Bulimia Nervosa 

• Recurrent episodes of binge eating. An episode of binge eating is characterized by both:
  • Eating in a discrete period of time (e.g. within any 2 hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances; 
  • A sense of lack of control over eating during the episodes (e.g. a feeling that one cannot stop eating or control what or how much one is eating. 
• Recurrent inappropriate compensatory behaviors to prevent weight gain, such as
  • self-induced vomiting
  • misuse of laxatives
  • diuretics, or other medications
  • fasting
  • excessive exercise. 
• The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months. 
• Self-evaluation is unduly influenced by body shape and weight. 
• The disturbance does not occur exclusively during episodes of anorexia nervosa. 
• Specify current severity:
  • Mild: An average of 1-3 episodes of inappropriate compensatory behaviours per week. 
  • Moderate: An average of 4-7 episodes of inappropriate compensatory behaviours per week. 
  • Severe: An average of 8-13 episodes of inappropriate compensatory behaviours per week. 
  • Extreme: An average of 14 or more episodes of inappropriate compensatory behaviours per week. 

Associated Features 

• fatigue and muscle weakness due to repetitive vomiting and fluid/electrolyte imbalance 
• tooth decay, perioral irritation, mouth ulcers 
• swollen appearance around angle of jaw and puffiness of eye sockets due to fluid retention, edema 
• reddened knuckles, Russell’s sign (knuckle callus from self-induced vomiting) 
• trouble concentrating, fatigue, headache, abdominal pain/reflux 
• weight fluctuation over time  

Management 

• medical admission for significant electrolyte abnormalities 
• biological: treatment of starvation effects, SSRIs (60 mg fluoxetine has the most evidence) as adjunct 
• psychological: develop trusting relationship with therapist to explore personal etiology and triggers, CBT, family therapy, recognition of health risks
  • Encourage excellent and healthy eating
    • Recognize hunger, eat healthy food.
    • Encourage others to do the same rather than stay hungry.
    • Eat a variety of food and make all kinds of the food part of your diet to keep it balanced.
    • Develop a taste for everything, and enjoy the meal.
    • Discourage and avoid making comments on food and promote eating healthy food.
    • Educate about damages associated with poor eating patterns and eating disorders.
• social: challenge destructive societal views of women, use of hospital environment to provide external patterning for normative eating behaviour 

Prognosis 

• relapsing/remitting disease 
• good prognostic factors: onset before age 15, achieving a healthy weight within 2 yr of treatment 
• poor prognostic factors: later age of onset, previous hospitalizations, individual and familial disturbance 
• 60% good treatment outcome, 30% intermediate outcome, 10% poor outcome (mortality rate of approximately 2% per decade)