My parents pulled me out of class and dropped me off at a center, leaving me there for almost 10 months. It was like being in prison. I was completely cut off from my friends and family. I was forced to eat unreasonable amounts of food at each meal. And I learned new [eating disorder] tricks from other patients that I tried later on. It was not a place conducive to recovery, at least for me. It just made my condition worse.”

Her medical history detailed emergency room hospitalizations for hypokalemia (16, 19, and 20 years of age [2014, 2017, 2018]), gastroesophageal reflux disorder (17–21 years of age [2015–2019]), gastric and duodenal ulcers (19 and 21 years of age [2017, 2019]), hypothyroidism (20–21 years of age [2018–2019]), and adrenocortical insufficiency (20–21 years of age [2018–2019]). Porcelain-laminate veneers were also placed on 10 of her teeth due to dental caries and enamel erosion from chronic purging (21 years of age [2019]).

Given the patient's extreme and chronic refractory state, her physician recommended repeated KAP, with the understanding it constituted an exploratory and off-label intervention for her eating disorder. She consented to treatment following a comprehensive medical evaluation and in-depth review of the procedures, risks, and possible side effects. A signed consent form was obtained. Prior to treatment, she met with a clinical psychologist to establish rapport and therapeutic alliance. The patient then underwent one course of repeated KAP, consisting of six sessions scheduled twice weekly for 3 weeks, with a minimum interval between sessions of 48 h ( Figure 1 ). Each KAP session involved guided psychotherapy combined with racemic ketamine hydrochloride (0.5 mg per kg bodyweight suspended in 0.9% normal saline) administered intravenously over 40 min. The drug regimen was standard practice in the clinic for sub-anesthetic ketamine infusions, which is most commonly used for treating psychiatric disorders and is supported by a substantial body of literature ( 43 , 44 ). A person-centered, humanistic approach to psychotherapy was employed to facilitate the process of self-actualization and therapeutic change. KAP sessions were preceded by 30 min of preparatory psychotherapy and delivered in a private room with dimmed lights, ambient music, and textile art on the ceiling. The intervention components and ketamine regimen remained the same for all five consecutive sessions; and blood pressure, heart rate, and oxygen saturation were continuously monitored. Due to the severity of her eating disorder, however, the patient returned to the clinic 1 month later for a second course of repeated KAP and then again 1 month later for a third.

Figure 1 . Timeline of clinical events. The patient received three courses of repeated KAP for extreme and enduring BN, consisting of six sessions per course scheduled twice weekly for 3 weeks. KAP, ketamine assisted psychotherapy; BN, bulimia nervosa; B/P, binge-eating and purging.

Dissociation, ego dissolution, and perceptual distortions were present during all KAP sessions, as evidenced by the patient's description of “being disconnected from reality,” “losing [her] sense of identity and self,” and “seeing abstract geometric patterns.” She further exhibited mild diplopia (double vision), nystagmus (involuntary oscillations of the eyes), and alogia (lack of speech) during treatment that resolved completely. No other side effects or adverse events were reported. The patient's eating disorder symptoms remitted over the course of treatments, as measured by change in scoring on the EDE-Q as well as entries from a daily tracking log that recorded frequency of binge-eating and purging. On the EDE-Q, her global score dropped from 31.8 at baseline to 15.0 by the end of all three courses (18 sessions), with similar patterns recorded across all four subscales: “Restraint” ( M = 5.0, SD = 2.2 to M = 1.8, SD = 1.3), “Eating Concern” ( M = 5.8, SD = 0.5 to M = 2.2, SD = 1.5), “Weight Concern” ( M = 5.8, SD = 0.5 to M = 4.0, SD = 1.9), and “Shape Concern” ( M = 5.5, SD = 0.8 to M = 2.5, SD = 1.6) ( Figure 2 ). Additionally, the patient's tracking log showed decreases in binge-eating and purging from 40 to 18 episodes per day after the first course of treatment (6 sessions), 18 to 13 episodes per day after the second course of treatment (12 sessions), and 13 to 4 episodes per day after the third course of treatment (18 sessions) ( Figure 3 ).

Figure 2 . Change in scoring on the Eating Disorder Examination Questionnaire (EDE-Q).

Figure 3 . Frequency of daily binge-eating and purging following repeated ketamine assisted psychotherapy.

Most notably, the patient stopped her binge-eating and purging behaviors 3 months post-treatment. Given her initial severity and chronic refractory state, this degree of improvement was striking. The patient's daily tracking log additionally showed no signs of relapse 1 year later, accompanied by marked improvement in psychosocial functioning. Specifically, she reported feeling “free” from intrusive BN thoughts and compulsions, “less impulsive” when faced with the urge to binge and purge, and “more confident” about her body in general. The patient has since resumed her academic studies in preparation for a doctoral program.

Severe, chronic, and refractory eating disorder symptoms are unfortunately common among patients with BN. In this case, we describe a young woman with extreme and enduring BN, who remained unresponsive to first-line treatment for nearly a decade, despite care at the outpatient, residential, and inpatient level. Her eating disorder was extreme, insofar as she engaged in recurrent binge-eating and purging by self-induced vomiting 40 episodes per day, which significantly exceeds DSM-5 criterion (14 or more episodes per week). Given the severity of her illness, complete and sustained remission with three courses of repeated KAP (18 sessions) was both remarkable and unanticipated. These findings are more robust provided the patient was not active in psychiatric treatment for 1 year prior to clinic admission, excluding her long-standing prescription of potassium chloride for hypokalemia and trazodone for sleep. If ketamine and psychotherapy act synergistically, with therapy priming and enhancing the response to treatment, then its combined effect may explain the striking improvements in symptoms. Serial treatments likely account for the durability of response necessary for sustained remission, which is consistent with literature ( 45 – 48 ).

Provided this is the first report of repeated KAP used as an exploratory and off-label intervention for BN, it is important to consider the a-priori context. Clinical recommendation to pursue repeated KAP was prompted by three factors. First, the patient's psychiatric and medical history that detailed unsuccessful treatment attempts, including pharmacotherapies, behavioral treatments, and nutritional counseling—even at higher levels of eating disorder care; and significant trauma to which accumulating evidence has shown ketamine to yield positive effects for ( 49 – 51 ). Second, her severe functional impairment in three major life domains, including academic work, social and family engagement, and personal responsibilities. The patient was binge-eating and purging nearly to the exclusion of all other activities, spending more time “alone in the bathroom than with [her] friends or family.” Finally, an open-label case series on repeated ketamine in severe and enduring anorexia nervosa, showing modest improvements in eating disorder symptoms ( 38 ).

The patient's impetus for treatment was largely driven by fear of premature mortality—that if she did not attempt something new, she was going to “eat [herself] to death,” quite literally. Serious degradation in the patient's physical and mental health status were particularly motivating. Apart from transient psychological (dissociation, ego dissolution, and perceptual distortions) and physiological (mild diplopia, nystagmus, and alogia) side effects of ketamine that resolved completely after each session, the treatment was well-tolerated. Following all three courses of treatment, the patient dramatically reduced her binge-eating and purging behaviors by 90% compared to baseline, as measured by the EDE-Q and daily tracking logs. She also demonstrated considerable improvements in disordered eating psychopathology that were captured by the subscales of the EDE-Q, most notably “Restraint” (e.g., dietary rules and avoidance of food) and “Eating Concerns” (e.g., preoccupation with calories and fear of losing control over eating). Moreover, the patient regained control of her impulsive eating as well as resolved her obsessive-compulsive neurosis, which align with previous BN-specific findings from a study on intermittent ketamine infusions in eating disorders ( 35 ). At 3 months follow-up, she achieved complete cessation of binge-eating and purging and no longer met diagnostic criteria for BN. The magnitude of response neither diminished over time, with no signs of relapse at 15 months follow-up, contrary to studies showing rapid decline of effects after treatment ( 28 , 52 , 53 ). With sustained remission, the patient has adopted a healthier relationship with food, established psychosocial stability in her life, and resumed her academic studies in preparation for graduate school.

This is a single case report with inherent limitations in generalizing the findings to other patients with BN. The lack of polypharmacy or medication washout is an additional limitation that may have unknowingly mediated improvements. Furthermore, it is unclear as to whether ketamine or psychotherapy produced greater clinical benefit, if both are coadjuvant and necessary, or if the treatment would have been as effective without psychotherapy and/or fewer sessions. Finally, a person-centered, humanistic approach to psychotherapy was employed, differing from more traditional methods, such as cognitive-behavioral, interpersonal, and psychodynamic therapy. Open pilot studies as well as fully-powered randomized controlled trials with longitudinal assessment are thus required to establish whether the outcome of this case can be replicated, to what degree ketamine and psychotherapy contribute to the overall success of the treatment, and the comparative efficacy of different psychotherapeutic interventions. Further research is also warranted to optimize KAP duration and frequency for this patient population.

Conclusions

This study provides compelling evidence that repeated KAP is an effective treatment for extreme and enduring BN, which is exceedingly resistant to first-line therapies and associated with poor prognosis. It further highlights the utility of combined strategies that may prolong ketamine's efficacy, and subsequently maximize therapeutic outcomes at the individual level.

Data Availability Statement

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.

Ethics Statement

Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

Author Contributions

PH-B assessed, treated, and followed-up with the patient. AR interviewed the patient, conceptualized the case report, drafted the manuscript, and developed all figures. LKJ and SC contributed to the literature review and assisted with manuscript preparation. LG, QT, and MR provided substantial contributions to the interpretation of data as well as manuscript revisions. All authors have read and approved the final manuscript.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Acknowledgments

We thank Dr. Andrew Petersen, the lead physician on this case, for his contributions to this study and continued innovation in the field.

Abbreviations

BMI, body mass index; BN, bulimia nervosa; DSM-5, diagnostics and statistical manual of mental disorders, 5th edition; EDE-Q, eating disorder examination questionnaire; KAP, ketamine assisted psychotherapy; NMDAr, N-methyl-D-aspartate receptor; PBS, pseudo-bartter's syndrome.

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Keywords: bulimia nervosa, eating disorder, binge-eating, purging, ketamine, ketamine assisted psychotherapy, psychopharmacology, case report

Citation: Ragnhildstveit A, Jackson LK, Cunningham S, Good L, Tanner Q, Roughan M and Henrie-Barrus P (2021) Case Report: Unexpected Remission From Extreme and Enduring Bulimia Nervosa With Repeated Ketamine Assisted Psychotherapy. Front. Psychiatry 12:764112. doi: 10.3389/fpsyt.2021.764112

Received: 25 August 2021; Accepted: 27 October 2021; Published: 17 November 2021.

Reviewed by:

Copyright © 2021 Ragnhildstveit, Jackson, Cunningham, Good, Tanner, Roughan and Henrie-Barrus. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Anya Ragnhildstveit, anya.ragnhildstveit@utah.edu

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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The Outcome of Bulimia Nervosa: Findings From One-Quarter Century of Research

• Hans-Christoph Steinhausen M.D., Ph.D., D.M.Sc.
• Sandy Weber Cand.Phil.

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Objective: The present review addresses the outcome of bulimia nervosa, effect variables, and prognostic factors. Method: A total of 79 study series covering 5,653 patients suffering from bulimia nervosa were analyzed with regard to recovery, improvement, chronicity, crossover to another eating disorder, mortality, and comorbid psychiatric disorders at outcome. Forty-nine studies dealt with prognosis only. Final analyses on prognostic factors were based on 4,639 patients. Results: Joint analyses of data were hampered by a lack of standardized outcome criteria. There were large variations in the outcome parameters across studies. Based on 27 studies with three outcome criteria (recovery, improvement, chronicity), close to 45% of the patients on average showed full recovery of bulimia nervosa, whereas 27% on average improved considerably and nearly 23% on average had a chronic protracted course. Crossover to another eating disorder at the follow-up evaluation in 23 studies amounted to a mean of 22.5%. The crude mortality rate was 0.32%, and other psychiatric disorders at outcome were very common. Among various variables of effect, duration of follow-up had the largest effect size. The data suggest a curvilinear course, with highest recovery rates between 4 and 9 years of follow-up evaluation and reverse peaks for both improvement and chronicity, including rates of crossover to another eating disorder, before 4 years and after 10 years of follow-up evaluation. For most prognostic factors, there was only conflicting evidence. Conclusions: One-quarter of a century of specific research in bulimia nervosa shows that the disorder still has an unsatisfactory outcome in many patients. More refined interventions may contribute to more favorable outcomes in the future.

The introduction and definition of bulimia nervosa were presented only 30 years ago. In his salient publication, Gerald Russell (1) emphasized the dread of overeating, various compensatory measures, and the morbid fear of gaining weight and getting fat. Within this relatively short period of time, a remarkably large number of outcome studies have been published. Early reviews included one review based on eight studies (2) and another on 24 follow-up studies (3) . The latter found a mean recovery rate of 47.5% and mean rates of 26% for both improvement and chronicity. Shortly before the turn of the century, Keel and Mitchell (4) analyzed the course of 56 patient series and found a recovery rate of 50% and chronicity in 20% of the patients. The mortality rate of 0.3% was slightly lower than that reported in the prior review of 24 studies (3) . The review by Vaz (5) concentrated on prognostic factors only, and Quadflieg and Fichter (6) reviewed various outcome measures in a total of 33 studies. Finally, a recent, more selective review based on very rigorous inclusion criteria by Berkman et al. (7) provided findings from 13 patient series. Steinhausen’s analysis (8) of the outcome of anorexia nervosa in the second half of the last century served as a model for the present review.

