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Bulimia nervosa

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Updated 2023 APA, 2022 USPSTF, 2022 SIGN, and 2021 CPG guidelines for the diagnosis and management of bulimia nervosa.



BN is an eating disorder characterized by recurrent episodes of binge eating followed by compensatory behaviors.
The pathophysiology of BN is complex and not fully understood. It is thought to involve dysregulation of key neurotransmitters and neuropeptides in the brain, such as serotonin, which play a role in appetite regulation and mood.
The prevalence of BN in females in the US is estimated at 2-3%.
Disease course
The clinical course of BN is marked by cycles of binge eating and compensatory behaviors, such as self-induced vomiting, laxative use, or excessive exercise, to prevent weight gain. These cycles can vary in frequency and intensity, and the disorder can be chronic, with periods of remission and relapse.
Prognosis and risk of recurrence
The prognosis of BN varies. While many individuals can achieve recovery with appropriate treatment, others may experience a chronic course with ongoing symptom fluctuation.


Key sources

The following summarized guidelines for the evaluation and management of bulimia nervosa are prepared by our editorial team based on guidelines from the American Psychiatric Association (APA 2023), the The Scottish Intercollegiate Guidelines Network (SIGN 2022), the U.S. Preventive Services Task Force (USPSTF 2022), the Canadian Practice Guidelines (CPG 2021,2020), the American Academy of Child and Adolescent Psychiatry (AACAP 2015), ...
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Screening and diagnosis

Indications for screening: as per APA 2023 guidelines, screen for the presence of an eating disorder as part of an initial psychiatric evaluation.
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Diagnostic investigations

Initial evaluation: as per APA 2023 guidelines, assess the following during the initial evaluation of patients with a possible eating disorder:
height and weight history (maximum and minimum weight, recent weight changes)
presence of, patterns in, and changes in restrictive eating, food avoidance, binge eating, and other eating-related behaviors (rumination, regurgitation, chewing, and spitting)
patterns and changes in food repertoire (breadth of food variety, narrowing or elimination of food groups)
presence of, patterns in, and changes in compensatory and other weight control behaviors, including dietary restriction, compulsive or driven exercise, purging behaviors (laxative use, self-induced vomiting), and use of medication to manipulate weight
percentage of time preoccupied with food, weight, and body shape
prior treatment and response to treatment for an eating disorder
psychosocial impairment secondary to eating or body image concerns or behaviors
family history of eating disorders, other psychiatric illnesses, and other medical conditions (obesity, IBD, diabetes mellitus).
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  • ECG

  • Laboratory tests

  • Screening for comorbidities

Medical management

Multidisciplinary care: as per APA 2023 guidelines, provide a documented, comprehensive, culturally appropriate, and person-centered treatment plan incorporating medical, psychiatric, psychological, and nutritional expertise, commonly via a coordinated multidisciplinary team, in patients with an eating disorder.

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  • Setting of care

  • Pharmacotherapy (general principles)

  • Pharmacotherapy (antidepressants)

  • Pharmacotherapy (antipsychotics)

  • Pharmacotherapy (obesity medications)

Nonpharmacologic interventions

As per APA 2023 guidelines:
Offer eating disorder-focused CBT in adult patients with BN.
Offer eating disorder-focused family-based treatment in adolescent and emerging adult patients with BN having an involved caregiver.

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  • Technology-based interventions

  • Yoga

Specific circumstances

Pregnant patients: as per SIGN 2022 guidelines, elicit history of current or past history of eating disorders in females during pregnancy and postnatal period, recognizing the potential barriers for disclosure.
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