Bulimia Nervosa

Edited by Shane R. Jimerson, Ph.D.
Contributed to by the Graduate Students in the Counseling, Clinical, andSchool Psychology Program at the University of California, Santa Barbara.

Ongoing design and publication of this site is completed by Shane R.Jimerson and Jeff R. Klein. Please forward comments regarding this site to Shane R. Jimerson. This page was last updated 7.9.98. © 1998

Author:
Micah Orliss
University of California, Santa Barbara

Symptoms
Epidemiology
Etiology
Assessment
Treatment

Bulimia nervosa is an important psychological disorder, yet has been the subject of less research than the other major eating disorder, anorexia nervosa. However, incidence rates indicate that it is more common than anorexia nervosa and, indeed, is most likely underreported, as individuals suffering from the disorder tend to be secretive about its existence and do not necessarily exhibit symptoms such as dramatically reduced body weight (Turnbull, Ward, Treasure, Jick, & Derby, 1996). Given this, it is important to be as aware and well-informed about bulimia nervosa as possible. This page will present some of the most current information and studies regarding bulimia nervosa in order to highlight the recent developments and new knowledge that has been gained about this historically overlooked disorder.

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DSM-IV Criteria for Bulimia Nervosa

Diagnostic criteria according to the DSM-IV (American Psychiatric Association, 1994) for Bulimia Nervosa:

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

1. eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances
2. a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)

A. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise.

B. The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months.

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

D. The disturbance does not occur exclusively during episodes of Anorexia Nervosa

Specify type:

Purging type: during the current episode of bulimia nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas

Nonpurging type: during the current episode of bulimia nervosa, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas

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Epidemiological Information

Various estimates of the prevalence of bulimia nervosa exist. According to a study by Turnbull et al. (1996) the prevalence of the disorder is 12.2 cases per 100,000 population, adjusted for age and gender, which was consistent with other research they reviewed. Bulimia nervosa is most common among female adolescents and young adults (American Psychiatric Association, 1994). It is estimated to occur in 1%-3% of this population. Some controversy exists as to whether the incidence of bulimia nervosa is increasing. While it does seem to be being diagnosed more frequently, it remains to be seen whether this reflects an increasing prevalence of the disease or a wider recognition of the symptoms of the disorder and therefore a higher rate of diagnosis (Turnbull et al., 1996). As mentioned earlier, bulimia nervosa occurs more often in females than males. This difference is striking: at least 90% of bulimics are women (Wilson, O’Leary, & Nathan, 1992). Bulimia nervosa typically has its onset during adolescence (American Psychiatric Association, 1994). It occurs most often, but not exclusively, in Caucasians (American Psychiatric Association, 1994).

Annotated Bibliography

Sullivan, P. F., Bulik, C. M., & Kendler, K. S. (1998). Genetic epidemiology of binging and vomiting. British Journal of Psychiatry, 173, 75-79.

This study presents interesting findings regarding the relative genetic and environmental influences of bulimia nervosa. It additionally examines the validity of the DSM-IV diagnostic criteria for the disorder. Using a study of 1897 female twins, the authors determine that 46% of binging variance and 72% of vomiting variance was accounted for by genetic factors. Individual-specific environmental factors accounted for the rest of the variance. The authors also determined that there was a significant overlap between the genetic factors accounting for binging and the genetic factors accounting for vomiting behaviors. The results also indicate that the DSM-IV criteria for bulimia nervosa are valid. This study is an important step forward in understanding the genetic and environmental epidemiology of bulimia nervosa, an issue which remains unresolved.

This article is a very good epidemiological study of both bulimia nervosa and anorexia nervosa. The authors made use of the General Practice Research Database, which holds the records of 550 general practitioners in the United Kingdom. This results in a database of over 4 million patients and is therefore a very broad and representative sample to examine. The authors examine the incidence rates of bulimia nervosa and anorexia nervosa in this sample over a six year period. Results are compared by gender and age. Frequency of diagnosis is also examined over this period. The authors conclude that the incidence of bulimia nervosa is increasing, which therefore necessitates a greater dissemination of information regarding the disorder and an increased knowledge of treatments.

