DSM-5 Diagnostic Criteria for Bulimia Nervosa
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) includes the following diagnostic criteria for bulimia nervosa:
- Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
- Eating, in a discrete period of time (e.g., within a two hour period), an amount of food that is definitely larger than what most people would eat during a similar period of time and under similar circumstances.
- Lack of control over eating during the episode (e.g., a feeling that you cannot stop eating, or control what or how much you are eating).
- Recurrent inappropriate compensatory behavior to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise.
- The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for three months.
- Self-evaluation is unduly influenced by body shape and weight.
- Binging or purging does not occur exclusively during episodes of behavior that would be common in those with anorexia nervosa.
Diagnostic Tests for Bulimia Nervosa
If your doctor suspects that you have bulimia, they will typically conduct several tests to help narrow down the diagnosis, eliminate other medical causes for weight loss or gain and check for any related complications.
- Physical Exam. This may include measuring your height and weight; checking your vital signs, such as heart rate, blood pressure and temperature; checking your skin and nails; listening to your heart and lungs, and examining your abdomen.
- Lab Tests. These may include a complete blood count and more specialized tests to check electrolytes and protein, as well as liver, kidney and thyroid functions. A urinalysis may also be performed.
- Psychological Evaluation. A therapist or mental health provider will likely inquire about your thoughts, feelings and eating habits. You may also be asked to complete a psychological self-assessment questionnaire.
- Other Studies. X-rays may be taken to measure your bone density, check for stress fractures or broken bones, or evaluate you for pneumonia or heart problems. Electrocardiograms may be used to identify heart irregularities. Tests may also be used to determine how much energy your body uses, which can help in planning nutritional requirements.
Based on the results of these tests, an appropriate treatment program will be recommended for you or your family member/loved one.
Read our blog posts about bulimia to learn more about bulimia symptoms, treatment and more.
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- How often do you think of food? … Tell me your thoughts. (Preoccupation with food)
- Do you spend a long time thinking about food/meal times/cooking, etc? (Preoccupation with food)
- Do you have any special rituals around meal times?
- Do you ever have bingeing periods? ….What I mean is eating large quantities of food in a short span of time, more than most people would eat. (Important to clarify what you mean by a binge)(Recurrent episodes of bingeing)
- Do you feel out of control when you binge?
- How do you feel after that?
- What do you do next? (in some cases self harm may occur due to feelings of sadness or guilt)
- Do you induce vomiting or take laxatives after bingeing? (Compensatory behaviours)
- Is your self esteem linked to the way you feel about your body and weight? (Self evaluation influenced by body shape and weight)
IMPORTANT POINTS IN CLINICAL PRACTICE
- Physical examination is a must. (Electrolyte abnormalities, low pulse and BP can indicate medical compromise)
- Brief cognitive examination, e.g. clock-drawing test with frontal lobe testing. (Compensatory behaviours can affect cognition)
- High degree of co-morbidity in Bulimia Nervosa. Rule out anxiety, depression, substance misuse and personality disorder.
- Personality Disorder of Borderline type is highly associated with Bulimia Nervosa. (Self identity issues and impulsivity maintain the eating disorder)
- Bulimia Nervosa can be associated with shop lifting. (Impulsivity as part of personality)
- Obsessional / Perfectionistic personality traits may also be present (Often linked to high levels of self criticality that are commonly found in individuals with low self esteem)
- Family history of obesity or eating disorder may be present
- Personal history may reveal role models, childhood sexual abuse, attachment difficulties, bullying, and obesity as a child.
- History will reveal worsening of eating disorder with stressors.
American Psychiatric Association: Desk Reference to the Diagnostic Criteria From DSM-5.Arlington, VA, American Psychiatric Association, 2013
ICD-10 Classification of Mental and Behavioural Disorders
Prevalence of Bulimia Nervosa in the United States is around 0.3% of the total population yet only around 16% of those affected seek treatment. This conditionis more commonly seen in young women than in men with an average age of onset of 20 years old. It is usually associated with childhood and parental obesity but is seen to have a better prognosis than Anorexia Nervosa.
Bulimia Nervosa can be classified by the manner in which the person compensates for the extra calories gained during binge eating. The first classification is called Purging Bulimia wherein the person gets rid of the calories by self-induced vomiting or by ingestion of any substance that will promote excretion of the ingested food (i.e. laxatives and diuretics). The other classification is called Nonpurging bulimia wherein the person prevents weight gain through an overly strict diet such as fasting or by exercising excessively. However, these behaviors often overlap and may be life threatening if the condition is chronic.