Selection criteria for the inclusion of studies in the present review were 1) data on at least one out of five outcome measures for bulimia nervosa after a minimum follow-up evaluation period of 6 months following the treatment episode and/or 2) data on any prognostic factor of the disorder. The aforementioned reviews consisted of a total of 141 studies. A systematic search with various databases was performed using the terms “bulimia nervosa,” “outcome,” “follow-up,” and “prognosis.” A search using PubMed led to an additional 60 studies, and a search using PsycINFO resulted in 19 studies. Thus, before applying any exclusion criteria, a total of 220 published studies were available. As a result of duplicate or review-type studies, 68 studies were excluded. Furthermore, 26 studies did not include sufficient information on the duration of follow-up evaluation or provided pre-post measures only or were based only on follow-up periods <6 months. In another 21 studies, information on the course of the disorder was insufficient (e.g., no information on sample size or no independent assessment of anorexia and bulimia nervosa patients was provided). Finally, there were 14 studies dealing with prognostic factors only, and another 12 studies presented additional data based on the same patient cohort. Thus, at the end, a total of 79 patient series were entered into the analyses for the outcome of bulimia nervosa in the present review. Findings were published between 1981 and 2007. Data based on reports from a total of 32 studies were extracted by the expert senior author. Decisions on the inclusion of the remaining studies were jointly made by both the junior and senior authors.

Study Characteristics

The 79 published reports (9 – 87) were composed of 5,653 patients (group mean size=71.6 [SD=113.4], range=4–884). There were considerable differences in design, group size, methods, duration of follow-up evaluation, and missing data. Diagnostic classification changed considerably over the period in which the studies were conducted. Since the 1990s, there has been an increasing reliance on DSM-IV and ICD-10 criteria. In 46 studies consisting of 2,508 patients, the mean age at onset was 17.2 years (SD=1.7, range=4.3–23.2), and the mean age at follow-up assessment was 28.4 years (SD=4.3, range=16.6–38.0) in 39 studies consisting of 2,478 patients. The mean duration of follow-up evaluation varied between 6 months and 12.5 years (mean=3.2 months [SD=3.3]) in 77 studies of 5,239 patients. In 66 studies of 3,830 patients, a total of 75 men (1.9%) were included.

A minority of studies used combined intervention and follow-up evaluation, whereas the majority of studies used only limited evaluation of treatment effects. The available information on treatment was classified as 1) nonbehavioral psychotherapy, 2) unspecified medical intervention, 3) cognitive-behavioral therapy (CBT), 4) family intervention, or 5) mixed or uncontrolled intervention.

In the analyses for prognostic factors, 35 studies included information on prognostic factors in addition to data on outcome (10 , 14 , 15 , 17 , 21 , 24 , 25 , 30 , 34 – 36 , 40 – 44 , 52 , 54 , 55 , 57 , 61 , 63 , 65 , 68 , 71 – 73 , 75 , 76 , 83 , 88 – 92) , and 14 studies (93 – 106) dealt exclusively with prognostic factors. The total sample of these studies on prognosis consisted of 4,639 patients (mean=94.62 [SD=133.76], range=4–884).

Outcome Measures

The five central outcome criteria for the present analyses were recovery, improvement, chronicity, mortality, and crossover to other eating disorders. In addition, information on comorbid mental disorders was collected. Information on recovery was provided in the studies as part of 1) a three-level classification in combination with improvement and chronicity, 2) a two-level classification mostly in combination with chronicity, or 3) a single criterion. There were 22 synonyms of recovery (e.g., “abstinent”). Improvement was most commonly used as a medium category of a three-level classification. In a few instances, rates of improvement were reported in combination with recovery only. Among the 27 synonyms of improvement were terms such as “intermediate course,” “some remaining symptoms,” or “partial remission.” Finally, among 21 synonyms of chronicity, the most common were “bulimia nervosa,” and “poor course.” Some studies used crossover to another eating disorder according to DSM-IV criteria as an outcome category in addition to recovery and chronicity. All mortality rates represented crude mortality rates. None of the studies reported standardized mortality rates.

Statistical Analyses

The five outcome measures were calculated in percentages that were rounded to the nearest whole value. In order to take into account the large variation in sample sizes, weighted percentages were calculated by weighting each reported rate with the size of the study group. Data for all studies were converted into individual data for performance of statistical analyses using SPSS 14 (SPSS, Chicago).

All analyses were based on adjusted sample sizes at follow-up assessments rather than actual sample sizes after patient recruitment. Differences between these two figures were considered the dropout rate. The latter was dichotomized into high (≥16% of the original sample) and low (0%–15% of the original sample) categories and served as a first independent effect variable. In accordance with previous analyses (8) , the duration of follow-up evaluations was the second independent effect variable and categorized as <4 years, 4 to 9 years, or ≥10 years. Studies with a variable length of course were not considered for analyses of effect. In case there was more than one report based on the same cohort, only the last report with the longest duration of follow-up assessment was considered for the analyses. The third independent variable was represented by the type of intervention. Because of limited data, the aforementioned classification of available information on treatment into five types was restricted to the following three types: nonbehavioral psychotherapy, unspecified medical therapy, and CBT.

Effects of these three variables for treatment type on four outcome measures were analyzed using multivariate analyses of variance. In addition, effect sizes were calculated using partial eta-squared (η 2 ) as a measure of association between independent and dependent variables. According to Cohen (107) , η 2 =0.01–0.059 represents a small effect, η 2 =0.06–0.13 represents a median effect, and there is a large effect starting with η 2 =0.14. Furthermore, the frequencies of positive, negative, and insignificant prognostic factors were calculated.

Main Outcome Findings

Detailed information on crossover diagnoses was available in 23 studies. As shown in Table 1 , more than one-fifth of the patients fulfilled this criterion, with a majority of 16% on average crossing over to eating disorder not otherwise specified, which in most cases was a subclinical manifestation of bulimia nervosa, and nearly 6% on average developed full anorexia nervosa. A few patients developed binge eating disorder.

Seventy-six studies reported on mortality, and there were 14 deaths among 4,309 patients, leading to a crude mortality rate of 0.32%. For two patients, car accidents were the cause of death, four deaths were the result of suicide, one death was the result of a drug overdose, two deaths were caused by an eating disorder, and no causes of death were given for two subjects.

There was a large list of reported comorbid mental disorders. At follow-up assessments, patients most frequently suffered from affective disorders, followed by neurotic disorders (mostly anxiety disorders). Nonspecific personality disorders and borderline personality disorder were also frequent. Substance use disorders were less frequently seen, and obsessive-compulsive and schizophrenia spectrum disorders were described only in a single study.

Findings From Repeated Follow-Up Assessments

A few studies shed some light on the differential course of bulimia nervosa across time. Fichter and Quadflieg (91) published findings after 2-, 6-, and 12-year follow-up evaluations (34) and found substantial improvement in patients who completed longer follow-up assessment periods. Similarly, in the study by Herzog et al. (42) , recovery rates increased between the first follow-up assessment after 2 years and the second follow-up assessment after 7 years, but rates of improvement and chronicity declined correspondingly. Another study on intervention (59) found that the reduction of binge eating episodes and compensatory vomiting and laxative abuse remained constant between the 6- and 12-month follow-up evaluations. A change in outcome rates was observed in two smaller studies. Nevonen and Broberg (64) found a decreased recovery rate and an increased improvement rate between 1 and 2.5 years of follow-up evaluation when comparing individual and group psychotherapy. Similarly, in a very small sample of six patients, Toro et al. (80) observed that all patients were recovered at the first follow-up evaluation, but only four patients remained recovered after 25 years.

Intervention Effects on Outcome

There are various intervention studies on bulimia nervosa that include follow-up assessments. Two studies (28 , 30) compared three types of interventions and found that both interpersonal therapy and CBT were superior to behavior therapy without cognitive components. Other studies reported that CBT was superior to interpersonal therapy (29 , 84) or found no significant differences in the effects of either CBT or the combination of behavior therapy and hypnotherapy (40) . In another study (12) , more patients became symptom-free by the use of a self-help manual rather than CBT. Physical activity, but not diet counseling, was shown to be superior to CBT in one report (78) .

In a study on the optimization of CBT (82) , one group of patients used a self-help manual and received additional CBT when necessary. The other patients received behavior therapy only. There were no significant differences between these two approaches. In a study on the effectiveness of either the antidepressant fluoxetine or interpersonal therapy after a first inefficient phase of CBT (62) , no significant differences between the two approaches were found.

When comparing the effects of the antidepressant desipramine, CBT, or a combination of both measures (11) , CBT or the combined intervention resulted in stronger reduction of symptoms after 24 weeks relative to the pure antidepressant treatment. Adding exposure and response prevention to CBT did not result in improved results (19) . Another study (59) revealed that relative to a coping with stress program, diet counseling led to a more rapid improvement of eating behavior and to reduction and abstinence of binge eating episodes.

Two studies on the effects of family therapy revealed contradictory findings. One study (74) found that family intervention was inferior to individual psychotherapy, whereas family therapy was found to be superior in another study (39) . No significant differences were found in the effectiveness of group versus individual psychotherapy (64) . Finally, a positive effect of after-treatment control visits on the course of bulimia nervosa has been documented (58) .

Effect Variables

As a result of methodological restrictions, the presentation of findings based on effect analyses was limited to the set of 27 studies that used the three-level classification with recovery, improvement, and chronicity, supplemented by the smaller number of studies that provided additional information on rates of diagnoses for crossover to other eating disorders. There were no missing data in this data set.

Dropout rate

Duration of follow-up evaluation.

Bulimia Nervosa Clinical Presentation

• Author: Guido Klaus Wilhelm Frank, MD; Chief Editor: David Bienenfeld, MD  more...
• Sections Bulimia Nervosa
• Practice Essentials
• Pathophysiology
• Epidemiology
• Mortality/Morbidity
• Patient Education
• Diagnostic Criteria
• Physical Examination
• Comorbidities
• Complications
• Laboratory Studies
• Imaging Studies
• Other Tests
• Approach Considerations
• Medical Care
• Nonpharmacologic Interventions
• Pharmacologic Treatments
• Surgical Care
• Consultations
• Long-Term Monitoring
• Media Gallery

Bulimia nervosa (BN) is often not diagnosed for many months or even years after onset because of patients' secretiveness about their symptoms, usually associated with a great deal of shame. These patients often see physicians for other problems, such as anxiety, depression, infertility, bowel irregularities, fatigue, or palpitations. Similarly, they may see mental health professionals for mood and anxiety problems, personality issues, relationship issues, histories of childhood or adolescent trauma, or substance abuse, without revealing the presence of an eating disorder.

One common presenting scenario is that of a patient who is concerned about their weight who seeks help with weight loss. Symptoms may include bloating, constipation, and menstrual irregularities. Far less often, people may present with palpitations resulting from arrhythmias, which are often associated with electrolyte abnormalities and dehydration. BN is also often, but not always, characterized by an inappropriate premium placed on slender physical appearance. It is important to note that the diagnostic criteria do not necessarily require an individual to express a desire to lose weight or change their appearance to meet criteria for BN. Some, especially younger patients, may not be able or willing to articulate why they engage in eating disorder behaviors. Others may express a motivation for control, a fear of fullness, or other reasons for their disordered eating behaviors. Failure to make an appropriate eating disorder diagnosis that an individual would otherwise meet criteria for, whether it be anorexia nervosa (AN), BN, or other specified feeding or eating disorder (OSFED), because of a lack of expressed concern or denial of concern about body weight/shape is dangerous for patients’ physical and mental health due to causing delays in diagnosis that can contribute to significant morbidity and mortality. 

A dietary history may reveal attempts to control weight by dieting and abstaining entirely from high-calorie foods at all times except during binge eating episodes. Often, an all-encompassing preoccupation with food and eating is present, and recurring cycles of extreme dieting and/or fasting may alternate with gorging behavior. The clinician should inquire further about types of foods and quantities of foods consumed when a patient endorses binging behavior. A binge eating episode, by definition, must constitute consumption of more food than would typically be consumed in a single setting by an individual, so there is some subjectivity in what is a binge. Some patients with AN or with periods of very restrictive eating patterns may endorse a “binge,” but on further inquiry may be describing an episode that would be either less than or normative for typical eating for a non-eating-disordered individual but perceived subjectively as a binge eating episode. In the context of highly restrictive eating, any instance of normative eating, such as consuming a dessert, eating high-calorie snacks, or even allowing oneself to eat until feeling full, might appear to be binge eating to an individual who is used to eating very little amounts of food most of the time. 