Conclusion

While less is known about bulimia nervosa than other similar disorders, an influx of new research is changing that. At the moment, incidence rates indicate that it is the most prevalent eating disorder. Like other eating disorders, it occurs strikingly more often in women and is most common during adolescence and young adulthood. The current DSM-IV conception of bulimia nervosa has been independently validated and seems appropriate. However, controversy still exists over whether or not the incidence is increasing. Additionally, there is still disagreement over the specific genetic and environmental influences of the disorder (e.g. Curtis, 1998; Morgan, 1998; Sullivan, 1998). It seems then, that while researchers are gaining a greater understanding of bulimia nervosa, many specific details of the disorder remain to be resolved.

References

American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th Edition). Washington, D.C.: American Psychiatric Association.

Curtis, D. (1998). Correspondence regarding genetic epidemiology of binging and vomiting. British Journal of Psychiatry, 173, 439.

Morgan, J. F. (1998). Correspondence regarding genetic epidemiology of binging and vomiting. British Journal of Psychiatry, 173, 439.

Sullivan, P. F., Bulik, C. M., & Kendler, K. S. (1998). Genetic epidemiology of binging and vomiting. British Journal of Psychiatry, 173, 75-79.

Sullivan, P. (1998). Author’s reply. British Journal of Psychiatry, 173, 439-440.

Turnbull, S., Ward, A., Treasure, J., Jick, H., & Derby, L. (1996). The demand for eating disorder care: An epidemiological study using the General Practice Research Database. British Journal of Psychiatry, 169, 705-712.

Wilson, G. T., O’Leary, K. D., & Nathan, P. (1992). Abnormal Psychology. Englewood Cliffs, NJ: Prentice Hall.

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Etiology of Bulimia Nervosa

There are several different perspectives on the etiology of bulimia nervosa. Proponents of a biological viewpoint point to evidence that shows abnormalities in the serotonergic functioning of bulimic individuals (Walsh & Devlin, 1998). Additionally, some evidence points to abnormal satiety system functioning in bulimic individuals (Walsh & Devlin, 1998). Finally, as mentioned in the epidemiology section, there is evidence to support a genetic predisposition to bulimia (Sullivan, Bulik, & Kendler, 1998). From a psychological perspective, there is substantial evidence that demonstrates an association between dieting and the onset of bulimia (Walsh & Devlin, 1998; Lowe, Gleaves, & Murphy-Eberenz, 1998). Researchers hypothesize that the psychological stress associated with dieting increases the likelihood of binge eating, which can then lead to purging behavior. Other research shows a high comorbidity between bulimia nervosa and mood disorders (Stice & Agras, 1998). This finding has caused researchers to theorize that binge eating can be used as a coping mechanism for those suffering from negative affect. From a sociocultural perspective, the female ‘thin ideal’ seen in Western culture and especially in the Caucasian subculture has been proposed as another cause of bulimia nervosa. Because of the much higher rates of bulimia nervosa seen in women and especially in Caucasian women, it is hypothesized that some women have internalized these sociocultural body-shape standards to such a high degree that they use extreme measures (dieting, bingeing, and purging) to control their weight and figure (Tantillo, 1998; Stice and Agras, 1998).

Annotated Bibliography of Articles Relating to the Etiology of Bulimia Nervosa

Biological

Sullivan, P. F., Bulik, C. M., & Kendler, K. S. (1998). Genetic epidemiology of binging and vomiting. British Journal of Psychiatry, 173, 75-79.

This article, also described in the epidemiology section, presents interesting findings related to genetic factors’ influence on bulimia nervosa. Based on a sample of 1897 female twins, the authors conclude that there are indeed several genetic factors related to bingeing and vomiting behaviors. The authors also compare the relative influences of such genetic factors to other individual-specific environmental factors.

Psychological

Lowe, M. R., Gleaves, D. H., & Murphy-Eberenz, K. P. (1998). On the relation of dieting and bingeing in bulimia nervosa. Journal of Abnormal Psychology, 107, 263-271.

This article provides a good overview of the psychological model that is proposed to underlie the dieting-bingeing-purging cycle. However, the purpose of this article is to criticize and modify the model somewhat. The authors suggest that dieting plays an important part only in the initial instigation of the cycle. From that point on, the authors present findings that suggest that dieting actually reduces bingeing behavior.

Sociocultural

Tantillo, M. (1998). A relational approach to group therapy for women with bulimia nervosa: Moving from understanding to action. International Journal of Group Psychotherapy, 48, 477-498.

