Bulimia Nervosa – Signs, Risks, DSM-5 Criteria and Treatment

What are the Signs and Symptoms of Bulimia Nervosa

• Recurrent binge eating episodes involving excessive food intake within a discrete period, often accompanied by a sense of loss of control.

• Compensatory behaviors to prevent weight gain, including purging (vomiting, laxative use), excessive exercise, or fasting.

• Frequent preoccupation with body shape and weight, often leading to extreme dieting and self-esteem issues.

• Binge eating often occurs in secrecy, with individuals consuming foods they would typically avoid and eating until uncomfortably full.

What is the likelihood of having Bulimia Nervosa?

• The 12-month prevalence of bulimia nervosa in young females is 1 to 1.5%.

• The peak onset occurs in older adolescence and young adulthood.

• Bulimia affects females significantly more than males, with a 10:1 female-to-male ratio.

What are the chances of recovering from Bulimia Nervosa?

• Many individuals experience remission, either with or without treatment, though treatment improves long-term outcomes.

• Periods of remission lasting over a year are associated with better long-term outcomes.

• 10-15% of individuals with bulimia nervosa transition to anorexia nervosa. However, many of these cases eventually revert to bulimia nervosa or experience multiple transitions between the two disorders.

• Some individuals stop engaging in compensatory behaviors but continue binge eating, leading to a diagnosis of binge-eating disorder.

What other mental health disorders may occur with Bulimia Nervosa?

• Depressive symptoms (low self-esteem, mood instability) and depressive disorders are commonly seen in individuals with bulimia.

• Substance use disorders, particularly alcohol or stimulant use (to control appetite), occur in at least 30% of cases.

• Borderline personality disorder is prevalent among individuals with bulimia nervosa.

What medical disorders may occur with Bulimia Nervosa?

• Menstrual irregularities or amenorrhea in females.

• Fluid and electrolyte imbalances (e.g., hyponatremia, hypokalemia, hypochloremia) can lead to severe complications.

• Metabolic disturbances include metabolic alkalosis from vomiting and metabolic acidosis from laxative and diuretic misuse.

• Gastrointestinal and cardiac risks: Rare but potentially fatal complications include gastroesophageal rupture and cardiac arrhythmias.

Standard investigations may include blood work such as CBC, electrolytes, renal function tests, liver function tests, cholesterol levels, serum amylase, and ECG.

What can predispose someone to Bulimia Nervosa?

• Childhood experiences: Childhood obesity, early pubertal maturation, and history of sexual or physical abuse.

• Psychological factors: Social anxiety disorder, weight concerns, low self-esteem, and childhood anxiety or depressive symptoms.

• Sociocultural influences: Internalization of a thin body ideal contributes to body dissatisfaction and increases the risk of bulimia.

DSM-5 Criteria for Bulimia Nervosa

According to the DSM-5, bulimia nervosa is diagnosed based on the following criteria:

A. Recurrent episodes of binge eating, characterized by:

1. Eating, in a discrete period (e.g., within 2 hours), an amount of food significantly larger than most individuals would eat in a similar period under similar circumstances.

2. A lack of control over eating during the episode.

B. Recurrent inappropriate compensatory behaviors to prevent weight gain, such as self-induced vomiting, misuse of laxatives, fasting, or excessive exercise.

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

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

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

Differentiating Bulimia from Anorexia and Binge-Eating Disorder

Bulimia nervosa can often be confused with other eating disorders, such as anorexia nervosa and binge-eating disorder. Key differences include:

1. Bulimia Nervosa vs. Anorexia Nervosa:

   • Individuals with anorexia nervosa have significantly low body weight (BMI < 17), whereas individuals with bulimia nervosa fall within the normal to overweight range (BMI > 17).

   • While Anorexia nervosa most commonly involves severe food restriction and bulimia nervosa most commonly involves binge eating and compensatory behaviors, none of these symptoms is specific to one diagnosis. The key differentiator is weight (BMI).

2. Bulimia Nervosa vs. Binge-Eating Disorder:

   • Both disorders involve binge eating, but binge-eating disorder lacks compensatory behaviors (e.g., purging, excessive exercise, or fasting).

   • Individuals with binge-eating disorder are often overweight or obese, while those with bulimia nervosa are more likely to have weight fluctuations within a normal range.