Most patients self-induce vomiting by gagging themselves with their fingers or a toothbrush. Some patients are able to regurgitate reflexively, without requiring external stimulation of the pharynx. [ 34 ] A minority of patients will chew, then regurgitate, without actually swallowing the food. One particularly dangerous form of vomiting is via induction through the use of emetics (eg, ipecac). Ipecac is a tightly binding and slowly released mycotoxin that may lead to fatal cardiomyopathy in habitual users. Up to 40% of patients misuse laxatives, thinking that their use will help them lose weight. In fact, laxative misuse results in additional dehydration and often electrolyte abnormalities as well. Screening for laxative use should be a routine topic of assessment. 

For children and adolescents, the parents/guardians of the patient should be asked to check for signs of vomiting and laxative misuse in the home when the patient is denying purging behavior but there is a strong suspicion of purging behaviors occurring. Indications of surreptitious purging behaviors that parents/guardians should be instructed to look for in the home include hidden vomitus in concealed places in the home (eg, closets, floorboards), concealed laxatives in the patients’ room or belongings, clogged drains with vomit, vomit in trash cans, and so on. The parents/guardians should also be instructed to be observant for other signs of purging behavior both for diagnostic and preventative purposes such as unusual online orders (which could be for laxatives or other emetics) and unusually long periods of time spent in the bathroom or shower, which may or may not be after meals and may or may not be accompanied by retching noises. For both children and adults, collateral informants can be very useful sources of information for the clinician about surreptitious purging or other eating disorder behaviors. 

Clinicians should be aware of misconceptions that eating disorders are almost exclusively present in young women to avoid missing diagnoses of BN or other eating disorders in male patients or older patients. Additionally, it is a misconception that eating disorders, including BN, mostly occur in White women and people from Western cultures. While research is still evolving on the epidemiology of BN and other eating disorders in males, older individuals, people in developing countries, and so on, in the authors’ clinical experiences, we have encountered a great many patients with BN and other eating disorders who are male, not White, and of a great many different ethnic and racial backgrounds. 

Patients with BN may experience the following symptoms:

General - Dizziness, lightheadedness, palpitations (due to dehydration, orthostatic hypotension, possibly hypokalemia)

Gastrointestinal symptoms - Pharyngeal irritation, abdominal pain (more common among persons who self-induce vomiting), blood in vomitus (from esophageal irritation and more rarely actual tears, which may be fatal), difficulty swallowing, bloating, flatulence, constipation, and obstipation

Pulmonary symptoms - Uncommonly aspiration pneumonitis or, more rarely, pneumomediastinum

A high index of suspicion is required in any depressed or anxious weight-conscious young woman.

A set of screening questions, such as the SCOFF mnemonic questionnaire, [ 35 ]  is useful to obtain a quick impression as to the potential need for further in-depth questioning. The SCOFF questionnaire includes the following 5 questions:

Do you make yourself  S ick because you feel uncomfortably full?

Do you worry you have lost  Co ntrol over how much you eat?

Have you recently lost more than  O ne stone (about 14 lbs or 6.35 kg) in a 3-month period?

Do you believe yourself to be  F at when others say you are too thin?

Would you say that  F ood dominates your life?

The Eating Disorder Screen for Primary Care (ESP) questionnaire is an alternative screening tool. [ 36 ] It contains the following 5 questions:

Are you satisfied with your eating patterns?

Do you ever eat in secret?

Does your weight affect the way you feel about yourself?

Have family members suffered from an eating disorder?

Do you currently suffer with or have you in the past suffered with an eating disorder?

The Eating Attitudes Test (EAT) is a self-report population-based screening instrument that patients can complete in the waiting room prior to seeing the health care provider. [ 37 ] (See  Psych Central  for more information.)

Family history of eating disorders, anxiety, mood disorders, and alcohol and/or substance abuse/dependence may contribute to the risk of BN and should be investigated.

Generally, patients with BN are more likely than controls to view their families as conflicted, badly organized, non-cohesive, and lacking in nurturance and caring. These patients have also been shown to more often appear to be angrily submissive to hostile and neglectful parents.

Perceptions of appearance-related teasing by family members may be present. [ 38 ]

For individuals still living with their parents, careful assessment of the family’s dynamics should be undertaken.

Physiological abnormalities

Many physiological abnormalities may be seen in association with eating disorders, but virtually all appear to be consequences of the abnormal behaviors, not their causes. In most cases of BN, laboratory abnormalities are relatively minor. In cases of very frequent purging (eg, daily or multiple times per day), abnormalities in electrolyte and serum amylase levels occur, but these and most other laboratory abnormalities are reversible with weight restoration and cessation of compensatory behaviors. 

Among the identified metabolic consequences sometimes seen in BN are low plasma insulin, C peptide, triiodothyronine, and glucose values, as well as increased beta-hydroxybutyrate and free fatty acid levels. Both fasting and post-binge/post-vomiting hypoglycemia are sometimes seen in some patients with BN. Some studies suggest increased secretory diurnal amplitudes in cortisol and adrenocorticotropic hormone (ACTH) in BN as well as blunted responses to corticotrophin-releasing hormone (CRH). However, these findings have been inconsistent among research studies.

Reports have also suggested abnormal responses to dexamethasone suppression like those seen in AN and major depressive disorder, more common among individuals with significant dietary restriction. Some authors have attributed these abnormalities to impaired dexamethasone absorption, which is demonstrated in some patients with BN. Similar to findings in AN, patients with BN tend to have higher growth hormone levels at night, while nocturnal prolactin levels tend to be less than those seen in controls.

About half of women with BN have anovulatory cycles, while about 20% have luteal phase defects. Patients with anovulatory cycles generally have impaired luteinizing hormone pulsatile secretion patterns and associated reduced estradiol and progesterone pulse amplitudes. [ 39 , 40 ]

Although the implications of many research findings are still unclear, and none of the following offer clinical tests of any merit, reports suggest involvement of the serotonin transporter, [ 41 , 42 ]  autoantibodies against neuropeptides, [ 43 ]  various chromosome regions, [ 44 ] brain-derived neurotrophic factor, [ 45 ]  and peptides leptin and ghrelin. [ 46 ] In a few instances, cerebral hemispheric lesions may be involved in pathogenesis. [ 47 ] Regional cerebral blood flow abnormalities have been noted in adolescents. [ 48 ] Endogenous opioids and beta-endorphins have been implicated in the maintenance of binge eating. Therefore, diagnosis of BN and other eating disorders should be made mostly on the basis of interview with the patient and their collateral informants as well as behavioral observation at times (eg, purging witnessed by family or a staff member). Laboratory tests and physical examination can provide important information about comorbid medical sequelae of BN, but diagnosis requires a thorough diagnostic interview and clinical history. 

The underlying causes for buimia nervosa (BN) remain elusive. However, a variety of biological and psychological factors have been suggested to be involved the development of BN.

Behavioral traits

BN has long been associated with inadequate mechanisms to control food intake beyond ones physiological needs, and behavioral traits could contribute. [ 183 , 184 , 185 , 186 , 187 ]  

Emotion regulation has been defined as the “extrinsic and intrinsic process responsible for monitoring, evaluating, and modifying emotional reactions, to accomplish one’s goals." [ 188 ] A disturbance in emotion regulation has been found in eating disorders. [ 189 ] Individuals with BN have difficulties modulating strong emotions and controlling rash, impulsive response. [ 190 ] Most but not all studies suggest that negative affect precedes binge eating episodes, [ 191 ] followed by initial relief. [ 192 , 193 ]  

Impulsivity, the “opposite to aspects of executive function,” [ 194 ] is a tendency to act with insufficient forethought, or a predisposition toward rapid, unplanned reactions to internal or external stimuli without regard for the negative consequences of these reactions. Impulsivity has relevance for binge eating behaviors, as those episodes typically occur impulsively in response to an external or internal trigger. Increased impulsivity had been found across BN. [ 195 , 196 ] Overall, the literature on executive function in BN is limited, but there is evidence that altered impulsivity and executive function distinguish binge eating individuals from normal weight or obese controls.

Negative urgency, the tendency to experience strong impulses under the influence of negative emotions, or to act rashly when distressed, is related to emotion regulation and impulsivity and has been associated with binge eating. [ 197 , 198 ] Negative urgency is a trait that is triggered by negative affect and may result in binge eating in vulnerable individuals. [ 199 , 200 , 201 , 202 , 203 , 204 ] Interestingly, negative urgency and affect seem to be more relevant than impulsivity, at least for some with binge eating. [ 205 ]  

Sensitivity to reward and punishment described in the reinforcement sensitivity theory (RST) provides a framework for how differences in brain systems' responsiveness to reward and punishment are reflected in individual personality. [ 206 , 207 ] Reward sensitivity influences decision making in eating disorders. [ 208 ] Sensitivity to reward was found elevated in BN and it has been hypothesized that an imbalance between reward sensitivity, impulsivity and inhibition are mechanistically involved in binge eating. [ 209 , 210 , 211 ] In addition, individuals with binge eating behaviors showed greater risk taking, and obese binge eating disorder has been associated with altered value computation and discrimination of salient stimuli. [ 212 ]

Taken together, emotion regulation, impulsivity, negative affect, negative urgency, and sensitivity to reward have been linked to binge eating and may create a vulnerability for developing or perpetuation BN behaviors. [ 213 ] However, we do not have a transdiagnostic model for their underlying neurobiology.

Neurocircuitry of emotion regulation, impulsiveness, and cognitive control in BN

A complex interplay exists between emotion regulation and cognitive control. Emotions affect attention, drive cognitive bias, and may interrupt proper decision making; on the other hand, attention to specific goals can control emotions and override strong feelings. [ 214 , 215 , 216 ] Control of food cravings is thought to involve prefrontal cortical areas, whereas greater caloric intake has been related to higher activation in gustatory cortex and brain regions for reward computation. [ 217 , 218 , 219 ] Little is known about how emotion regulation and cognitive control circuits affect binge eating. One study found reduced prefrontal cortical activity in BN when viewing food pictures. [ 220 ] BN showed hypoactivity in brain areas involved in self-regulation and impulse control, such as the prefrontal cortex or insula. [ 221 , 222 , 223 , 224 ] Only one study directly investigated negative affect in relation to binge eating in BN, finding a positive correlation between negative affect and striatal brain response during anticipation of a milkshake. [ 225 ] Altogether, studies suggest altered brain function related to emotion regulation in individuals with binge eating, but the literature is inconsistent.

Neurotransmitters and hormones

Animal models have shown that dopamine, serotonin, acetylcholine, and norepinephrine have all been associated with cognitive control and impulse control in frontal cortical circuits. [ 226 , 227 ] For instance, dopamine D2 and serotonin 2A and 2C receptor signaling can modulate impulsivity. [ 228 , 229 ] Human studies in BN found that serotonin 1A or dopamine D2/3 receptor binding correlated with harm avoidance or behavior inhibition. [ 230 , 231 ] Endocrine factors such as ghrelin, leptin, sex hormones, and cortisol can influence food intake behaviors, [ 232 ] but how they contribute to eating disorders is still elusive. [ 233 , 234 ] Basic research on the gut–brain axis showed how leptin or ghrelin activate brain stem and ventral striatum to activate dopamine circuits and motivation to eat. [ 231 , 234 ] Stress, via cortisol and gut hormone activation, leads to dopamine-mediated decreased food intake in animals, although in humans stress often leads to increased food intake, suggesting a different pathophysiology. [ 235 ] Dopamine drives motivation and food approach, while hedonic aspects of food intake (“liking”) are processed by opioids. [ 236 , 237 ] Those systems could be altered premorbidly as a vulnerability factor but also change in response to extremes of eating, which is an important part of our overall model of eating disorder pathophysiology. [ 238 ] Dopamine has a unique position. It is the only neurotransmitter that we have a mathematical understanding of neuronal function for, which can be used for computational modeling of brain function. Dopamine mediates reward learning [ 239 ] and has been implicated in the pathophysiology of taste and reward processing in eating disorders using the so-called prediction error model, which provides a very strong framework to study reward function in eating disorders. [ 240 , 241 , 242 , 243 , 244 ]

Although patients with bulimia nervosa (BN) are often unremarkable in general appearance and frequently have no signs of illness on physical examination, several characteristic findings may occur.

Physical findings may include the following:

• Bilateral parotid enlargement, largely consequent to noninflammatory stimulation of the salivary glands, may be seen. [ 65 ]  See parotid gland swelling in following image.

Parotid hypertrophy. Reprinted with permission from Mandel, L and Siamak, A. Diagnosing bulimia nervosa with parotid gland swelling. J Am Dent Assoc 2004, Vol 135, No 5, 613-616.

See the list below:

• In patients with significant self-induced vomiting, erosions of the lingual surface of the teeth, loss of enamel, periodontal disease, and extensive dental caries may be observed, as in the following image. [ 66 ]

Dental caries. Reprinted with permission from Wolcott, RB, Yager, J, Gordon, G. Dental sequelae to the binge-purge syndrome (bulimia): report of cases. JADA. 1984; 109:723-725.