An interesting article that describes how the psychology of women can be used in group therapy for women with bulimia nervosa. Within the article, the author provides a nice overview of relational theory and its perspective on the etiology of bulimia nervosa. According to this theory, the bingeing and purging behavior seen in bulimia nervosa is a strategy women use to take control and express themselves in the absence of any mutual relationships with other individuals.

Carlat D. J., Camargo, C. A., Herzog, D. B. (1997). Eating disorders in males: A report on 135 patients. American Journal of Psychiatry, 154, 1127-1132.

This article represents one of the larger-sample studies examining eating disorders in men. The researchers found a much higher incidence of homosexuality and/or bisexuality among men with eating disorders than is seen in the overall male population. The researchers theorize that this higher incidence is related to the pressure towards thinness seen in the gay male subculture.

General

Stice, E. & Agras, W. S. (1998). Predicting onset and cessation of bulimic behaviors during adolescence: A longitudinal grouping analysis. Behavior Therapy, 29, 257-276.

Using the statistical technique of longitudinal grouping analysis, the researchers were able to examine certain predictors of the onset and cessation of bulimic behaviors. These predictors represent factors that can be included in all the above theories of the etiology of bulimia nervosa and this article therefore provides a good overview of how the above models might interact in bulimic patients.

Walsh, B. T. & Devlin, M. J. (1998). Eating disorders: Progress and problems. Science, 280, 1387-1390.

This article is a well written, if brief, overview of the current knowledge regarding both bulimia nervosa and anorexia nervosa. Biological, psychological, and cultural theories of the etiology are reviewed and treatments are discussed. Directions for future research are also presented.

Developmental Perspective

The developmental perspective views disorders, such as bulimia nervosa, in relation to ‘normal’ human development. This framework examines the various factors that preceded the development of the disorder and the consequences that occur as a result of the disorder’s onset. The course of a disorder is compared to ‘normal’ development in order to gain a greater understanding of the differences and possible reasons for them. As mentioned earlier, there are biological, psychological, and sociocultural explanations for the development of bulimia nervosa. A developmental perspective would examine all these factors together and theorize as to how they contributed to the development of bulimia nervosa. The developmental perspective is therefore ideal for incorporating various perspectives on the disorder and relating these theories to the course of normal human development. This highlights the complexity underlying the etiology of bulimia nervosa.

World Wide Web Sites Relating to Bulimia Nervosa

http://www.noah.cuny.edu/illness/mentalhealth/cornell/conditions/bulimia.html

This page is part of the New York Hospital-Cornell Medical Center’s web site of psychiatric disorders. It provides a few sentences pertaining to the definition, symptoms, cause, course, and treatment of bulimia nervosa. While this page is not especially in-depth, it does provide a quick snapshot of bulimia nervosa for those trying to gain a basic understanding of the disorder.

http://www.mentalhealth.com/dis/p20-et02.html

This page presents a very thorough review of bulimia nervosa in a well-designed manner. A straightforward title page allows viewers to read a description of the disorder, as well as learn about the diagnosis and treatment of bulimia nervosa. Additionally, readers can read an updated review of the research on bulimia nervosa, or link to booklets, magazine articles, and other web pages related to the disorder. This page allows the reader to gain as in-depth an examination of bulimia nervosa as he or she would like.

http://www.ex.ac.uk/cimh/help/anor_frame.html

This colorful and eye-catching page presents a fairly thorough review of bulimia nervosa and is designed for the general public. The easy-to-read text is written in paragraph form and covers symptoms, causes and treatments of the disorder. Additionally, it presents a bibliography of books related to eating disorders, again written for the general public. While clinicians might find this page less suited to their needs and interests, it is ideal for the casual reader.

http://www.cps.ca/english/statements/AM/am96-04.html

This page is a position paper on eating disorders written by the Canadian Paediatric Society (CPS) and was based on an article that appeared in the Journal of Adolescent Health. Written for an academic audience, this page presents the positions of the CPS on bulimia nervosa, broken down into the following categories: diagnosis, medical complications, nutritional and psychosocial disturbances, treatment, and barriers to care. The page includes journal references and is especially good for those interested in the biological model of the disorder or those interested in the disorder as it relates specifically to adolescents.

http://www.psych.org/public_info/eating.html

This is the APA’s web page on eating disorders. Despite a relatively poor design, the page should provide relevant information for both casual readers and a more academic audience. The page covers the standard topics of definitions, etiology and treatment. It also provides illustrative vignettes and a bibliography of other literature for interested parties. Addresses of other eating disorder resources are also given.

