Recent Research on Bulimia Nervosa

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Key points

  • There has been a decrease in the presentation of bulimia nervosa (BN) in primary care but an increase in disordered eating not meeting full diagnostic criteria.

  • Disordered eating is associated with long-term significant impairment to both physical and mental quality of life.

  • BN is associated with a significantly higher likelihood of self-harm, suicide, and death.

  • Assessment should adopt a motivationally enhancing stance given the high level of ambivalence associated with BN.

  • Cognitive behavior

Diagnosis

Bulimia nervosa (BN) is an eating disorder that is characterized by 3 main diagnostic elements:

  • Objective binge episodes (eating a large amount of food within a 2-hour period),

  • Attempts to compensate for this binge eating (either through use of purging, driven exercise, fasting or underdosing with insulin in the presence of type I diabetes),

  • Overevaluation of the importance of weight and/or shape.

Diagnostically, the required frequency of binge episodes and compensatory behaviors is once a week for

Epidemiology

Estimates of lifetime Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) DSM-IV3 BN vary across studies, ranging from 1.5% to 4.6%. Estimates of lifetime DSM-51 BN, with more relaxed criteria, are between 4% and 6.7%.4 Community incidence rates based on tracking eating disorders in general practice suggest that there has been a decrease in the presentation of BN in primary care across several countries.5, 6, 7 There has, however, been an increase in disordered eating not

Emergence

BN emerges somewhat later in life than anorexia nervosa, with binge and purge symptoms having a peak age of onset in late adolescence and early adulthood.10, 11 The mean age of emergence of BN is around 19 years of age, ranging from 10 to 29 years.12 Around 24% to 31% of people with BN will have experienced a previous diagnosis of anorexia nervosa.13

Comorbidity

More than 70% of individuals with eating disorders report comorbidity,14 with anxiety disorders (50%), mood disorders (40%), self-harm (20%), and

Managing Ambivalence

Less than one-third of community cases with BN are detected by health professionals.13 Several reasons account for this low rate, including the ambivalence and shame felt by patients, as outlined in Table 1. The ambivalence is driven largely by expectancies that thinness and control over weight, shape, and eating will lead to an improved life, including intrapersonal and interpersonal life functioning.33, 34 The assessment process shown in Table 2 offers an important opportunity to explore the

Predisposing Factors

BN is associated with numerous predisposing factors,45 with research most consistently supporting genetic risk, gender (female), obstetric complications and perinatal factors, higher body mass index, experiences of sexual abuse or neglect during childhood, a cluster of factors around negative affect/psychiatric morbidity/neuroticism, diminished interoceptive awareness, escape-avoidance style of coping, and increased weight and shape concerns.

Precipitating Factors

The most commonly noted precipitating factors involve

Prognosis

In community samples, around 45% of patients can be expected to attain an asymptomatic status 14 years after initial onset,12 with the remainder continuing to experience some symptoms; 14% will still be experiencing significant levels of disordered eating. The prior diagnosis of anorexia nervosa (regardless of age of onset or purging vs nonpurging subtype) decreases the likelihood of recovery from BN within 5 years.

Meta-Analytic Results

Numerous treatment studies now exist for BN, as attested to by a body of meta-analytic studies. The most recent of these found that cognitive behavior therapy specific to eating disorders (CBT-ED) outperformed all other active psychological comparisons, including interpersonal psychotherapy.52 A network meta-analysis that informed current NICE guidelines39 concluded that the treatments most likely to achieve full remission are individual CBT-ED and guided self-help CBT-ED.53 A comparison of

Summary

Although there has been a decrease in the presentation of BN in primary care, there is an increase in disordered eating not meeting full diagnostic criteria that impacts adversely on long-term physical and psychological quality of life. Less than one-third of community cases of BN are detected by professionals due to a mix of patient ambivalence and shame, coupled with failure on the part of the professional to ask about or identify symptoms. Assessment should adopt a motivationally enhancing

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