• Russell sign (one of the few physical examination findings in psychiatry) manifests as callosities, scarring, and abrasions on the knuckles secondary to repeated self-induced vomiting. [ 67 ]

Russell sign. Reprinted with permission from Glorio R, et al. Prevalence of cutaneous manifestations in 200 patients with eating disorders. Int J Derm, 2000, 39(5), 348-353.

Other cutaneous manifestations can include telogen effluvium (sudden, diffuse hair loss), acne, xerosis (dry skin), nail dystrophy (degeneration), and scarring resulting from cutting, burning, and other self-induced trauma. [ 68 ]

Other nonspecific but suggestive findings that may reflect the severity of the disease include bradycardia or tachycardia, hypothermia, and hypotension (often associated with dehydration). Edema, particularly of the feet (and less commonly the hands), is found more often among patients with a history of diuretic abuse, laxative abuse, or both or in patients with significant protein malnourishment causing hypoalbuminemia.

Some patients may be clinically obese, but morbid obesity is rare. Patients with BN who are overweight may have excessive fat folds that favor humidity and maceration with bacterial and fungal overgrowth, striae due to skin overextension, stasis pigmentation related to peripheral vascular disease, and plantar hyperkeratosis due to increased weight. [ 68 ]

A community-based household survey involving 52,095 adults in 19 countries found, after adjustment for pertinent comorbidities, that the rate of BN among the 2580 identified cases of adult-onset diabetes mellitus was twice that of non-diabetic individuals. [ 69 ]

A typical Mental Status Examination for a patient with BN is detailed below. (The formal Folstein Mini-Mental Status Examination [MMSE] is usually unnecessary in the evaluation of patients with BN because symptoms of dementia and delirium are not common in these patients.)

Appearance: Patients are typically neat, well dressed, and show attention to detail. Grooming is often meticulous and may further demonstrate a patient's concern about personal appearance.

Behavior: Patients usually do not have kinetic abnormalities, but anxious feelings may heighten psychomotor agitation. Movements are spontaneous, and patients generally are cooperative and able to carry out requested tasks.

Cooperation: Patients generally avoid eye contact due to shame and embarrassment.

Mood and affect: Patients often demonstrate a depressed mood but may also have significant anxiety.

Speech: Content and articulation are generally normal.

Thought process: Patients likely have a linear thought process that is goal-directed.

Thought content: Thoughts tend to revolve around food and concerns regarding body image and weight.

Perceptual disturbances: Delusions and hallucinations are typically absent.

Suicidal ideation: Suicidal ideation is a significant consideration, especially in patients with depressed moo. Although suicidal ideation is often restricted to thoughts rather than concrete plans, suicidal thinking should be taken very seriously.

Homicidal ideations: Homicidal ideation is not typically associated with those diagnosed with BN.

Cognition: Patients are generally alert, and oriented to their surroundings. Attention and concentration typically measured by serial sevens and digit span are generally normal. Immediate memory is normal, as is recent and remote memory recall. Intellect is usually judged as normal, and in some cases, intellect ability may surpass average. Capacity to read and write is within normal limits. Visuospatial functions are also intact.

Judgment: Patients generally demonstrate poor judgment regarding self-care and treatment. Weight-reducing strategies such as induced vomiting, laxative, and diuretic ingestion are often perceived as legitimate and appropriate methods of weight management.

Insight: Insight regarding the presence and significance of disturbances is variable. While patients typically admit to episodes of binge eating, they often do not appreciate their inappropriate fixation on eating or their distorted ideas of body image and weight.

A national comorbidity study examined lifetime comorbidities of other psychiatric diagnoses in conjunction with bulimia nervosa (BN). [ 10 ] In general, the lifetime comorbidity of any psychiatric disorder is 94.5%.

Affective disorders

The common co-occurrence of eating disorders with affective disorders suggests a possible relationship between them. [ 49 ]   Major depressive disorder (MDD) is particularly common (approximately 50%) in this regard. Whether the association is causative (primary), secondary to the BN itself, or represents a common set of risk factors for BN and MDD is still unclear. Depressive symptoms can occur during pregnancy and postpartum in women with BN. [ 50 ]  Bipolar II disorder also appears to be more common in patients with BN than in patients without eating disorders. The lifetime comorbidity for bipolar I or II is 17.7%.

Anxiety disorders

Obsessive-compulsive disorder (OCD) is more common in persons with BN (17.4% lifetime comorbidity) than in controls. Panic disorder , social phobia , specific phobias , generalized anxiety disorder (GAD), and posttraumatic stress disorder (PTSD) significantly contribute to comorbidity. Lifetime comorbidities have been reported at approximately 17.4% for OCD, 16.2% for panic disorder, 41.3% for social phobia, 50.1% for specific phobias, 11.8% for GAD, and 45.4% for PTSD.

One study suggests that baseline clinical predictors such as female gender and family history of eating disorders might be specific to the later development of eating disorders in the context of childhood OCD. [ 51 ]

Substance use disorders

Some evidence suggested a relationship between disorders of substance abuse and dependence and BN, including alcohol dependence, [ 52 ]  nicotine dependence, [ 53 ]  and drug dependence. [ 54 ]  For example, with regard to smoking in healthy controls, there were significantly more smokers among people with bulimia (lifetime OR = 2.165) and BED (lifetime OR = 1.792), but not for those with AN (lifetime OR = 0.927). Studies on caffeine intake are mixed. [ 55 ]  Alcohol abuse or dependence has a lifetime comorbidity with BN of 33.7%, whereas illicit drug abuse or dependence has a lifetime comorbidity of 26%.

Impulse control disorders

In a study of lifetime prevalence of impulse control disorders in patients with BN, compulsive buying, and intermittent explosive disorder were the most frequently reported disorders, at 17.6% and 13.2%, respectively. Higher than expected rates of kleptomania, pathological gambling, and trichotillomania have also been reported in patients with BN. [ 56 ]

Attention deficit hyperactivity disorder (ADHD)

ADHD may be associated with BN. [ 57 ]  In one study of more than 2000 female inpatients treated for BN, 9% were also diagnosed with ADHD. The average rate of ADHD in the general population of young women is approximately 3.4%. [ 58 ]  Lifetime comorbidity with ADHD and BN has been reported to be as high as 34.9%.

Other psychopathology

The role of sexual abuse in the development of eating disorders is controversial. [ 59 ]  Some reports suggest a strong association, while others detect no increased association. Borderline personality disorder is found frequently. [ 60 ]  These patients usually have histories of trauma and abuse and may represent a distinct subgroup. Pathologic narcissism [ 61 ]  and identity impairment [ 62 ]  may be present. Features of obsessive-compulsive personality disorder (OCPD), particularly perfectionism, may be increased among patients with BN.

Suicidal behavior

BN is associated with increased risk of suicide attempts and suicidal ideations. [ 63 ]  In one study, all-cause mortality rate for BN was 3.9%, higher than other studies reported in the past. [ 64 ]  However, the standardized mortality ratio with respect to suicide was 6.51, a much higher than expected rate.

Psychiatric complications

Studies suggest that patients with bulimia nervosa (BN) have increased rates of major depressive disorder, substance abuse, anxiety disorders, bipolar II disorder, and sexual abuse; these conditions should be considered and managed as necessary. Mortality and morbidity associated with depression (suicidal thoughts or self-injury) and poor impulse control (eg, substance abuse, sexually transmitted diseases, unintended pregnancy, accidental injuries) should always be anticipated and assessed. Patients with BN who are depressed and who have concurrent alcohol dependence are at exceptionally high risk of suicide, particularly those who overexercise. Studies have shown that in people with eating disorders, excessive exercise appears to be linked to an increased prevalence of acquired capability for suicide (ACS) and suicide attempts. [ 75 , 76 ]

Medical complications

The all-cause mortality rate for BN per se is slightly lower than for anorexia nervosa (AN) (3.9% vs 4.0%, respectively). [ 64 ]  Medical complications do arise and should be assessed carefully.

While the results of formal gastric emptying studies in patients with BN have yielded variable results (some suggesting delayed emptying time and others suggesting normal emptying time), acute gastric dilatation is a rare but concerning risk. This complication may result in gastric rupture, which may be fatal.

Among other rare potential complications are Mallory-Weiss tears of the esophagus, esophageal rupture, reflux esophagitis, and cardiomyopathies secondary to ipecac use.

Ipecac toxicity may be associated with skeletal myopathy, while chronic hypokalemia may also be associated with intestinal ileus, abdominal distension, exertional rhabdomyolysis, or both.

Hypokalemia-related distal renal tubulopathy is very rarely associated with BN.

Xerosis (dry skin) is a common finding in bulimia nervosa, which appears to be related to the chronic dehydration to which persons with BN are often prone.

Skin health usually requires an overall healthy nutritional status. Dermatological treatment is ordinarily topical.

Patients who chronically overuse and abuse laxatives risk chronic constipation, cathartic colon with pseudo-Hirschsprung syndrome, melanosis coli with increased risk for colon cancer, steatorrhea, and/or protein-losing enteropathy and metabolic consequences of hypophosphatemia and hypomagnesemia.

Other potential complications include osteopenia or osteoporosis, menstrual irregularity and infertility, and, less commonly, cognitive changes associated with dehydration and electrolyte and metabolic abnormalities.

A 21-year-old woman is brought into an outpatient clinic by her mother, who complains that her daughter has been demonstrating unusual eating patterns since she moved back home 6 months ago. Her mother observes her to eat large amounts of food, such as desserts, when she is alone, often finding food wrappers hidden in her daughter’s room. She is worried that her daughter may be engaging in vomiting after these episodes of heavy eating. She often isolates herself in the bathroom for 10–20 minutes after a large meal.

When the patient was asked about her eating habits, she admitted to a “loss of control.” She described feeling deep remorse when she eats more than she would like. Furthermore, she described feeling so laden with guilt about her eating binges that she purposefully induces vomiting at least once every other day. This act gives her tremendous relief. She admits that she is unhappy with her overall appearance and feels that she is “fat” and “out of shape.” She is preoccupied with her appearance and says that she compares herself to other women “all day long.” She also admits to feeling sad most days. She endorses experiencing occasional missed menstrual periods, low libido, low energy, and intermittent sore throat.

Historically, the patient has memories of a chaotic childhood. She is an only child whose parents fought often and finally divorced when she was 9 years old. The patient remembers the first time she induced vomiting at 10 years old, after she felt “too full after a large meal.” The mother describes her daughter as having few friends and as tending to isolate herself. However, the mother describes her as very bright; in fact, she was valedictorian of her high school.

On physical examination, the patient’s blood pressure is 90/60, heart rate is 100, and BMI is 19. Her oropharynx appears injected without areas of erosion, and multiple dental caries are seen. Bilateral parotid enlargement with minor tenderness is present. The patient is tachycardic and bowel sounds are hyperactive. The abdomen is soft, nontender, and nondistended. Skin turgor is poor.

On mental status examination, the patient presents as a young White woman with average body habitus and pale skin. She is meticulously dressed and groomed. She answers questions curtly, makes poor eye contact, and demonstrates mild foot tapping throughout the interview. Her mood is anxious, and her affect is mood congruent but restricted to negative emotionality. She is highly articulate. Thought process is linear and goal directed. Methodical about her statements, she often takes time to clarify what she “really means.”

Thought content displays themes of shame and self-reproach, [ 33 ] though it is unclear whether shame is a risk factor for the development of the eating problems or a consequence of these difficulties; while guilt may be present, its role is unclear. No active delusions or hallucinations are present. Her cognition is grossly intact. She denies suicidal thoughts, but sometimes wishes she was “invisible.” She has no violent or homicidal thoughts. Insight is limited regarding her ability to acknowledge her psychiatric illness. Her judgment is impaired considering her inability to recognize the potential negative health consequences of her eating behaviors.

Prior to entering the clinic, laboratory assessment obtained at the suggestion of the patient's primary care doctor reveals a serum potassium level of 3.8 Meq/L and serum amylase level of 140 Units/L.

Take-home points

• The differential diagnosis of BN includes depression, anxiety and age-appropriate developmental problems (eg, lack of esteem). These issues are common comorbidities.
• A biopsychosocial treatment plan will be necessary to provide the patient with the care she needs.
• Developing a treatment team and collaboration with primary care providers and psychotherapist is often necessary for the short term and sometimes for the long term.

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• Parotid hypertrophy. Reprinted with permission [Mandel L, Siamak A. Diagnosing bulimia nervosa with parotid gland swelling. J Am Dent Assoc. 2004 May;135 (5):613-16.]
• Dental caries. Reprinted with permission [Wolcott RB, Yager J, Gordon G. Dental sequelae to the binge-purge syndrome (bulimia): report of cases. J Am Dent Assoc. 1984 Nov;109(5):723-25.].
• Russell sign. Reprinted with permission [Glorio R, Allevato M, De Pablo A, et al. Prevalence of cutaneous manifestations in 200 patients with eating disorders. Int J Derm. 2001 Dec;39(5):348-53.].
• This chest radiograph demonstrates pneumomediastinum, which can occur in association with esophageal rupture from forceful vomiting.
• Water-soluble contrast esophagram from a patient with esophageal perforation after esophageal dilation shows contrast leak (arrowheads) and normal esophageal lumen (arrows).
• Mallory-Weiss tear. Typical longitudinal mucosal tear with overlying fibrinous exudate extending from the distal esophagus to the gastric cardia. Courtesy of Christopher J Gostout, MD.