Conclusion

Biological, psychological, and sociocultural factors all seem to play a role in the etiology of bulimia nervosa. This makes the developmental perspective ideal to use when considering the disorder, as it is able to include all of these theories. Further research will only increase our understanding of the underlying causes of bulimia nervosa and should provide a more solid foundation on which to base treatments of the disorder.

References

Carlat D. J., Camargo, C. A., Herzog, D. B. (1997). Eating disorders in males: A report on 135 patients. American Journal of Psychiatry, 154, 1127-1132.

Lowe, M. R., Gleaves, D. H., & Murphy-Eberenz, K. P. (1998). On the relation of dieting and bingeing in bulimia nervosa. Journal of Abnormal Psychology, 107, 263-271.

Stice, E. & Agras, W. S. (1998). Predicting onset and cessation of bulimic behaviors during adolescence: A longitudinal grouping analysis. Behavior Therapy, 29, 257-276.

Sullivan, P. F., Bulik, C. M., & Kendler, K. S. (1998). Genetic epidemiology of binging and vomiting. British Journal of Psychiatry, 173, 75-79.

Tantillo, M. (1998). A relational approach to group therapy for women with bulimia nervosa: Moving from understanding to action. International Journal of Group Psychotherapy, 48, 477-498.

Walsh, B. T. & Devlin, M. J. (1998). Eating disorders: Progress and problems. Science, 280, 1387-1390.

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Assessment

There are several strategies used in the assessment of bulimia nervosa. One standard technique is the use of questionnaires. Among the most common questionnaires are the Eating Attitudes Test-26 (EAT-26; Garner, Olmsted, Bohr, & Garfinkel, 1982), the Eating Disorder Inventory-2 (EDI-2; Kutlesic, Williamson, Gleaves, Barbin, & Murphy-Eberenz, 1998), the Bulimia Test-Revised (BULIT-R; Thelan, Farmer, Wonderlich, & Smith, 1991), and the Questionnaire for Eating Disorder Diagnosis (Q-EDD; Mintz, O’Halloran, Mulholland, & Schneider, 1997). Of these inventories, only the Q-EDD is based on DSM-IV diagnostic criteria and is therefore the only one that can provide an assessment of bulimia nervosa in line with current thinking on the disorder (Mintz et al., 1997). However, the BULIT-R has recently been shown to reliably differentiate DSM-IV bulimics from non-bulimics, despite having been based on DSM-III-R diagnostic criteria (Mintz et al., 1997). The EAT-26 and EDI-2, though somewhat outdated, are still commonly used and can provide valuable information in the form of specific behaviors an individual might be exhibiting, such as bingeing or purging (Lowe, Gleaves, & Murphy-Eberenz, 1998). In fact, all the above questionnaires can be used for this purpose and can be useful in identifying individuals who might be symptomatic for bulimia nervosa, but fall short of being diagnosable.
Another frequently-used technique for assessing bulimia nervosa is through the use of a structured interview. Two such interviews are the Eating Disorders Examination (EDE; Fairburn & Cooper, 1993) and the Interview for the Diagnosis of Eating Disorders-IV (IDED-IV; Kutlesic et al., 1998). The EDE is the older of the two interviews and, like some of the above questionnaires, was not based on current DSM-IV diagnostic criteria. Additionally, the EDE makes its diagnosis on the basis of current symptoms only and does not take into account the patient’s developmental history (Kutlesic et al., 1998). However, despite these criticisms, the EDE is still widely used in the assessment of bulimia nervosa. The IDED-IV is a newer and less-studied interview, but it claims to have solved some of the problems the EDE suffers from. Based on DSM-IV diagnostic criteria, the IDED-IV provides diagnoses of bulimia nervosa, anorexia, and binge eating disorder (Kutlesic et al., 1998). In addition, it identifies patients who are below the threshold for diagnosis of an eating disorder, but are still symptomatic and may therefore need treatment.
A third strategy that can be used to assess bulimia nervosa is physiological examination. This can be used to assess specific symptoms of bulimia nervosa. For example, bulimics who use vomiting as a compensatory behavior often show small cuts on their fingers, loss of enamel on their teeth, and raw throats. Additionally, menstrual irregularities can occur in bulimic women (Casper, 1998). Determining whether physical symptoms such as these exist can also aid in the diagnosis of bulimia nervosa.

