Bulimia Nervosa + Binge Eating Disorder - DSM-5

Diagnostic Criteria [Bulimia]

A) repeated binge-eating episodes, characterised by eating more food than most people would under similar circumstances within a discrete timeframe + feeling a lack of control over their eating during the episode (eg: can’t stop, can’t control how much / what they’re eating)

B) repeated inappropriate compensatory behaviours to prevent weight gain (eg: self-induced vomiting, abusing laxatives / diuretics / meds, fasting, excessive exercise)

C) binge-eating + compensatory behaviours both happen, on avg, at least once a week for 3+ mos.

D) self-evaluation is overly influenced by body shape + weight

E) disturbance doesn’t exclusively happen during anorexic episodes

Diagnostic Features [Bulimia]

• 1 binge-eating episode can take place over multiple settings 

• some people describe a dissociative quality during or after binge

• some feel that binge-eating episodes no longer feel like acute loss of control — instead, more general pattern of uncontrolled eating (eg: if someone says they’ve given up trying to control their eating, that counts)

• most common triggers for binge-eating episodes: negative affect, interpersonal stressors, dietary restraint, negative feelings about body / food, boredom

  • may mitigate these feelings in short-term but lead to negative self-evaluation + dysphoria later

• usually people feel ashamed of binge-eating + try to hide it, only doing so in secret

• vomiting is most common compensatory behaviour + can become its own goal (ie: bingeing in order to vomit or vomiting after only eating a small amount)

Associated Features [Bulimia]

• typically within normal weight to overweight range

• menstrual irregularity

• gastrointestinal symptoms

Prevalence [Bulimia]

• 12-mo in US adults: .14 - .3%

  • much higher in women (.22 - .5%) than men (.05 - .1%)

• lifetime in US adults: .28 - 1%

  • W: .46 - 1.5%; M: .05 - .08%

• most prevalent in high-income industrialised countries

Development + Course [Bulimia]

• usually starts in adolescence or young adulthood

• uncommon for onset before puberty / after 40

• often starts during / after an instance of dieting to lose weight or after multiple stressful life events

• high percentage of people have disordered eating behaviours for several years; can be chronic or intermittent

• symptoms tend to decrease w/ or without treatment, tho treatment is still impactful on outcome

• periods of remission lasting 1+ yr: associated w/ better outcome

• crude mortality rate: 2% per decade, both all-cause + suicide

• 10 - 15% of people w/ bulimia experience diagnostic crossover to anorexia

  • typically will revert back to bulimia or cross back and forth repeatedly

• some stop compensating + just binge-eat, diagnostically crossing to binge-eating disorder or other specified ED

Risk Factors [Bulimia]

• temperamental: weight concerns, low self-esteem, depressive symptoms, social anxiety disorder, childhood generalised anxiety disorder

• environmental: internalising thin body ideal → increased risk for weight concerns → increased risk of bulimia; childhood sexual / physical abuse also increases risk

• genetic: childhood obesity + early pubertal maturation increases risk; possible familial transmission or genetic vulnerabilities

• course modifiers: severity of psychiatric comorbidity → worse longterm outcome

Functional Consequences [Bulimia]

• ¼ - 1/3 have experienced suicidal ideation or attempted suicide

• range of functional impairment

• decreased health-related quality of life

• minority have severe role impairment, mostly around social life

Differential Diagnoses [Bulimia]

• anorexia (binge-eating/purging type)

• binge-eating disorder

• Kleine-Levin syndrome

• major depressive disorder w/ atypical features

• borderline personality disorder

Differential Diagnosis: Anorexia (Binge-Eating/Purging Type) [Bulimia]

if bingeing / purging behaviours only happen during periods of anorexia, anorexia should be diagnosed. if individual was initially diagnosed w/ anorexia (binge-eating/purging type) but no longer meets full criteria for anorexia, bulimia diagnosis should only be given when all bulimia criteria have been met for at least 3mos

Differential Diagnosis: Binge-Eating Disorder [Bulimia]

some people binge but lack compensatory behaviours, indicating binge-eating disorder

Differential Diagnosis: Kleine-Levin Syndrome [Bulimia]

in neurological or other medical conditions like Kleine-Levin syndrome, disturbed eating behaviours are present, but the psychological features of bulimia (eg: body image disturbance) are not

Differential Diagnosis: Major Depressive Disorder With Atypical Features [Bulimia]

overeating is common in major depressive disorder w/ atypical features, but compensatory behaviours + body image concerns will be absent. if criteria for both disorders are met, both diagnoses can be made

Differential Diagnosis: Borderline Personality Disorder [Bulimia]

binge-eating is included in impulsive behaviour criterion for BPD. if criteria for both are met, both should be diagnosed

Comorbidity [Bulimia]

• common: most have at least 1 other disorder + many have multiple

• occurs across wide range of disorders

• increased frequency of depressive symptoms & bipolar + depressive disorders

  • for many, mood disturbance onset was @ same time or after bulimia onset, feeling that bulimia caused disturbance — but some have mood disturbance first