Contributor Information and Disclosures

Guido Klaus Wilhelm Frank, MD Professor, Department of Psychiatry, University of California, San Diego, School of Medicine; Director of Psychiatry, Medical Behavioral Unit, Rady Children’s Hospital-San Diego Guido Klaus Wilhelm Frank, MD is a member of the following medical societies: Academy for Eating Disorders, American Academy of Child and Adolescent Psychiatry , American College of Neuropsychopharmacology , Eating Disorders Research Society, German Medical Association , Society of Biological Psychiatry Disclosure: Nothing to disclose.

Lisa D Adler, MD Assistant Professor of Clinical Health Sciences, Department of Psychiatry, University of California San Diego Health Sciences, UCSD Eating Disorder Center for Treatment and Research, Medical Behavioral Unit, Rady Children’s Hospital Lisa D Adler, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape.

David Bienenfeld, MD Professor, Departments of Psychiatry and Geriatric Medicine, Wright State University, Boonshoft School of Medicine David Bienenfeld, MD is a member of the following medical societies: American Medical Association , American Psychiatric Association , Association for Academic Psychiatry Disclosure: Nothing to disclose.

Donald M Hilty, MD, MBA Associate Chief of Staff, Mental Health, Northern California VA Healthcare System; Professor of Psychiatry, Department of Psychiatry and Behavioral Sciences, University of California, Davis, School of Medicine Donald M Hilty, MD, MBA is a member of the following medical societies: American Association for Technology in Psychiatry , American Psychiatric Association , American Telemedicine Association , Association for Academic Psychiatry Disclosure: Nothing to disclose.

Christine I Osterhout, MD Resident Physician, Department of Psychiatry and Behavioral Sciences, University of California, Davis Health System Christine I Osterhout, MD is a member of the following medical societies: Alpha Omega Alpha , American Academy of Child and Adolescent Psychiatry , American Academy of Psychiatry and the Law , American Medical Association , American Psychiatric Association Disclosure: Nothing to disclose.

Lorin M Scher, MD, FACLP Clinical Professor of Psychiatry and Behavioral Sciences, Vice-Chair for Education, Roy T Brophy Endowed Chair, Director, Integrated Behavioral Health Services, Medical Director, Government and Community Relations, UC Davis Health Lorin M Scher, MD, FACLP is a member of the following medical societies: Academy of Consultation-Liaison Psychiatry, Alpha Omega Alpha , American Medical Association , American Psychiatric Association , Association of Directors of Medical Student Education in Psychiatry, California Medical Association , Central California Psychiatric Society, Sierra Sacramento Valley Medical Society Disclosure: Nothing to disclose.

Joel Yager, MD Professor of Psychiatry, University of Colorado Health Sciences Center; Professor of Psychiatry Emeritus, University of California, Los Angeles, David Geffen School of Medicine; Professor of Psychiatry Emeritus, University of New Mexico School of Medicine Joel Yager, MD is a member of the following medical societies: Alpha Omega Alpha , American Association for the Advancement of Science , American Medical Association , American Psychiatric Association , Association for Academic Psychiatry Disclosure: Nothing to disclose.

Gagandeep Randhawa, MBBS Resident Physician, Department of Psychiatry, Kaweah Delta Medical Center, University of California, Irvine, School of Medicine Gagandeep Randhawa, MBBS is a member of the following medical societies: American Psychiatric Association , Indian Doctors for Peace and Development Disclosure: Nothing to disclose.

Robert C Daly, MB, ChB, MPH Senior Fellow, Department of Behavioral Endocrinology, National Institute of Mental Health, National Institutes of Health

Disclosure: Nothing to disclose.

Raj K Kalapatapu, MD Fellow, Addiction Psychiatry, Columbia University College of Physicians and Surgeons

Raj K Kalapatapu is a member of the following medical societies: American Academy of Addiction Psychiatry, American Academy of Child and Adolescent Psychiatry, American Association for Geriatric Psychiatry, American Medical Association, and American Psychiatric Association.

Gabriel I Uwaifo, MD Associate Professor, Section of Endocrinology, Diabetes and Metabolism, Louisiana State University School of Medicine in New Orleans; Adjunct Professor, Joint Program on Diabetes, Endocrinology and Metabolism, Pennington Biomedical Research Center in Baton Rouge

Gabriel I Uwaifo, MD is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians-American Society of Internal Medicine, American Diabetes Association, American Medical Association, American Society of Hypertension, and The Endocrine Society

Kelda Harris Walsh, MD Assistant Professor of Clinical Psychiatry, Section of Child and Adolescent Psychiatry, Department of Psychiatry, Indiana University School of Medicine; Chief, Obsessive-Compulsive/Tourette/Anxiety Disorders Clinic, Riley Hospital for Children

Acknowledgments

The authors would also like to acknowledge the contributions of Rebecca Davis, Librarian at the University of California (UC), Davis and Dr. Eric Rickin, Director for the Center for Overcoming Problem Eating (COPE) at the Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center. Finally, the authors thank the Department of Psychiatry and Behavioral Sciences at UC Davis.

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Case Study of Bulimia Nervosa (BN)

• By : Maggie Molloy

Bulimia Nervosa is an eating disorder characterized by binge eating followed by purging. Binge eating refers to eating a large amount of food in a short amount of time.  Purging refers to the attempts to get rid of the food consumed.  Bulimia means to ‘eat like an ox’, although people have been known to ‘eat like an ox‘ from antiquity, it was not until 1979 that a London psychiatrist, Gerald Russell, identified 40% of his Anorexia Nervosa patients with an ‘ominous variation’ of the disorder – the variation being that they from time to time went on binges.

In this case study I sought to give an insight into Cognitive Behavioural Therapy (CBT) treatment for Bulimia Nervosa (BN).  It was important to back up my assessment in the first session with a G.P report which contained Complete  blood count;

Chem-20 panel which measures electrolytes, vitamins, liver and pancreatic function, adrenal glands, (levels of cortisol and adrenaline produced in times of stress);

Thyroid and parathyroid pane l which indicates level of metabolic functions.

**Ask permission from your client to get the report.

Suitability for treatment was formally measured using the Safron and Segal (1990) Suitability for Short–term Cognitive Therapy Rating Scale. (aspects of the cognitive therapy process are rated on a scale of 0-5).  High Rating indicate a good prognosis and low ratings indicate a poor one.

Client History

Jessica (pseudonym) aged 22 presented to the centre with a four-year history of binge eating, vomiting and laxative use.  Jessica stated that at the age of 18, following the break-up of a one-year relationship with her boyfriend (she did not want to become intimate with him). She had begun to eat excessively at times (comfort eating) as a way of coping with the heartache it caused.

Jessica put on some extra weight, approximately 4 kg over the course of a few months and  was very upset when she discovered that some of her outfits were not fitting her, especially in the run up to a summer holiday.

Jessica had known about people vomiting as a means of weight control and recalled some of her school friends telling her it was a handy way not to put on weight.  However, she had never really considered doing this herself, as she thought it was a ‘disgusting thing to do’.

She stated that one evening after a particularly large bout of over eating, she felt very uncomfortable and thought that if she could only vomit it would at least relieve the discomfort. Using her forefinger, she stuck it down the back of her throat and began vomiting.

Afterwards she felt unwell, her throat was raw and her stomach sore, but she admitted feeling some relief from the feeling of guilt and regret of having eaten too much. She vowed at the time never to do it again. A few evenings later after a night out with friends and having consumed ‘a few too many‘ alcoholic beverages she engaged in what she described as a ‘feeding frenzy ‘, eating almost anything she could get her hands on in the fridge and cupboard.

It seemed easier to vomit this time and the next day she bought a packet of laxatives, to clear out the system, taking 3 times the recommended dose.

Jessica tried starving herself over the next few days, feeling determined to try and get her weight under control and start a ‘new chapter in her life’. This lasted until day 3 when weak with hunger and coming home from a late night at work, she could not resist the temptation to stop off at a local Chinese restaurant as she passed by it. They had a buffet–style service that meant she could keep going back up to eat whatever she wanted. Having left feeling stuffed and very guilty, vomiting seemed the obvious option and laxatives were used the following day.

Over the course of the next few months a pattern developed whereby she would attempt any and every new diet, she lasted 2 to 4 days and this would end up in bingeing and purging behaviour.

Jessica Weight was 9st-8lbs and her Height was 5ft-3ins

None of Jessica’s family or friends were aware of her difficulties, although they know she was constantly dieting.  Jessica felt very unhappy with life, the thought of suicide had occasionally crossed her mind but it always occurred after a night out drinking followed by a binge and purging episode.  Jessica was taking 40 mg of Fluoxetine (Prozac) when she attended therapy.

Personal background

Jessica was raised the eldest the eldest of 5 children.  She had 1 sister and 3  brothers, her parents divorced when she was aged 16 yrs, mainly due to her father’s drinking.

Jessica felt close to her Mum who had a history of been treated for depression by her G.P.

Jessica disclosed that from the age of 12 to 14 she was sexually abused by a neighbour, she never told her parents until she reached the age of sixteen after they moved back to Ireland.  Leaving school at sixteen she managed to secure employment in a marketing company and had worked her way up the firm, taking  several professional examinations along the way.

The main DSM-V criteria for Bulimia Nervosa that Jessica was displaying were as follows;

• Eating a large amount of food with a short space of time
• Bingeing three to four times per week
•  She also experiences a sense of lack of control over eating, a feeling that she cannot stop.
• She was taking laxatives at least twice a week
• Over-evaluation or concern about shape, weight and appearance
• Secretive behaviour
• Vomiting three to four times per week
• Co-morbidity features – depression, alcohol misuse

CBT Treatment

Phase 1: Sessions 1 to 4

Establishing a sound therapeutic relationship.  Setting treatment goals, setting homework.  Explaining the CBT model of Bulimia Nervosa, including discussing predisposing, precipitating and perpetuating factors which resulted in an initial formulation been established.  Motivation for Change (Pros and Cons of changing)

Psychoeducation, educating Jessica on the adverse consequences of bingeing and purging behaviour and explained the blood sugar imbalance, glycemic index (GI), foods that have high and low GI and how neurotransmitters influence hunger and mood.

Explaining the importance of introducing a regular eating pattern of 3 meals and 2 snacks/day (gave her a detailed specific food dairy).  Disrupting the vicious cycle of bingeing and purging behaviour, noting particular triggers.  Identifying the connection between thoughts, feelings and behaviour within the context of the Eating Disorder.

Phase 2: Sessions 5 to 15

This phase is at the heart of therapy for Jessica.  It involved addressing the maintaining factors listed below:

• Negative Body Image
• Cognitive Distortions
• Feelings, (regret, guilt, low mood, shame etc.)
• Lifestyle activities, Self –Esteem
• Physiology (blood sugar, stimulants)
• Relationships
• Food Scripts
• Addictive Process (bingeing/purging alcohol misuse)

Interventions and homework worksheets in treating the above was carried out in the sessions.

Phase 3 (Final):  Sessions 16 -19

Relapse Management Skills discussed.

• What made her vulnerable to developing the problem in the first place?
• What has she learned in Treatment?
• What areas leave her vulnerable?
• What strategies can undermine these vulnerabilities?
• Dealing with a setback
• What are her personal strengths?

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Psychological Intervention in a Case of Bulimia Nervosa: A Case Report

• Published: 20 February 2014
• Volume 59 , pages 68–75, ( 2014 )

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• Paakhi Srivastava 1 ,
• Piyali Mandal 1 ,
• Manju Mehta 1 &
• Rajesh Sagar 1  

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This paper presents a case report detailing the use of an enhanced form of enhanced cognitive behavior therapy (CBT) and other techniques that were employed when faced with impediments in adhering to manualized CBT-E. Ms. S, 22 years old unmarried female pursuing MBBS final year, belonging to upper middle socioeconomic status and urban domicile was provided with 28 weekly sessions of psychotherapy to simultaneously address the patient’s symptoms and try to effect change across multiple domains. A single case design was adopted. Therapy was conducted over 9 months. A total of 28 sessions were taken, with the frequency of two sessions/week initially, and then moving onto one session/week. Pre and Post assessments using Binge Eating Scale, BDI-II, height and weight measurements and frequency of binging episodes using visual analogue scale were done. On measures of pre and post assessment there was 87 % improvement in Binging Episodes, 82 % improvement on Binge Eating Scale and client had 3 kg weight gain with reduction in depression as assessed on BDI-II. The gains were maintained at 1 month follow up. The use and deviations from CBT E, therapy process, role of family and challenges to intervention will be discussed in this case report.

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Acknowledgments

It has been an invaluable learning experience for the therapist to understand phenomenology of eating disorders, role of family and the process of therapy including preparation of this manuscript.