Diagnosis of Bulimia Nervosa
Clinical diagnosis of Bulimia Nervosa isbased on the Diagnostic and Statistical Manual of Mental Disorders 4 th edition criteria. The criteria is as follows:
- Recurrent and uncontrollable episodes of binge eating wherein the person ingests a large amount of food in a short time
- Recurrent and abnormal compensatory behaviors in response to the binge eating earlier such as: self induced vomiting, diuretic and laxative abuse
- Occurrence of this binge-purge cycle at least twice weekly for at least 3 months
- Excessive concern with self image, body shape and weight
Signs and Symptoms of Bulimia Nervosa
People with Bulimia Nervosa often has normal weight with some even being overweight which is a stark difference from people with Anorexia Nervosa who are severely underweight. Another difference is the presence of menstruation seen in people with Bulimia Nervosa which is absent in people with Anorexia Nervosa. Other signs and symptoms are as follows:
- Presence of calluses and abrasion over the dorsum or the back of the hand that occurs when the incisors abrade that area during gag reflex stimulation
- Salivary gland enlargement
- Dental erosion from the acid during vomiting
- Electrolyte imbalance
Behavioral abnormalities may also be apparent that usually begin during late adolescence or early adulthood. These abnormalities are as follows:
- Self imposed caloric restriction that makes the person more hungry and more prone to binge eat
- Presence of compensatory behaviors: purging, laxative and diuretic abuse
- The binge purge cycle continues with a diminished sense of control on eating
- Associated with a more depressed mood that leads to:
- Suicide attempts
- Sexual promiscuity
- Drug and alcohol abuse
- Can develop the ability to elicit vomiting without stimulating the gag reflex with the hand
The most common symptom of bulimia nervosa is binge eating followed by self-induced vomiting and other abnormal compensatory behaviors
Treatment for Bulimia Nervosa
Treatment for Bulimia Nervosa will entail a more holistic approach that involves both medical and psychological interventions. These are as follows:
- Cognitive behavioral therapy that focuses on body image and eating habits. This tries to target the abnormal thoughts and behaviors that push the person to binge eat and purge afterwards.
- Although antidepressants are said to be less effective than cognitive behavioral therapy, they may still be recommended if there are other psychiatric abnormalities aside from Bulimia Nervosa. However, only Fluoxetine (Prozac), 60 mg/day, is approved by the United States Food and Drug Administration.
Bulimia Nervosa, or more commonly called as bulimia, is a type of eating disorder characterized by recurrent episodes of binge eating followed by abnormal compensatory behaviors such as self-induced vomiting.
Bulimia nervosa is an eating issue that can be assessed using a variety of diagnostic tools. Because there are many different measures to evaluate bulimia, some researchers believe that overestimation or underestimation of bulimia exists. To cloud the issue further, a large majority of people who have symptoms of bulimia often have comorbid psychological conditions, including mood problems, anxiety, depression, and drug or alcohol use.
Less than half of the individuals who demonstrate bulimic symptoms seek treatment for them. Although many do enter treatment for comorbid issues, the bulimia is often discovered secondarily and does not always receive the attention it deserves. Bulimia can lead to serious negative health outcomes and even suicide. For clinicians to identify those most at risk and intervene at the earliest point possible, it is imperative that consistency in symptom assessment and diagnosis be achieved.
Katie Sandberg of the Department of Education Specialties at Loyola University in Maryland wanted to test the reliability, consistency and validity of the six most commonly used tools for assessing bulimia. She conducted an analysis of existing research involving studies using the Eating Disorder Examination (EDE), the Eating Attitudes Test (EAT), the Eating Disorder Inventory-3 (EDI-3), the Body Shape Questionnaire (BSQ), the Bulimic Investigatory Test, Edinburgh (BITE), and the Three-Factor Eating Questionnaire (TFEQ).
Sandberg found that all six measures were able to assess bulimic symptoms with relative accuracy, but in unique ways. Based on symptoms of purging, binging, laxative use, and overall body dissatisfaction, she found that the EDI and the EAT were the most reliable at assessing bulimia. When she looked at body dissatisfaction, the BSQ and the EDE emerged as the most reliable tools.
In sum, Sandberg believes these findings show the importance of utilizing multiple screening tools when evaluating clients for bulimia. She said, “The best way for clinicians and researchers to document treatment effects is to use a multitude of high-quality instruments to achieve triangulation.” Further, she believes implementing screening tools before and during treatment can provide clinicians with accurate measures of progress and can help clients and clinicians identify persistent symptoms that need further attention.
