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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.
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Disordered eating is associated with long-term significant impairment to both physical and mental quality of life.
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BN is associated with a significantly higher likelihood of self-harm, suicide, and death.
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Assessment should adopt a motivationally enhancing stance given the high level of ambivalence associated with BN.
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Cognitive behavior
Recent Research on Bulimia Nervosa
Section snippets
Key points
Diagnosis
Bulimia nervosa (BN) is an eating disorder that is characterized by 3 main diagnostic elements:
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Objective binge episodes (eating a large amount of food within a 2-hour period),
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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),
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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
References (64)
- et al.
The prevalence and correlates of binge eating disorder in the World Health Organization World Mental Health Surveys
Biol Psychiatry
(2013) - et al.
Suicidality in eating disorders: occurrence, correlates, and clinical implications
Clin Psychol Rev
(2006) - et al.
Suicide attempts in bulimia nervosa: personality and psychopathological correlates
Eur Psychiatry
(2009) - et al.
Dimensions of emotion dysregulation in anorexia nervosa and bulimia nervosa: a conceptual review of the empirical literature
Clin Psychol Rev
(2015) - et al.
Another look at Impulsivity: a meta-analytic review comparing specifics dispositions to rash action in their relationship to bulimic symptoms
Clin Psychol Rev
(2008) - et al.
An interoceptive model of bulimia nervosa: a neurobiological systematic review
J Psychiatr Res
(2017) - et al.
Eating disorders
Lancet
(2003) - et al.
A randomised trial investigating guided self-help to reduce perfectionism and its impact on bulimia nervosa
Behav Res Ther
(2008) Diagnostic and statistical manual of mental disorders
(2013)- et al.
Eating disorder examination (16.0D)
Diagnostic and statistical manual of mental disorders
Epidemiology of eating disorders
Three decades of eating disorders in Dutch primary care: decreasing incidence of bulimia nervosa but not anorexia nervosa
Psychol Med
Point prevalence of bulimia nervosa in 1982, 1992, and 2002
Psychol Med
Time trends in eating disorder incidence
Br J Psychiatry
Eating disorder behaviors are increasing: findings from two sequential community surveys in South Australia
PLos One
A longitudinal investigation of the impact of disordered eating on young women's quality of life
Health Psychol
Time trends in age of onset of anorexia nervosa and bulimia nervosa
J Clin Psychiatry
Prevalence and long-term course of lifetime eating disorders in an adult Australian twin cohort
Aust N Z J Psychiatry
Incidence and outcomes of bulimia nervosa: a nationwide population-based study
Psychol Med
Epidemiology of eating disorders in Europe: prevalence, incidence, comorbidity, course, consequences, and risk factors
Curr Opin Psychiatry
Comprehensive meta-analysis of the risk of suicide in eating disorders
Acta Psychiatr Scand
Temperament, character and suicide attempts in anorexia nervosa, bulimia nervosa and major depression
Acta Psychiatr Scand
Suicidality in eating disorders: clinical and psychological correlates
Acta Psychiatr Scand
Eating disorders and their relationship to impulsivity
Curr Treat Options Psychiatry
Sex influences on shared risk factors for bulimia nervosa and other psychiatric disorders
Arch Gen Psychiatry
Association between broadly defined bulimia nervosa and drug use disorders: common genetic and environmental influences
Int J Eat Disord
Eating disorder symptomatology and substance use disorders: prevalence and shared risk in a population based twin sample
Int J Eat Disord
Stigmatizing attitudes and beliefs toward bulimia nervosa: the importance of knowledge and eating disorder symptoms
J Ner Ment Dis
Perceived acceptability of anorexia and bulimia in women with and without eating disorder symptoms
Aust J Psychol
Stigmatizing attitudes and beliefs about bulimia nervosa: gender, age, education and income variability in a community sample
Int J Eat Disord
Eating disorders: a hidden phenomenon in outpatient mental health?
Int J Eat Disord
Cited by (26)
Bulimia nervosa
2023, Encyclopedia of Child and Adolescent Health, First EditionA randomized controlled trial of two 10-session cognitive behaviour therapies for eating disorders: An exploratory investigation of which approach works best for whom
2021, Behaviour Research and TherapyCitation Excerpt :It is somewhat lower than the 76% estimate across randomized controlled trials of CBT (Linardon et al., 2018), which can be expected to have more exclusion criteria. All eating disorders are attended by a high level of ambivalence, including bulimia nervosa (Wade, 2019, pp. 21–32), and engagement in treatment is challenging compared to some other psychological disorders. Our approach of informing people of the importance of early change for predicting outcome, and collaboratively ceasing therapy if this early progress was not evident, tries to manage this ambivalence by suggesting that now is not the right time for therapy rather than representing a failure, and that participants would be welcome to return when they feel more able to engage with the core therapy tasks.
Association of 5-HTR2A -1438A/G polymorphism with anorexia nervosa and bulimia nervosa: A meta-analysis
2021, Neuroscience LettersCitation Excerpt :AN is characterized by an inability to maintain a normal healthy body weight, typically arising from a morbid fear of weight gain, which motivates patients to avoid eating [41]. BN comprises recurrent episodes of binge eating, followed by compensatory behaviors to counteract it [43]. The majority of researchers agree that AN and BN are disorders of heterogeneous etiology.
Features of schizophrenia following premorbid eating disorders
2019, Psychiatry ResearchCitation Excerpt :Eating disorders (ED) are marked by systematic changes in eating-related behavior that result in diminished or excessive consumption of food along with impaired psychosocial function or physical health. Bulimia Nervosa (BN) entails recurrent episodes of binge eating over which one feels no control and for which one may try to compensate (Wade, 2019). It is often comorbid with Anorexia Nervosa (AN), which is characterized by weight loss, or by lack of appropriate weight gain in growing children, and difficulties in maintaining an appropriate body weight for one's height, age, and stature (Frank et al., 2019).
Eating disorders
2020, The LancetCitation Excerpt :Bulimia nervosa can occur at normal or elevated weight (if weight is less than the threshold for bulimia nervosa, then a diagnosis of anorexia nervosa is given with binge purge subtype as specifier). Bulimia nervosa is characterised by recurrent episodes of binge eating (ie, eating large amounts with loss of control) and compensatory behaviours to prevent weight gain.8 The most common compensatory behaviour is self-induced vomiting, but inappropriate use of medicines, fasting, or extreme exercise are also used.
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