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Paakhi Srivastava, Piyali Mandal, Manju Mehta & Rajesh Sagar

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Srivastava, P., Mandal, P., Mehta, M. et al. Psychological Intervention in a Case of Bulimia Nervosa: A Case Report. Psychol Stud 59 , 68–75 (2014). https://doi.org/10.1007/s12646-014-0242-1

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Name : Shelly Hunter Source : Hunger Point (movie, 2003)

Background Information

Shelly Hunter is a Caucasian female currently in high school. Although her age is unknown, she is presumed to be a teenager. A first look at Hunter gives evidential proof that she is seriously underweight. This raises serious concerns about her health. Hunter lives at home with her domineering mother, Marsha, and David, her passive father. She is the younger sister of Frannie, who is away at college and also struggles with eating. Shelly has a very strenuous relationship with her mother. As a child Hunter was always very slender, but she grew up listening to her mother lecture Frannie, who was not as slender, on the importance’s of being slim. Mrs. Hunter’s obsessive belief that being slender is the most important thing has severely distorted Hunter’s views on eating. Hunter clearly seeks approval from her mother and puts great strains on her body to reach that approval. Hunter’s life is devoted to her weight. Her time is spent obsessing about being slender. She does not know how to cope with her eating disorder and her irrational views on being skinny. The eating disorder is also causing severe mental problems with Hunter. She is exhibiting signs of depression and distrust from her family.

Description of the Problem

Hunter displays the symptoms of an eating disorder. She is abnormally underweight for her age and is very unhealthy. She exhibits the characteristics of Bulimia Nervosa. She eats very little when she is in the presence of other people. Most undoubtedly when she is eating in front of her mother, she becomes very self conscious about what and how much she eats. After restraining from food intake for a period of time she then will over eat. She stuffs herself with large portions of food. After doing so she begins to feel shame and guilt for over eating. The way she deals with her guilt is to self- induce vomiting. This purging is a defense mechanism Hunter uses to cope with “disappointing” herself as well as her mother. Although it only lasts for a short while, she feels satisfied with her body after vomiting.

The diagnosis for Hunter appropriately fits Bulimia Nervosa (307.51).

To be diagnosed with Bulimia Nervosa one or more or a combination of the following characteristics must be present:

1. Eating in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances; it is common for more than 10,000 calories to be consumed per binge. 2. An abnormal constant craving for food; a sense of a lack of control of eating during an episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating). 3. Eating is usually done in secret.

Hunter displays the characteristics of 1 and 3. As described in the “Description of the Problem” she eats large portions of food alone. B. Recurrent inappropriate, compensatory behavior in order to prevent weight gain. Such as self-induced vomiting, misuse of laxatives, diuretics, enemas, or other medications, fasting, or excessive exercise.

Hunter exhibits these compensatory behaviors in order to prevent weight gain. She fasts for a long period of time. She then will binge eat and self-induce vomiting. C. The binge eating and inappropriate compensatory behaviors both occur on average at least twice a week for three months.

Hunter began binge eating at a very young age and continues to binge eat into her high school years. D. Self-evaluation is unduly influenced by body shape and weight. Hunter has a very unhealthy view about her body. She is constantly concerned with gaining weight. Even though she looks too slender and unhealthy to others, she views herself as overweight. E. The disturbance does not occur exclusively during episodes of Anorexia Nervosa.

Hunter will eat very little for a short period of time, and then she will binge eat to self-induce vomiting.

Accuracy of Portrayal

The average person watching this movie would see an accurate portrayal of the behavioral characteristics of Bulimia Nervosa. Hunter displays the onset characteristics of someone suffering from this disorder. Someone watching this movie would learn that having an eating disorder can cause many other problems. Hunter became very untrusting and displayed signs of depression. Bulimia Nervosa took control over Hunter’s life and began to affect her mentally. Therefore, the movie Hunger Point portrays an accurate depiction of Bulimia Nervosa.

After fully examining Hunter it might be best to start her on some medications. To help with depression Tricyclic antidepressants or Selective Serotonin Re-Uptake Inhibitors (SSRI’s) could be prescribed to elevate her mood. Vitamin and mineral supplements would be prescribed until signs of deficiency disappeared and normal eating patterns were reestablished. The vitamins would also help to treat acid reflux caused by bulimia. After Hunter’s weight becomes stabilized it would be a good idea to start a behavioral therapy program. This will help to change the mindset of Hunter and her negative views about her body. This will also help to control her binge eating habits. Not only does Hunter need individual therapy, but she and her mother need family therapy. Mrs. Hunter needs therapy in order to understand that her obsessive beliefs, about being slender, caused her daughter to become diagnosed with bulimia nervosa. Communication exercises will be exhibited to help resolve conflict and re-establishing boundaries. The treatments will better help Hunter to have control over Bulimia Nervosa and to gradually overcome the disorder.

A YouTube element has been excluded from this version of the text. You can view it online here: http://pb.libretexts.org/apsy/?p=174

Name : Blair Waldorf

Source : Gossip Girl (television series, 2007-present)

Blair Waldorf is a 16 year old female who lives in Manhattan, New York. She is a full time student, and attends a private high school. She is in good health, and her family is in good mental health. Her parents are divorced, mother in Manhattan and father in Paris. She has a great relationship with her father, but he left his family for a male model, so Blair suffers slightly with separation anxiety and depression. Her mother has very high status in Manhattan, and would do anything to keep it that way. Blair and her mother get into arguments every now and then, but no more than a normal teen and her mother. Blair is an only child. Serena is Blair’s best friend and has been since they were little. Blair is snobbier of the two, and Serena keeps her grounded without going overboard. They often get into tiffs, but always end up making up. Blair’s ex-boyfriend is Nate. They dated from age 5 until 16. Dealing with the breakup of her longtime lover, Blair goes a little crazy and her separation anxiety and depression shows up again. Blair drinks often, and for some reason in the world that she lives in, adults do not seem to care. She could walk into a bar and drink martinis all night, and it would be completely normal. She does not do drugs, however. Her biggest life difficulty is staying queen bee at her high school. She goes through a lot throughout the show, but staying the most popular girl in school is always her top priority. Her number one goal is to attend Yale after she graduates, and later become a trophy wife just like her mother was. Blair copes with her problems by putting other people down. She loves the fact that she is at the top of the totem pole, and she is not afraid to let anyone and everyone know it. She also often uses alcohol to cope with her problems.

During the first season of Gossip Girl, the fact that Blair had been to treatment in her past comes up a few times. Blair’s eating habits are normal for the first few episodes, but after she experiences different stressors, her eating habits become abnormal again. She starts to pick at food most of the time, but binges at other times. Also, her best friend Serena and her mother started to bring up the fact that her symptoms were returning. She completely closed them off and ignored the fact that they were. Every time that she would get into a fight with Serena, her ex boyfriend, or her mother, her lack of control for eating would return. One incident that was shown on the show was that Blair had gotten into a huge fight with Serena on Thanksgiving, which caused Blair to be extremely snappy with her mother. She found out that her mother lied to her about her father coming into town for the holiday, which caused a fight with her mother as well. She was picking at her Thanksgiving meal during dinner, and when her mother told her to go pick out a dessert, she stormed off to the kitchen. She found an apple pie that she wanted to eat, but instead of just taking one piece, she stared at it for a few minutes, and binged and ate the entire pie. Immediately, she went into her bathroom and started to purposely vomit. She has always had an issue with her self-image, and the binging and purging was her solution to make herself feel better. After vomiting in her bathroom, she called Serena, and she quickly came over and let Blair cry on her shoulder. This is not the only incident that Blair had with binging and purging, but it was a very critical event to Blair’s illness.

The diagnosis for Blair Waldorf fits most appropriately with Bulimia Nervosa (307.51). To be diagnosed with Bulimia Nervosa, you must have the following characteristics:

• Eating in a discrete period of time (e.g., within any 2-hour period), an amount of food that is larger than most people would eat during a similar period of time and under similar circumstances.
• A sense of lack of control of eating during an episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).

Blair Waldorf displays both of these characteristics. When she has an episode, it is as if she cannot control what food she is putting into her body, or how much food she is putting into her body.

• Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise.

Blair Waldorf will do whatever she thinks is necessary to prevent weight gain, and her methods of choice are self-induced vomiting and fasting.

• The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for three months.

The television show does not state what age Blair Waldorf started binge eating, but while she was only 16 years old, her mother discussed Blair already having gone to treatment for her Bulimia. So this must have been a problem in her life for quite a few years.

• Self-evaluation is unduly influenced by body shape and weight.

Blair Waldorf is very self conscious of her body image and her weight. Her mother mentions a few times that she needs to watch her weight, so this may have helped lead to Blair’s body image issues.

• The disturbance does not occur exclusively during episodes of anorexia nervosa.

Blair Waldorf will eat a very small amount and continue to pick at food at every meal, until another episode of binging and purging occurs.

The average person watching Gossip Girl and watching Blair with her eating disorder would learn the behavioral characteristics of Bulimia Nervosa. Someone watching this television show would understand that it is a disorder that a person cannot necessarily always control. There can be triggers that can lead to an episode, just like any other illness. This portrayal is accurate of Bulimia Nervosa. However, the show does not show the seriousness as much as it should of this disorder. It was mislabeled in this way because it has affected Blair’s mental health, so any issue in her life that leads to her showing any signs of depression will most likely lead to an episode. This is her way of dealing with problems in her life, and Gossip Girl does not show the severity of this.

After evaluating Blair Waldorf’s condition, it would be best to start her with a behavioral therapy program. She was not taught the proper way to handle her emotions and deal with problems that arise in her life, and therapy would help approach these issues. Therapy could also approach her body image issues, and help her to devise an exercise program that would make her feel more in shape and healthy. Her mother and her friends would have to help monitor her eating habits, but after understanding her condition fully and seeing that there are other ways of dealing with issues, Blair would take on a better eating schedule. Also, putting Blair on a very low dosage antidepressant or Selective Serotonin Re-Uptake Inhibitors (SSRI’s) and monitoring her progress very closely while on this medication would help a great deal. Communication exercises will also be necessary between Blair and her mother to teach them how to discuss this illness in a healthier manner. These different treatments will, in time, help Blair overcome this disorder. She will be able to talk about her feelings and problems, rather than regressing to binging and purging.

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Retrospective Correlates for Bulimia Nervosa: A Matched Case-Control Study

Affiliations.

• 1 Psychotherapy and Psychopathology Research Unit - CIPsi, School of Psychology, University of Minho, Braga, Portugal.
• 2 Centre for Studies in Human Development, Faculty of Education and Psychology, Catholic University of Portugal, Porto, Portugal.
• 3 Parnassia Psychiatric Institute, The Hague, the Netherlands.
• 4 Department of Epidemiology, Columbia University, New York, NY, USA.
• 5 Department of Psychiatry, University of Groningen, Groningen, the Netherlands.
• PMID: 26841218
• DOI: 10.1002/erv.2434

Objective: There have been few studies investigating the risk factors for bulimia nervosa (BN), and most have been in Anglo-Saxon countries. This study aimed to (i) replicate the uncontested retrospective correlates for BN and clarify the role of factors with inconsistent findings and (ii) evaluate the strength of these factors in a different culture.

Method: A case-control design was used to compare 60 women who met the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for BN to 60 healthy controls and 60 participants with other psychiatric disorders. Retrospective correlates were assessed by interviewing each person with the Oxford Risk Factor Interview.

Results: The primary retrospective correlates identified from the comparison of BN participants to healthy controls were general high maternal expectations, negative attitudes about parental weight and obesity in childhood and adolescence. Compared with participants with other psychiatric disorders, those with BN also reported higher rates of childhood obesity, deliberate self-harm, family conflicts, general high maternal expectations and feeling fat in childhood.

Conclusions: The common findings across cultures suggest that, at least, individuals subjectively experience a number of similar factors that increase risk for developing BN. In addition, the difference regarding self-harm is notable.

Keywords: bulimia nervosa; risk factors.

Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.