• may be increased frequency of anxiety symptoms + anxiety disorders

• mood + anxiety disturbances often remit after effective bulimia treatment

• liftime prevalence of substance use disorder (esp. alcohol + stimulants) is at least 30%

  • many start stimulant use as way to control appetite / weight

• substantial overlap with personality disorders, esp. BPD

Diagnostic Criteria [Binge-Eating Disorder]

A) repeated binge-eating episodes, characterised by eating more food than most people would under similar circumstances within a discrete timeframe + feeling a lack of control over their eating during the episode (eg: can’t stop, can’t control how much / what they’re eating)

B) binge-eating episodes are associated w/ 3+ of the following:

1. eating much faster than normal

2. eating until uncomfortably full

3. eating large amounts of food when not physically hungry

4. eating alone out of embarrassment about how much they’re eating

5. feeling disgusted w/ self, depressed, or guilty afterwards

C) marked distress about binge-eating

D) binge-eating happens, on avg, at least once a week for 3mos

E) binge-eating behaviour isn’t associated w/ repeated inappropriate compensatory behaviours + doesn’t happen exclusively during anorexia / bulimia episodes

Associated Features [Binge-Eating Disorder]

• happens in normal weight, overweight, + obese people

  • in treatment-seeking individuals, reliably associated w/ being overweight + obese 

• obese people w/ binge-eating disorder consume more calories, have higher functional impairment, lower quality of life, more subjective distress, + greater psychiatric comorbidity than obsese people without binge-eating disorder

Prevalence [Binge-Eating Disorder]

• 12-mo in US: .44 - 1.2%

  • 2 - 3x higher in women (.6 - 1.6%) than men (.26 - .8%)

• lifetime in US: .85 - 2.8%

  • W: 1.25 - 3.5%; M: .42 - 2%

Development + Course [Binge-Eating Disorder]

• not much known about development

• binge-eating + loss-of-control eating happen in kids + are associated w/ weight gain, increased body fat + psych symptoms

• binge-eating + loss-of-control eating may be prodromal ED phase for some

• typically starts in adolescence or young adulthood, but can start later

• dieting follows development of binge-eating for many (unlike bulimia, where it tends to precede)

• people seeking treatment are usually older than people w/ anorexia or bulimia seeking treatment

• remission rates are higher than for bulimia / anorexia, both w/ + without treatment

• course = variable, but commonly seems to be persistent w/ periods of relapse + remittance (similar to bulimia in severity + duration)

• crossover from binge-eating disorder to other disorders is uncommon

Risk Factors [Binge-Eating Disorder]

• genetic: seems to run in families, indicating genetic influence

Functional Consequences [Binge-Eating Disorder]

• 25% experience suicidal ideation

• associated w/ range of functional consequences, inc. social role adjustment problems, decreased health-related quality of life + life satisfaction, increased medical morbidity + mortality, + increased health care utilisation

• may be associated w/ increased risk for weight gain + obesity development

Differential Diagnoses [Binge-Eating Disorder]

• bulimia nervosa

• obesity

• bipolar disorders

• depressive disorders

• borderline personality disorders

Differential Diagnosis: Bulimia [Binge-Eating Disorder]

overlap in recurrent binge-eating, but people w/ binge-eating disorder are missing compensatory behaviours + tend not to have sustained dietary restrictions between episodes (tho attempts at dieting may be made). people w/ binge-eating disorder tend to respond better to treatment + have higher improvement rates than people w/ bulimia

Differential Diagnosis: Obesity [Binge-Eating Disorder]

levels of overvaluing body weight + shape, + psychiatric comorbidity, are higher in obese people w/ binge-eating disorder than obese people without. outcome of evidence-based treatment for binge-eating tends to be more successful than treatment of obesity in people w/ comorbid obesity + binge-eating disorder

Differential Diagnosis: Bipolar Disorders [Binge-Eating Disorder]

increased appetite + weight gain are atypical feature specifiers for bipolar disorders. binge-eating + other disordered eating symptoms are also seen in association w/ bipolar. if full criteria for both disorders are met, both should be diagnosed

Differential Diagnosis: Depressive Disorders [Binge-Eating Disorder]

increased appetite + weight gain are major depressive disorder criteria + atypical feature specifiers for depressive disorders. increased eating during a major depressive episode may or may not be associated w/ loss of control. if full criteria for both are met, both should be diagnosed

Differential Diagnosis: Borderline Personality Disorder [Binge-Eating Disorder]

binge-eating is included in impulsive behaviour criterion of BPD. if full criteria for both are met, both should be diagnosed

Comorbidity [Binge-Eating Disorder]

• associated w/ significant psychiatric comorbidity, comparable to bulimia or anorexia

• most common: major depressive disorder + alcohol use disorder

• linked to severity of binge-eating, not to degree of obesity