Annotated Bibliography of Articles Relating to the Assessment of Bulimia Nervosa

Questionnaires

Mintz, L. B., O’Halloran, M. S., Mulholland, A. M., & Schneider, P. A. (1997). Questionnaire for Eating Disorder Diagnosis: Reliability and validity of operationalizing DSM-IV criteria into a self-report format. Journal of Counseling Psychology, 44, 63-79.

This article describes the development of the Q-EDD. This is a very promising new eating disorder assessment tool and the article explains how the Q-EDD has improved on other existing questionnaires. Promising reliability and validity data are presented in support of the Q-EDD. In addition, the authors provide a fairly thorough overview of other eating disorder questionnaires. The authors conclude by discussing possible uses and limitations of the Q-EDD.

Hohlstein, L. A., Smith, G. T., & Atlas, J. G. (1998). An application of expectancy theory to eating disorders: Development and validation of measures of eating and dieting expectancies. Psychological Assessment, 10, 49-58.

The authors use learned expectancy theory to examine eating disorders. In doing so they describe their development of instruments assessing learned expectations for reinforcement from eating and dieting. They also provide a brief, but thorough, overview of other eating disorder questionnaires. The authors then present their findings based on the administration of their questionnaire. These results should be of special interest to those examining eating disorders from a cognitive-behavioral perspective.

Interviews

Kutlesic, V., Williamson, D. A., Gleaves, D. H., Barbin, J. M., & Murphy-Eberenz, K. P. (1998). The Interview for the Diagnosis of Eating Disorders-IV: Application to DSM-IV diagnostic criteria. Psychological Assessment, 10, 41-48.

The authors present reliability and validity results for the IDED-IV. They also discuss its development and how it differs from previous IDED interviews. Comparisons are made to other structured interviews used to assess eating disorders. The results seem promising and the IDED-IV appears to be a very well-designed assessment tool that incorporates the current theories and understanding of eating disorders.

Lowe, M. R., Gleaves, D. H., & Murphy-Eberenz, K. P. (1998). On the relation of dieting and bingeing in bulimia nervosa. Journal of Abnormal Psychology, 107, 263-271.

This article, also cited in the etiology section, provides a good overview of some of the interviews and questionnaires used to assess eating disorders. For the purposes of the study, the authors used the BULIT-R, EDI-2, EDE, and EAT-26 to asses eating behaviors. The article provides a nice description of all of these items, including the EDE. However, as mentioned earlier, the authors main purpose is to describe their findings regarding the dieting-bingeing-purging cycle. In any case, it should be relevant for those interested in the etiology or assessment of bulimia nervosa.

Physiological Measurements

Casper, R. C. Recognizing eating disorders in women. Psychopharmacology Bulletin, 34, 267-269.

This article, though fairly brief, provides a good overall outline of how eating disorders are diagnosed. As the author is an M. D., she provides especially good insights into the physiological symptoms of eating disorders. This article is good for those interested in the biological perspective of eating disorders.

Walsh, B. T. & Devlin, M. J. (1998). Eating disorders: Progress and problems. Science, 280, 1387-1390.

This article, also cited in the etiology section, presents a broad overview of the current thinking on eating disorders. Special emphasis is placed on the biological perspective and the authors provide a fairly in-depth review of the physiological symptoms one would expect to find in patients with bulimia nervosa and anorexia. This is another good article for those interested in the physiological symptoms of eating disorders.

Developmental Perspective

The developmental perspective is a valuable framework to use when assessing bulimia nervosa. Certain developmental patterns of the disorder have been well established. Specifically, bulimia nervosa is known to rarely emerge in pre-adolescent children. More often it emerges in mid to late adolescence or early adulthood (APA, 1994). Additionally, it occurs much more often in females than males. While the symptoms of bulimia nervosa are never developmentally appropriate and should require treatment under any circumstances, other diagnoses should be kept in mind if young children or males present with any of the symptoms.
Aside from such known developmental patterns, the developmental perspective can be of additional use in assessing bulimia nervosa. Because the developmental theory can incorporate the many possible underpinnings of a disorder, such as biological, sociocultural, and psychological causes, this perspective can allow clinicians to take all of these factors into account when assessing the disorder. Limitations need not be placed on the information a clinician can use to assess the disorder.
Furthermore, the developmental perspective can be useful way to help individuals who are symptomatic, but not yet diagnosable for bulimia nervosa. These individuals should not be considered non-bulimic and therefore not worthy of treatment. Rather, the developmental perspective would see them on the path to developing a full eating disorder and therefore in need of preventative treatment. Treating these individuals might be easier than treating a diagnosable individual and therefore would save time and energy for all involved. However, very few of the assessment tools mentioned earlier distinguish between individuals who are symptomatic, but not diagnosable for bulimia nervosa and those who are not at all symptomatic. The Q-EDD is one tool that does make this distinction, however.
One final benefit of the developmental perspective in assessing bulimia nervosa is that it allows clinicians to take into account a patient’s history, rather than their current symptoms alone. Individuals with a history of bulimia nervosa should be assessed with added scrutiny if the disorder seems to be reoccurring. Such individuals are at added risk and should receive treatment even if the disorder has not reemerged fully. One weakness of many of the assessment questionnaires and interviews mentioned above is that they only examine current symptoms when assessing bulimia nervosa. The EDE is a notable exception to this trend, however.