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• Self-injurious behavior and attempted suicide in purging bulimia nervosa: associations with psychiatric comorbidity. Favaro A, Santonastaso P, Monteleone P, Bellodi L, Mauri M, Rotondo A, Erzegovesi S, Maj M. Favaro A, et al. J Affect Disord. 2008 Jan;105(1-3):285-9. doi: 10.1016/j.jad.2007.05.010. Epub 2007 Jun 12. J Affect Disord. 2008. PMID: 17568684
• Bulimia symptoms and anger and aggression among adolescents. Koposov R, Stickley A, Sukhodolsky D, Ruchkin V. Koposov R, et al. BMC Public Health. 2023 May 5;23(1):833. doi: 10.1186/s12889-023-15664-1. BMC Public Health. 2023. PMID: 37147644 Free PMC article.
• Body Image Perception in High School Students: The Relationship with Gender, Weight Status, and Physical Activity. Toselli S, Zaccagni L, Rinaldo N, Mauro M, Grigoletto A, Maietta Latessa P, Marini S. Toselli S, et al. Children (Basel). 2023 Jan 10;10(1):137. doi: 10.3390/children10010137. Children (Basel). 2023. PMID: 36670687 Free PMC article.
• Risk factors for eating disorders: findings from a rapid review. Barakat S, McLean SA, Bryant E, Le A, Marks P; National Eating Disorder Research Consortium; Touyz S, Maguire S. Barakat S, et al. J Eat Disord. 2023 Jan 17;11(1):8. doi: 10.1186/s40337-022-00717-4. J Eat Disord. 2023. PMID: 36650572 Free PMC article. Review.
• Biological, psychological and familial specific correlates in eating disorders at onset: a control-case study protocol (ANOBAS). Sepúlveda AR, Moreno-Encinas A, Nova E, Gómez-Martínez S, Marcos A, Carrobles JA, Graell M. Sepúlveda AR, et al. Actas Esp Psiquiatr. 2022 Mar;50(2):92-105. Epub 2022 Mar 1. Actas Esp Psiquiatr. 2022. PMID: 35312995 Free PMC article.
• Toward a Biological, Psychological and Familial Approach of Eating Disorders at Onset: Case-Control ANOBAS Study. Sepúlveda AR, Moreno-Encinas A, Martínez-Huertas JA, Anastasiadou D, Nova E, Marcos A, Gómez-Martínez S, Villa-Asensi JR, Mollejo E, Graell M. Sepúlveda AR, et al. Front Psychol. 2021 Sep 9;12:714414. doi: 10.3389/fpsyg.2021.714414. eCollection 2021. Front Psychol. 2021. PMID: 34566794 Free PMC article.
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Bulimia Nervosa: A Primary Care Review

Bulimia nervosa is a psychiatric condition that affects many adolescent and young adult women. The disorder is characterized by bingeing and purging behavior and can lead to medical complications. Thus, patients with bulimia nervosa commonly present in the primary care setting. Physical and laboratory examinations reveal markers of bulimia nervosa that are useful in making the diagnosis. Treatment is beneficial, and outcomes of early intervention are good. This article discusses the history, presentation, and tools needed for recognizing and treating bulimia nervosa in primary care.

In the United States, eating disorders affect 5 to 10 million people, primarily young women between the ages of 14 and 40 years. 1 Much attention has been paid to the identification and treatment of anorexia nervosa in this age group. 2, 3 However, bulimia nervosa is a more prevalent disorder that is more difficult to identify in the primary care setting. It is imperative that primary care physicians are aware of the presentation and subsequent interventions available to treat patients with bulimia nervosa, considering the relatively silent presentation of the disease. In this article, we provide an overview of bulimia nervosa, associated physical and laboratory examination findings, and diagnostic strategies pertinent to primary care practice.

Bulimia nervosa was described as an ominous variant of anorexia nervosa by Russell in 1979. 4 However, as more research has been conducted and more patients suffering from bulimia nervosa have been identified, bulimia nervosa and anorexia nervosa are now recognized as 2 distinct syndromes. According to the Diagnostic and Statistical Manual for Mental Disorders , Fourth Edition (DSM-IV), bulimia nervosa is characterized by recurrent episodes of binge eating followed by 1 or more compensatory behaviors to eliminate the calories (vomiting, laxatives, fasting, etc.) that take place on average a minimum of twice weekly for 3 or more months. 5 Patients who do not meet the frequency or length criteria may be diagnosed with DSM-IV eating disorder not otherwise specified. 5

Bulimia nervosa is also delineated into 2 distinct subtypes: purging and nonpurging. With the purging subtype, patients engage in some method to remove the binged food from their bodies. This is most often accomplished by self-induced vomiting but can include the misuse of laxatives, enemas, or diuretics. Nonpurging bulimics use fasting or excessive exercise as the primary compensation for binges but do not regularly purge. Regardless of subtype, bulimic patients have negative self-evaluations, placing inappropriate importance on weight and body image.

EPIDEMIOLOGY

Whereas the prevalence of anorexia nervosa for women in the United States is 0.5% to 1%, the prevalence of bulimia nervosa is 2% to 3% and can be as high as 10% in vulnerable populations, such as college-aged women. 6 Males are affected by eating disorders at a rate one tenth of that of females. Demographically, most patients with bulimia nervosa are single, college educated, and in their mid-20s. However, most patients begin experiencing bulimic symptoms during adolescence. 7 Bulimia nervosa occurs in 2.3% of white women but in only 0.40% of black women. 8

Risk factors for bulimia nervosa include, but are not limited to, childhood sexual abuse, male homosexuality, eating alone, living in a sorority house, diabetic poor glycemic control, low self-esteem, dieting, involvement in athletics, and occupations that focus on weight. 9–14 Patients with these risk factors or in high-risk populations and those who the practitioner suspects may have an eating disorder should undergo screening.

SCREENING FOR BULIMIA NERVOSA

Many tools are available for screening in the primary care setting, yet few tools focus on the diagnosis of bulimia nervosa. In the spirit of the CAGE assessment for alcohol abuse, 15 the SCOFF questionnaire screens for eating disorders using 5 simple, easy-to-remember questions. 16 An eating disorder can be suspected with 84.6% sensitivity and 89.6% specificity if a patient responds positively to 2 or more questions. 17 The negative predictive value is 99.3% for the SCOFF questionnaire, which makes this tool useful for screening in clinical practice.

The SCOFF was recently tested against a new instrument, the Eating Disorder Screen for Primary Care. 18 The latter instrument performed slightly better than the SCOFF, with 1 or no abnormal responses ruling out an eating disorder (likelihood ratio [LR] = 0.0) compared with the SCOFF (LR = 0.25). Both were similarly effective in ruling positive for an eating disorder (LR = 11). 18

A 2-item assessment specific to bulimia nervosa may also be an effective screening tool. For responders who answered positively to 1 of the 2 screening questions (Do you ever eat in secret? and Are you satisfied with your eating patterns?), the positive and negative predictive values were 22% and 91% when based upon the gold-standard of a clinical assessment that found a 16% prevalence of bulimia nervosa in the studied population. 19 These 2 screening items had been previously shown to have a sensitivity of 1.00 and specificity of 0.90 for bulimia nervosa. 20

The Bulimic Investigatory Test, Edinburgh (BITE) questionnaire is a brief test for the detection and description of bulimia nervosa. 21 The BITE consists of a set of 33 questions (30 yes/no type and 3 graded-response) that simultaneously assess the presence and relative severity of a binge-eating disorder. The BITE is divided into 2 sections: the symptom scale and the severity scale. The symptom scale consists of the 30 yes/no questions; 1 point is assigned for every “yes” answer, and a score of 20 or greater indicates a binge-eating disorder. The 3 graded-response questions make up the severity scale and ask the patient to score the frequency of their actions. A score of 5 or more on this section is considered clinically significant, and a score of 10 or more is considered severe. The BITE takes an average of 10 minutes to complete and can be immediately scored by the practitioner. Although not intended for screening in primary care, this instrument could be used to track disease severity in patients with known disease.

The Eating Attitudes Test has been widely used in epidemiologic studies, particularly to assess for symptoms of anorexia nervosa. 22–25 The instrument has been validated for bulimia nervosa and modified for use in patients with diabetes mellitus. 26–28 We recommend starting with the Eating Disorder Screen for Primary Care or the SCOFF for screening purposes in primary care.

CLINICAL PRESENTATION

The diagnosis and long-term treatment of bulimia nervosa require the practitioner to have insight into the patient's thoughts regarding weight, food, and eating rituals. The cardinal symptoms of bulimia nervosa include only inappropriate bingeing and compensatory behavior, not low body weight. It is possible for a patient to suffer from bulimia nervosa and be at or above normal weight. For this reason, normal and overweight patients should not be overlooked if other symptoms or signs of bulimia nervosa are present.

It is necessary to understand the patient's eating behaviors, especially those involving binge eating. The bulimic's idea of a binge may not be, and most likely is not, the same as the physician's idea of a binge. Although a binge is loosely defined as a large consumption of calories in a brief period of time, bulimics tend to define binges by the type of food consumed and their mood state while consuming, not necessarily by the actual caloric intake. 29, 30 For instance, snack foods and desserts are viewed as binge foods more often than are other foods. Some bulimics may have an internal list of forbidden foods that, when consumed, will constitute a binge to that patient, regardless of caloric content. A bulimic could consume a large quantity of fruits and vegetables of the same caloric amount as a candy bar but not view it as a binge because fruits and vegetables are “good” or “safe” foods.

In any case, a sense of loss of control over eating is an important feature of bulimia nervosa. Subjective binges are defined not by the amount of food consumed, but by an appraisal that more food was eaten than should have been consumed and a concomitant sense of lack of control. 31, 32 Further, a typical behavioral pattern may be noted around the time of the binge episode. The bulimic may experience pre-episode boredom, cravings, and depression followed by post-episode depression and lack of self-control. 33 Bulimics commonly binge in private, and some may plan binges and purges according to time of day and privacy issues. They may eat normally around friends and family but then binge at other times when alone. In more severe cases, bulimics may alter daily schedules to be assured of time for bingeing and purging. They may also deprive themselves of food for hours before the binge, and it is thought that this deprivation plays into the ritualistic pattern of bulimic eating. 34 Because regular binges may be costly, food may be stolen from grocery and convenience stores. 35 The severity of weight and eating attitudes may fuel the frequency of binge and purge behaviors. It is these behaviors that may lead to serious medical and psychiatric complications.

MEDICAL COMPLICATIONS

Whereas amenorrhea is required for a DSM-IV classification of anorexia nervosa in women, only one half of patients with bulimia nervosa experience menstrual disturbances, including amenorrhea or oligomenorrhea. 36 Menstrual disturbances occurring in women with eating disorders may be secondary to a decrease in the pulsatility of gonadotropin-releasing hormone and possibly to the hormonal mechanisms of leptin, which decreases with decreasing weight. 37, 38 Since a threshold level of weight or body fat is believed to be necessary for normal reproductive functioning, normal or overweight bulimics are less likely to experience amenorrhea. 39

Gastrointestinal (GI) tract abnormalities may occur in bulimics and typically are secondary to purging behaviors. The most commonly reported GI symptoms are bloating, flatulence, and constipation. 40 Gastric emptying and motility may be delayed. 41 The patient also may develop gastroesophageal reflux disease and Mallory-Weiss tears from excessive vomiting. Rectal prolapse has been described, and when it occurs in a young woman, the clinician should include bulimia nervosa in the differential diagnosis. 42

Ipecac, an over-the-counter emetic agent, is often used by bulimics to induce vomiting. Nearly 8% of women with eating disorders may experiment with ipecac, while 1% to 2% regularly abuse the medication. 43 Ipecac has been associated with serious cardiac toxicity, including cardiomyopathy with left ventricular dysfunction. Whether or not this dysfunction is reversible remains controversial. 44 Patients with a history of ipecac abuse may be candidates for echocardiography, especially if symptoms of heart failure are present.

Due to excessive vomiting, patients may exhibit enamel erosion, especially on the lingual surface of the teeth; calluses on middle phalanges from using fingers to induce vomiting (Russell's sign); and sialadenosis, a noninflammatory enlargement of the salivary glands. 45, 46 Parotid gland swelling is commonly found. Sialadenosis is almost always associated with an underlying systemic disorder, including diabetes, alcoholism, malnutrition, anorexia nervosa, and bulimia nervosa. In bulimics, the incidence of sialadenosis ranges from 10% to 66%. The clinician should suspect bulimia nervosa in a young woman with sialadenosis who has no underlying medical conditions. 47, 48 It is thought that the various causes of sialadenosis all result in a common pathogenic effect in that they produce a peripheral autonomic neuropathy responsible for disordered metabolism and secretion, resulting in acinar enlargement. 46, 49 Although the condition may reverse once vomiting ceases, in cases of refractory swelling, parotidectomy may be considered as a last resort to improve facial aesthetics. 46

Unlike patients with anorexia nervosa, bulimic patients generally do not have disturbances in bone mineral density, especially when weight-bearing exercise is used as a compensatory mechanism. 50 Risk factors for decreased bone mineral density include total duration of amenorrhea, age at first menarche, time since last menstrual period, and low body weight. 51 Therefore, early-onset osteopenia is not a major concern for normal or overweight bulimic patients, unless a history of anorexia nervosa with a period of greater than 5 months spent below normal weight is also present.

PSYCHIATRIC COMORBIDITY

The psychiatric comorbidity associated with bulimia nervosa is striking. Bulimic patients are characterized as extroverted perfectionists who are self-critical, impulsive, and emotionally undercontrolled. 52 High prevalence rates of any affective disorder (75%), major depressive disorder (63%), and anxiety disorders (36%) have been reported. 53 The majority of patients report that the initial presentation of the depression or anxiety disorder occurred prior to the presentation of bulimic symptoms. 53 Thus, positive early identification of an affective or anxiety disorder may provide an opportunity to prevent development of eating symptoms and disorders, especially in high-risk populations. Studies describing the incidence of comorbidities in bulimia nervosa may suffer from sampling bias, referral bias, and lack of appropriate control groups.

