History and exam

Key diagnostic factors

common

presence of risk factors

Risk factors that are strongly associated with bulimia nervosa include: female sex; certain personality disorders; body dissatisfaction; impulsivity; history of sexual abuse; family history of alcoholism, depression, or eating disorder; past obesity; exposure to media pressure. Early onset of puberty is associated with early onset of bulimia nervosa.[18]

recurrent episodes of binge eating

Necessary for diagnosis.

Binge eating must occur within a discrete period of time (e.g., 2 hours) and involve an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.

A sense of lack of control must be present during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).

Occurs, on average, at least once a week for 3 months.

recurrent inappropriate compensatory behaviour

There must always be some form of compensatory behaviour to attempt to burn off calories. This may be purging (vomiting, laxatives, enemas, suppositories) or non-purging (exercise, fasting).

Occurs, on average, at least once a week for 3 months.

eating disturbance not exclusively during periods of anorexia nervosa

Confirmation of an eating disturbance that does not occur exclusively during periods of anorexia nervosa is a diagnostic requirement in DSM-5-TR.[69]

depression and low self-esteem

Patients usually have low self-esteem, lack of confidence, and depressive thoughts. Treatment of concurrent depression improves outcome. Concurrent depression may be related to drug or alcohol use. Should be monitored and addressed in treatment.[70]

concern about weight and body shape

Nearly always present, although it may be denied initially. Self-evaluation is unduly influenced by body shape and weight.

Men with bulimia nervosa may be more weight- and shape-conscious, and usually want to gain weight in the form of muscle, but lose fat.

Athletes who participate in weight-sensitive sports, such as figure-skating or wrestling, may wish to lose or gain weight to fit a desired body type or weight-class.[57]

dental erosion

Erosion of adult teeth is permanent and can be extremely costly to correct. Dental changes often reduce self-esteem and can make it painful and difficult to chew hot or cold food.

It is important to prevent and treat dental erosion. Better appearance is also a motivational tool. Focusing on the changes in gums and teeth that point to a progression of tooth loss can motivate patients to accept treatment.

parotid hypertrophy

The parotid glands are bilaterally enlarged but are usually not tender unless the purging is frequent.[62][71][72]

Russell's sign

Scarring over the dorsum of the hands. This results from pressing fingers against the teeth inserted into the mouth to induce vomiting.[62][63][64][65]

arrhythmia

More common in presence of hypokalaemia or hypomagnesaemia. Loss of consciousness, fainting, ventricular arrhythmias, and arrhythmias lasting more than a few minutes are rare.

Other diagnostic factors

common

age 20 to 35 years

Most common onset is in women of this age group.[73]

menstrual irregularity

Occasional missed or abnormal menstrual periods can occur. Important for counselling, particularly because contraceptive pills may be purged. A skipped period may be due to pregnancy or to the bulimia itself.[74]

drug-seeking behaviour

Physicians should be aware that abuse of laxatives and drug-seeking behaviour for laxatives and appetite suppressants is common. In addition, medications may be collected to use for suicide.[70][75]

deliberate misuse of insulin

Patients with diabetes may skip insulin to control their weight.[4]​ This leads to marked fluctuations in blood sugar and rapid onset of diabetic microvascular complications.[76]

self-injurious behaviour

Patients will usually not mention such behaviour. Therefore, their skin should be examined.[66]

gastrointestinal symptoms

Oesophageal reflux, diarrhoea, constipation, and abdominal pain are frequent in bulimia nervosa.

These result from volume depletion and deficiencies of vitamins and minerals arising from bingeing on large volumes of food, with erratic eating in between vomiting.

history of dieting

Patients with bulimia nervosa are often ashamed to admit they have the disease. Therefore, a high index of suspicion is important. A history of dieting would raise suspicion for the condition.

marked fluctuations in weight

A history of dieting along with a high index of suspicion would raise the possibility of the condition.

uncommon

shoplifting behaviour

Seen occasionally among bulimic patients.

use of ipecac

Used by some patients to induce vomiting. It can cause a cardiomyopathy.​[77]​​[78]

needle marks on skin

Patients may self-phlebotomise as a form of purging, but rarely give this history. Anaemia and the presence of needle marks may be the only clues.[79]

vomiting in pregnancy

Marked vomiting can be due to or confused with hyperemesis gravidarum. Bulimia nervosa may first present clinically during pregnancy when patients report worsening bingeing and purging. Patients may be more concerned about weight and shape, or about implications for the pregnancy.[68]

Risk factors

strong

female sex

90% of patients are female.[15][19]

The research on men with bulimia nervosa is poor due to the condition not being as common in men, and because they are often excluded from research trials to reduce the number of confounding factors.[5]​​[6]​​[7]​​[8]​​

personality disorder

Association reported between negative emotionality, perfectionism, drive for thinness, poor interoceptive (body stimuli) awareness, a perception of ineffectiveness in one's life, and obsessive-compulsive personality traits. These factors may predict a poorer course and/or outcome.[20][21]

Obsessive-compulsive disorder predicts a poorer outcome if it is not treated. Histrionic personality traits and self-directedness predict a more favourable course and/or outcome.[22][23][24]

The association of personality disorder with bulimia nervosa by self-reported instruments may greatly overestimate their association, and their co-occurrence does not influence the outcome of bulimia nervosa up to 3 years after treatment.[20][25]

body-image dissatisfaction

Common in those with bulimia nervosa, as well as in the mothers of people with bulimia. Body-image dissatisfaction is often reduced after improvement in bulimia nervosa.[26][27][28][29][30]

history of sexual abuse

There is an association between sexual abuse and a lifetime diagnosis of psychiatric disorders including eating disorders.[31] Sexual abuse before puberty can cause severe body image dissatisfaction and increase the risk of bulimia nervosa.

impulsivity

Impulsivity and self-injurious behaviour are increased in bulimia nervosa according to cross-sectional studies.

Impulsivity and self-injurious behaviour were increased in frequency in very ill patients with bulimia nervosa and were higher in bulimia nervosa than in anorexia nervosa.[32]​​[33][34]​​[35]

Cause and effect are unclear.

family history of alcoholism

Alcoholism is more common in the family history of those with bulimia nervosa than in those with anorexia nervosa. Alcoholism may be a marker for other psychiatric or social abnormalities.[36][37][38]

family history of depression

Depressive symptomatology is common in bulimia nervosa, and major depressive disorder can worsen the course of bulimia.[39][40]

family history of eating disorder

Excessive concern about weight and shape is common in such families.[41][42]

childhood overweight or obesity

Being obese or overweight in childhood increases the risk of bulimia nervosa.[43][44][45]

exposure to media pressure

Idealisation of body shape and eating has a strong effect on the development of bulimia nervosa.[46][47][48][49][50][51]

early onset of puberty

Early onset of puberty is associated with early onset of bulimia nervosa.[18]

weak

urbanisation

Association reported.[16] Bulimia nervosa is more common in urban areas, as are schizophrenia and depression. By contrast, prevalence of anorexia nervosa is no different in rural and urban areas.

Bulimia is highly related to societal and cultural pressures.​[52]​ Anorexia is more likely to depend on specific genetic predisposition and triggered by weight loss.[16]

family history of obesity

Weak predictor of bulimia.[17]

participation in elite-level sports

One study reported a higher prevalence of bulimia nervosa in athletes compared to non-athletes, while disordered eating behaviours are also more common in this group.[53][54][55][56][57]​​​​​​​​

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