Bulimia nervosa is characterized by binge eating and inappropriate compensatory behaviors, such as vomiting, fasting, excessive exercise and the misuse of diuretics, laxatives or enemas. Although the etiology of this disorder is unknown, genetic and neurochemical factors have been implicated. Bulimia nervosa is 10 times more common in females than in males and affects up to 3 percent of young women. The condition usually becomes symptomatic between the ages of 13 and 20 years, and it has a chronic, sometimes episodic course. The long-term outcome has not been clarified. Other psychiatric conditions, including substance abuse, are frequently associated with bulimia nervosa and may compromise its diagnosis and treatment. Serious medical complications of bulimia nervosa are uncommon, but patients may suffer from dental erosion, swollen salivary glands, oral and hand trauma, gastrointestinal irritation and electrolyte imbalances (especially of potassium, calcium, sodium and hydrogen chloride). Treatment strategies are based on medication, psychotherapy or a combination of these modalities.

Bulimia nervosa is a psychiatric syndrome with potentially serious consequences.1,2 Relatively effective treatments for this disorder have been developed, and early intervention is more likely to facilitate eventual recovery.2 Unfortunately, few health care professionals receive training in the assessment of bulimia nervosa. Therefore, they may be unable to identify and treat patients with the disorder.

Historically, patients with bulimia nervosa often were hospitalized until the most disruptive symptoms ceased. In today's health care environment, hospitalization for bulimia nervosa is infrequent and tends to take the form of brief admissions focused on crisis management.3 Specialists in the field of eating disorders have responded to the present cost-containment measures by developing a combination of treatment modalities, including medication and individual and group psychotherapy, that can be used in the outpatient care of patients with bulimia nervosa. This article discusses the assessment and treatment of bulimia nervosa and considers how this disorder can best be handled in a managed care environment.

Definitions and Etiology

Bulimia nervosa is a multifaceted disorder with psychologic, physiologic, developmental and cultural components.1,2 There may be a genetic predisposition for the disorder. Other predisposing factors include psychologic and personality factors, such as perfectionism, impaired self-concept, affective instability, poor impulse control and an absence of adaptive functioning to maturational tasks and developmental stressors (e.g., puberty, peer and parental relationships, sexuality, marriage and pregnancy).

Biologic researchers suggest that abnormalities of central nervous system neurotransmitters may also play a role in bulimia nervosa.4 Furthermore, several familial factors may increase the risk of developing this disorder. For example, researchers have discovered that first- and second-degree relatives of individuals with bulimia nervosa have an increased incidence of depression and manic-depressive illnesses, eating disorders, and alcohol and substance abuse problems.5-7

Regardless of the cause, once bulimia nervosa is present, the physiologic effects of disordered eating appear to maintain the core features of the disorder, resulting in a self-perpetuating cycle.

Diagnostic Criteria

The diagnostic criteria for bulimia nervosa (Table 1) now include subtypes to distinguish patients who compensate for binge eating by purging (vomiting and/or the abuse of laxatives and diuretics) from those who use nonpurging behaviors (e.g., fasting or excessive exercising).1

A binge eating/purging subtype of anorexia nervosa also exists. Low body weight is the major factor that differentiates bulimia nervosa from this subtype of anorexia nervosa. Thus, according to the established diagnostic criteria,1 patients who are 15 percent below natural body weight and binge eat or purge are considered to have anorexia nervosa. Patients can, and frequently do, move between diagnostic categories as their symptom pattern and weight change over the course of the illness.