Substance abuse is an additional common comorbidity. The National Center on Addiction and Substance Abuse at Columbia University reported that 30% to 70% of bulimics have a substance abuse problem. 54 Substances of abuse include tobacco, alcohol, and prescription and over-the-counter medications, such as diet pills and stimulants. Alcoholism has been reported to affect 31% of bulimics and is often found with major depressive disorder and posttraumatic stress disorder. 55 Strong familial relationships have also been observed between bulimia nervosa and alcoholism. 56

A controlled community sample study compared women with bulimia nervosa with normal controls and controls with other psychiatric disorders. Although current alcoholism was similar among the groups, bulimics had higher rates of deliberate self-harm than both control groups and more illicit drug use than the normal controls. 57

Self-injury is a concern for patients with bulimia nervosa. In one study, 34% of bulimic patients reported having injured themselves at sometime in their lives, and 21.3% reported having injured themselves in the last 5 months. 58 Patients most often injure themselves by cutting or scratching their arms, hands, legs, or face, and many of these injuries result in bleeding and scarring. Patients with borderline personality disorder who injure themselves are more likely to also suffer from bulimia nervosa than are those who do not injure themselves. Comorbid diagnoses of bulimia nervosa and borderline personality disorder have been shown to increase risk of frequent self-mutilation, which may influence rates of attempted and completed suicide in these patients. 59

Bulimic patients are more likely to have experienced parental alcoholism, low parental contact, and high parental expectations. 60 Although the core symptoms of this disorder are disturbed eating habits and self-perception, the significant comorbidities complicate the identification and treatment of bulimia nervosa.

LABORATORY ABNORMALITIES

The normal-weight or overweight bulimic may or may not have significant laboratory abnormalities. Laboratory abnormalities become more common with decreasing weight and increasing severity of purging behaviors. The electrolyte levels are most likely to be affected.

Hypokalemia, hypochloremia, hyperphosphatemia, and metabolic alkalosis are common, especially in lower-weight bulimics. The severity of hypokalemia and hypochloremia is directly related to the number of purging episodes the patient experiences, especially those involving diuretics, laxatives, and repetitive vomiting. 61 A recent case-control study 62 suggested that the ratio of urine sodium to urine chloride is the best predictor of bulimic behavior. A ratio of > 1.16 identified nearly 52% of cases, and the false-positive rate was 5%. 62 Additionally, the presence of metabolic alkalosis and elevated phosphorus levels should also raise clinical suspicion for surreptitious vomiting. 63–65 Although serum potassium levels have been considered a good marker for bulimic behavior, the relative infrequency (4.1% to 13.7%) of clinically significant hypokalemia among bulimics lowers its sensitivity as a screening test. 61, 62, 64, 66

Importantly, the patient's overall laboratory picture is dependent on the compensatory mechanisms. Patients who purge by vomiting may present with metabolic alkalosis (elevated serum bicarbonate levels) due to volume contraction. However, patients who primarily abuse laxatives may present with metabolic acidosis (decreased serum bicarbonate levels) due to loss of alkaline fluid from the bowel. 63 Patients using more than one purging mechanism may display mixed acid-base findings. These electrolyte imbalances contribute to weakness, fatigue, and, in severe cases, may predispose the patient to cardiac arrhythmias and sudden death.

Serum amylase determination may help to diagnose and monitor bulimia nervosa. An elevated amylase level may suggest that a patient has been vomiting. In some cases, it will be necessary to rule out an organic cause of elevated amylase levels or vomiting, such as pancreatitis. When fractionated into serum and salivary components, elevations are usually disproportionate, with elevated salivary amylase exceeding pancreatic amylase in patients who have been vomiting. The fractionated test, therefore, may be helpful to use as a diagnostic aid in cases where vomiting is denied and to monitor continued vomiting in patients undergoing treatment. 67

PHYSICAL AND LABORATORY ASSESSMENT

Unlike anorexia nervosa, which is easily discernible given low body weight, the variance in weight presentation among bulimics makes this condition more difficult to diagnose. A baseline assessment for patients suspected of eating disorders includes several elements. Historical information, including prior episodes of electrolyte abnormalities, menstrual irregularities, or GI symptoms such as constipation, provide important clues if these are otherwise unexplained.

Given time constraints in the primary care clinic, the clinician may choose to use either the 2-question assessment discussed previously or the Eating Disorder Screen for Primary Care. 18 Negative scores on these instruments do not rule out the possibility of an eating disorder, as patients who wish to keep the condition secret may not answer the questions in a positive fashion. The physical examination may provide important clues suggesting the presence of bulimia nervosa, particularly the purging subtype of the disorder. On examination, the clinician may look for signs of the medical complications mentioned previously, including dental erosion, scarring or abrasion on the knuckles, and swollen parotid glands.

Primary care providers should consider the use of laboratory tests in both the diagnostic and follow-up evaluation. For underweight patients, patients in whom bulimia nervosa is suspected but denied, and patients in whom physical symptoms and signs are present, laboratory tests may be useful to rule out other disorders or to positively diagnose bulimia nervosa. Although no standard panel of tests is described, serum and urine electrolyte counts, acid-base assessments, and phosphorus levels should be obtained from the underweight patient at both diagnosis and follow-up. Fractionated amylase testing may be beneficial in evaluating for vomiting in patients suspected of having bulimia nervosa and in patients undergoing treatment for the disorder. Electrocardiogram monitoring should be performed in bulimic patients with electrolyte abnormalities, palpitations, chest pain, or low body weight. The bulimic patient with at least a 5-month history of low body weight or anorexia should have a bone density assessment. Other testing, such as upper or lower GI endoscopy, should be considered, depending on the constellation of symptoms and signs. For instance, other conditions that can manifest with GI symptoms include inflammatory bowel diseases, celiac sprue, and irritable bowel syndrome.

Most patients with bulimia nervosa do not require hospitalization, and the preferred method of treatment is outpatient-based. 68 Cognitive-behavioral therapy (CBT) is the standard and preferred psychological method of treatment for these patients. In multiple studies, CBT has been demonstrated superior to other forms of psychological treatment, such as interpersonal psychotherapy. 59, 69 This method of treatment for bulimia nervosa was first described by Fairburn in 1981 and has 2 goals: (1) to stop the vicious circle of overeating and vomiting and (2) to modify the abnormal attitudes toward food. 70 The CBT method has 3 phases that overlap in a 20-week course of therapy. 71 During the first phase, patients are taught about bulimia nervosa and actions that perpetuate the disease. The patient keeps detailed food records, including the frequency of bingeing or purging, which are used in therapy sessions. The second phase consists of teaching the patient to broaden food choices, and additional time is spent on correcting dysfunctional food and body thoughts. The final 3 therapy sessions comprise the third stage and focus on maintenance and relapse prevention. Upon completion of CBT, 45% of patients stopped bingeing and purging and 35% no longer met diagnostic criteria for bulimia nervosa. 71

Relapse primarily occurs during the first 4 months after CBT and affects 31% to 44% of patients. 72 Relapse has been attributed to low motivation during treatment and overly ritualized eating and high frequency of vomiting before treatment. 72, 73 Rapid and sustained response to CBT has been found to be dependent upon frequency of bingeing before treatment and a self-directed personality. 74

Pharmacologic treatment may be a primary or adjunct therapy for bulimia nervosa. Fluoxetine has been shown to be effective in the treatment of bulimia nervosa. One 16-week and 2 double-blind 8-week clinical trials conducted in the early to mid-1990s all found fluoxetine, 60 mg/day, to significantly decrease overall binge eating and vomiting. 41–43, 75–77 Fluoxetine also has been reported to significantly decrease vomiting and binge eating in as little as 4 weeks of therapy. 78 Bulimic patients followed for up to 1 year on fluoxetine therapy were found to have a significantly decreased likelihood of relapse and improved overall outcome when compared with placebo. 79 A case series of 5 underweight patients with binge-eating and purging reported sertraline to be effective in weight restoration and reduction of core eating disorder behaviors. 80 Although citalopram 81 was effective in treating binge-eating disorder, no differences were noted between cases and controls for fluvoxamine. 82 Milnacipran, an antidepressant with both serotonergic and noradrenergic function, was effective for the reduction of bulimic symptoms in an uncontrolled case series. 83 To date, fluoxetine remains the only medication approved by the U.S. Food and Drug Administration for the treatment of bulimia nervosa.

The combination of CBT with fluoxetine therapy has been shown to be superior to medication or CBT alone. 84 Frequency and severity of vomiting and binge eating were decreased in patients on both therapies. Also, in a recent study, patients reported better social adjustment up to 10 years after receiving CBT, fluoxetine, or both therapies for treatment of bulimia nervosa compared with that of women who had been randomized to placebo. 85 For bulimic patients who do not respond to CBT, fluoxetine has been shown to be effective in decreasing bulimic features. 86 In light of this research, the current treatment for bulimia nervosa consists of outpatient-based CBT and fluoxetine therapy.

Generally, treatment of physical symptoms is dependent upon severity of the problem (e.g., hypokalemia) and whether or not reversal is expected at cessation of purging behaviors (e.g., dysphagia).

Primary care physicians should consider referring patients for specialty care in situations where eating disorder symptoms are persistent, comorbid psychopathology is present, or self-injurious behaviors or suicidal ideation is encountered. Specialty clinics directed at the care of patients with eating disorders may be most beneficial. 87, 88

Primary care physicians, patients, and families may benefit from reading about eating disorders or researching community or college campus resources. The American Psychiatric Association issued practice guidelines for the assessment and treatment of anorexia nervosa and bulimia nervosa. These guidelines include an overview of the clinical characteristics and evidence-based treatments. 1 Online resources are plentiful, but among the most comprehensive Web sites are http://www.mentalhealth.com and http://www.besttreatments.org/bulimianervosa . 89, 90 The former provides links to the American Psychiatric Association and National Institute of Mental Health guidelines, as well as recent articles and research advances. The latter source was produced in affiliation with the Clinical Evidence Program of the British Medical Journal . This site is designed for the lay public and provides descriptions of the clinical features of and treatment options for bulimia nervosa.

Although bulimia nervosa is more common than anorexia nervosa, the mortality rate is lower and the recovery rate higher than that of anorexia nervosa. 91 Mortality from bulimia nervosa is approximated at 0% to 3% but may be underestimated due to few long-term follow-up studies involving bulimic patients. Approximately 50% of patients are free from all bulimic symptoms 5 years after treatment. 91 Although outcomes research on bulimia nervosa is sparse, with limited statistical estimates, it has been shown that mortality and recovery are directly related to early intervention and treatment. 88

Patients who suffer from anorexia nervosa and exhibit bulimic features have more difficulty reaching normal body weight and tend to be at lower body weights, even after treatment. 92 Anorexics are also prone to developing binge eating after treatment for anorexia nervosa. A 1997 study reported that 30% of treated anorexics developed binge-eating behavior up to 5 years posthospitalization. 87 When assessing a normal or overweight patient with bulimia nervosa, it is important to gather historical information about the presence and duration of past anorexia nervosa. Anorexia nervosa complicated by bulimic symptoms is associated with higher mortality rates than those from bulimia nervosa alone. 93 However, mortality rates and comorbidity rates for all eating disorders may be overestimated due to the fact that most studies take place in academic or specialty research settings. These patients are often more severely ill than patients in outpatient, community-based settings. The actual recovery rates for eating disorders are probably greater, and the overall outcome picture not so bleak. 94 Yet, it is important for primary care physicians to be familiar with the presenting symptoms of bulimia nervosa or anorexia nervosa complicated by bulimia and to intervene early in the disease course. Unfortunately, in a study conducted nearly 10 years ago, approximately 1 in 10 patients with bulimia nervosa were in treatment. 95

CONCLUSIONS

Bulimia nervosa is a common and treatable condition that often presents in the primary care setting. The hallmark sign for bulimia nervosa is a distorted view of food and eating. Patients with this condition often maintain a normal or above-normal weight. Purging can present outwardly via sialadenosis, dental enamel erosion, and calloused middle phalanges. Patients with bulimia nervosa may have electrolyte and acid-base abnormalities. Bulimia nervosa is also often associated with depression, borderline personality disorder, substance abuse, self-injury, and a troubled family life.

Bulimia nervosa is a treatable disease, especially when diagnosed early. The majority of patients are successfully treated with fluoxetine and CBT. However, better outcomes are associated with prevention and early detection of abnormal eating patterns. It is important that primary care physicians consider this disease in patients with eating or weight symptoms, especially in the most at-risk population: single, white, educated, college-aged women. Early treatment and specialty referral for these patients is indicated.

Drug names: citalopram (Celexa), fluoxetine (Prozac and others), sertraline (Zoloft).

Pretest and Objectives

Instructions and Posttest

Registration and Evaluation

This work was supported by the University of Iowa Roy J. and Lucille A. Carver College of Medicine Summer Research Fellowship (Ms. Rushing) and grant K08 MH01932-01A1 from the National Institute of Mental Health, Bethesda, Md. (Dr. Carney).

In the spirit of full disclosure and in compliance with all ACCME Essential Areas and Policies, the faculty for this CME activity were asked to complete a full disclosure statement. The information received is as follows: Mss. Jones and Rushing and Dr. Carney have no significant commercial relationships to disclose relative to this article.

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