Optimal Assessment Strategy

When assessing bulimia nervosa, the Q-EDD is quite possibly the optimal tool to use. One of its greatest benefits is its recent development, a fact that allows it to make use of the current DSM-IV diagnostic criteria as well as the current understanding of the disorder. In addition, it is able to provide numerous conclusions about an individual, rather than simply classifying him or her as bulimic or non-bulimic. The Q-EDD has the ability to diagnose an individual into numerous categories, the most broad being eating disordered or non-eating-disordered. Each of these groups can then be broken down into further categories. The non-eating-disordered group is divided into individuals who are symptomatic and those who are not symptomatic. The eating disordered group can be classified as bulimic, anorexic (including the various DSM-IV subtypes of these two disorders), or eating disordered, type not otherwise specified. This last category has four subgroups that reflect subtypes listed in the DSM-IV. In short, the Q-EDD can provide a wide variety of eating disorder diagnoses at the clinical and subclinical levels. As mentioned earlier, this is a much better way of classifying individuals with eating disorders.
There are some limitations to the Q-EDD, however. It does not assess whether an individual has had a history of bulimia nervosa or other eating disorder. However, this should not be too difficult for a clinician to determine in an interview setting and is therefore a relatively minor criticism. One other drawback to the Q-EDD is that due to its recent development, there has not been a great deal of research that has conclusively demonstrated its validity. Early results look very promising, however, and it will only be a matter of time before other research confirms or refutes these initial findings.

Conclusion

There are numerous techniques that can be used to aid in the assessment of bulimia nervosa. Questionnaires, interviews, and physiological measures can be used in order to determine whether or not an individual is bulimic. From a developmental perspective, clinicians should be concerned not only with the diagnosis of bulimia, but also with the assessment of bulimic symptoms and bulimia nervosa history. Preventative treatments can be used for individuals who fit either of these two categories. However, few of the assessment tools mentioned earlier gather either of these pieces of information. Notable exceptions are the Q-EDD and the IDED-IV. It is ultimately the clinician’s responsibility to incorporate all of the necessary information when assessing bulimia nervosa. A developmental perspective is well-suited for this purpose.

WWW Sites Related to the Assessment of Bulimia Nervosa

http://www.aabainc.org/general/bulimia.html

This site, put up by the American Anorexia Bulimia Association (AABA), provides a thorough description of the symptoms of bulimia nervosa. Designed for the lay audience, readers can get a broad picture of how a bulimic individual might appear or act. While it does not provide DSM-IV diagnostic criteria, it does present a well written overview of the disorder that should answer many basic questions about the disorder. Their main page also presents further information about bulimia nervosa and other eating disorders. This page is best for people who want a relatively brief overview of the disorder.

http://chat.concernedcounseling.com/

This page provides a good starting point to this excellent and exhaustive site. They have lots of different things here, even as far as assessment options go. Specifically, they have an online eating disorder assessment test, a BMI calculator, and various other interactive eating disorder screening surveys. DSM-IV criteria are also presented. In addition to all of that, they provide access to online counselors and phone numbers to reach counselors 24 hours a day. Support chat rooms exist, personal accounts of eating disorders abound, the latest research information is also presented - this site really has it all. This is a good page for professionals and non-professionals alike, and a model for other pages to strive towards.