Sandberg, Katie, and Bradley T. Erford. “Choosing Assessment Instruments for Bulimia Practice and Outcome Research.” Journal of Counseling and Development : JCD 91.3 (2013): 367-79. ProQuest. Web. 26 July 2013.
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, MD, Columbia University Medical Center;
, MD, College of Physicians and Surgeons, Columbia University
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People eat large amounts of food, then make themselves vomit, use laxatives, diet, fast, or vigorously exercise to compensate.
Doctors suspect the diagnosis when people are overly concerned about their weight and their weight fluctuates a lot.
Cognitive-behavioral therapy, a selective serotonin reuptake inhibitor (a type of antidepressant), or both may be used to treat the disorder.
As in anorexia nervosa Anorexia Nervosa Anorexia nervosa is an eating disorder characterized by a relentless pursuit of thinness, a distorted body image, an extreme fear of obesity, and restriction of food consumption, leading to. read more , bulimia nervosa is influenced by hereditary and social factors. Also as in anorexia nervosa, most people who have bulimia nervosa are young women who are deeply concerned about body shape and weight.
Bulimia nervosa affects mainly adolescents and young adults. In a given year, about 1 in 100 young females have bulimia nervosa. The disorder is much less common among males.
Symptoms of Bulimia Nervosa
People with bulimia nervosa have repeated episodes of binge eating. That is, they eat much larger amounts of food than most people would eat in a similar time under similar circumstances. Circumstances and culture are important because the amount considered excessive for a normal meal may differ from the amount considered excessive for a holiday meal.
Emotional stress often triggers the binges, which are usually done in secret. Binge eating, which is accompanied by a feeling of a loss of control, usually includes eating when not hungry and eating to the point of physical discomfort.
People tend to consume sweet, high-fat foods, such as ice cream and cake. The amount of food consumed varies and sometimes involves thousands of calories. Binges may occur as often as several times a day.
Did You Know?
People with bulimia nervosa tend to feel very remorseful or guilty about their behavior.
People with bulimia nervosa may have scars on their knuckles from using their fingers to make themselves vomit.
In an attempt to counteract the effects of the excess food, people use various means to compensate:
Purging—for example, by making themselves vomit (self-induced vomiting) or taking laxatives or diuretics (drugs that cause the kidneys to excrete more water)
Rigorously dieting or fasting
Any combination of the above
Some also take diuretics to treat perceived bloating.
Unlike in anorexia nervosa, the body weight of people with bulimia nervosa tends to fluctuate around normal. Only a few are overweight or obese.
Self-induced vomiting can erode tooth enamel, enlarge the salivary glands in the cheeks (parotid glands), and inflame the esophagus. Vomiting can lower potassium levels in the blood, causing abnormal heart rhythms. Sudden death can result from an abnormal heart rhythm in people who repeatedly take large quantities of ipecac to induce vomiting. Rarely, during a binge or purge, the stomach ruptures or the esophagus tears, leading to life-threatening complications.
People with bulimia nervosa are preoccupied with and judge themselves based on their weight and body shape. Their self-esteem is largely based on their body weight and shape.
Compared with people who have anorexia nervosa, those who have bulimia nervosa tend to be more aware of their behavior and to feel remorseful or guilty about it. They are more likely to admit their concerns to a doctor or other confidant. Generally, people with bulimia nervosa are more outgoing. They also are more prone to impulsive behavior, drug or alcohol abuse Overview of Substance-Related Disorders Drugs are an integral part of everyday life for many people, whether the drugs are used for legitimate medical purposes or recreationally (see table Drugs with Medical and Recreational Uses). read more , and depression Depression A short discussion of prolonged grief disorder. Depression is a feeling of sadness and/or a decreased interest or pleasure in activities that becomes a disorder when it is intense enough to. read more . They are anxious about their weight and about participation in social activities.
Diagnosis of Bulimia Nervosa
A doctor’s evaluation
Doctors diagnose bulimia nervosa when people, particularly young women, do the following:
Report binge eating at least once a week for 3 months or more
Feel out of control during and after the binge
Compensate for the binges by purging (for example, by making themselves vomit or using laxatives), by fasting, or by exercising excessively
Express marked concern about weight gain and base their self-image largely on weight and body shape
Doctors also check for other clues that support the diagnosis of bulimia nervosa:
Wide fluctuations in weight, especially if there are clues suggesting excessive laxative use (such as diarrhea and abdominal cramps)
Swollen salivary glands in the cheeks
Scars on the knuckles from using the fingers to induce vomiting
Erosion of tooth enamel from stomach acid
A low level of potassium detected by a blood test