http://www.onlinepsych.com/index.html/Eating_Disorders/

This is another very comprehensive that professionals and non-professionals will find useful. Published by Online Psych, this page has a list of numerous articles related to eating disorders, some of which are targeted at a lay audience and others that are targeted at clinicians and researchers. As far as assessment of bulimia nervosa goes, they provide lists of symptoms, articles on how to obtain a professional diagnosis, and a search engine where you can access the latest articles from Medline. Not quite as self-explanatory as Concerned Counseling, but very thorough nonetheless. Another good site.

http://www.something-fishy.org/bul.htm

This site has a pretty strange name (Something Fishy on Eating Disorders), but is actually very comprehensive. Targeted more at the lay audience, there is still lots of information to be had. In regards to assessing bulimia nervosa, a relatively brief overview is initially presented, with a link to a much more thorough list of signs and symptoms. Information is also provided on how to contact a professional. This site is designed well ? if you’re looking for a specific piece of information you should be able to find it fairly quickly, but if you just want to look around, there’s plenty to read. This site is definitely worth a visit.

http://www.mirror-mirror.org/edtest.htm

This is an eating disorders test presented by the lager page Mirror-Mirror (on the wall). Basically, it’s a list of 23 symptoms to which you answer yes or no. They recommend that you be concerned if you answer yes to three or more questions. At the bottom of the page is a list of the other parts of the site which includes both an overview and a more thorough list of symptoms of bulimia nervosa. This page seems designed primarily to help those who think they or someone they know might have an eating disorder. There’s lots of information here, but it’s mostly targeted at a lay audience.

References

American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th Edition). Washington, D.C.: American Psychiatric Association.

Casper, R. C. Recognizing eating disorders in women. Psychopharmacology Bulletin, 34, 267-269.

Fairburn, C. G. & Cooper, Z. (1993). The Eating Disorder Examination (12th edition). In: Fairburn, C. G. and Wilson, G. T., eds. Binge Eating: Nature, Assessment, and Treatment. New York, NY: Guilford Press.

Garner, D. M., Olmsted, M. P., Bohr, Y., & Garfinkel, P. E. (1982). The Eating Attitudes Test: Psychometric features and clinical correlates. Psychological Medicine, 12, 871-878.

Lowe, M. R., Gleaves, D. H., & Murphy-Eberenz, K. P. (1998). On the relation of dieting and bingeing in bulimia nervosa. Journal of Abnormal Psychology, 107, 263-271.

Thelan, M. H., Farmer, J., Wonderlich, S., & Smith, M. (1991). A revision of the Bulimia Test: The BULIT-R. Psychological Assessment, 3, 119-124.

Walsh, B. T. & Devlin, M. J. (1998). Eating disorders: Progress and problems. Science, 280, 1387-1390.

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Treatment

While numerous treatments for bulimia nervosa exist, two strategies predominate and have the most empirical support. Probably the most well-established treatment is cognitive-behavioral therapy. This is a very useful approach, as it allows for treatment of both the immediate symptoms as well as their underlying cognitions. Typically, treatment is given in three phases (Wilfley & Cohen, 1997). The first phase consists of behavioral interventions designed to interrupt the bingeing/purging cycle. One such intervention could be the introduction of a schedule of healthy eating (Lewandowski et al., 1997). Next, cognitive strategies are used to challenge the disordered thought patterns that influence the disordered eating. Distorted body image is an example of something that might be targeted in this stage. Treatment concludes with relapse prevention techniques that help ensure the patient will not resume his or her old thoughts and behaviors. Studies have generally shown cognitive-behavioral therapy to be superior to other forms of treatment (e.g. Wilfley & Cohen, 1997; Walsh et al., 1997). It therefore should be included in the treatment of bulimia nervosa in most cases.
The other major technique used in the treatment of bulimia nervosa is medication. Psychopharmeceuticals were initially used in treating bulimia nervosa because of its high comorbidity with depressive disorders. However, subsequent studies showed that antidepressants were as effective in treating bulimic clients with no depressive symptoms as they were in treating depressed bulimics (Robin, Gilroy, & Dennis, 1998). These findings have lead to the frequent usage of antidepressants in the treatment of bulimia nervosa. Studies have shown that medication alone reduces binge and purge episodes by about 70% (Agras, 1997). About one third of all patients fully recover. Evidence has also shown that if a specific medication is not effective, the substitution of a second antidepressant can significantly decrease symptoms of the disorder (Walsh et al, 1997). However, about 25% of clients drop out due to side effects of the medications. Yet overall, there therefore seems to be good support for the usage of psychoactive drugs in the treatment of bulimia nervosa.

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