Bulimia Nervosa Follow-up

  • Author: Christine I Osterhout, MD; Chief Editor: David Bienenfeld, MD   more...
 
Updated: Nov 15, 2011
 

Deterrence/Prevention

All eating disorders appear to arise within a cultural context that places too high a value on thinness and engenders unreasonable expectations regarding physical appearance. Awareness of the cultural and social forces and education for both children and their parents regarding the attitudes and behaviors that foster eating disorders may reduce the prevalence of these syndromes. Opportunities for this kind of intervention abound in primary care, athletic, and educational settings. School-based programs that emphasize health, fitness and a range of physical and psychological competences have shown promise in being able to reduce the development of eating disorder-associated attitudes in vulnerable school-age populations.[82]

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Complications

Psychiatric complications

Studies suggest that patients with bulimia nervosa have increased rates of substance abuse, anxiety disorders, bipolar II disorder, and sexual abuse; these conditions should be considered and managed as necessary. Mortality and morbidity associated with depression (suicidal thoughts or self-injury) and poor impulse control (eg, substance abuse, sexually transmitted diseases, unintended pregnancy, accidental injuries) should always be anticipated and assessed.

Medical complications

  • The all-cause mortality rate for bulimia nervosa per se is slightly lower than for anorexia nervosa (3.9% vs 4.0%, respectively).[43] Medical complications do arise and should be assessed carefully.
  • While the results of formal gastric emptying studies in patients with bulimia nervosa have yielded variable results (some suggesting delayed emptying time and others suggesting normal emptying time), acute gastric dilatation is a rare but concerning risk. This complication may result in gastric rupture, which may be fatal.
  • Among other rare potential complications are Mallory-Weiss tears of the esophagus, esophageal rupture, reflux esophagitis, and cardiomyopathies secondary to ipecac use.
  • Ipecac toxicity may be associated with skeletal myopathy, while chronic hypokalemia may also be associated with intestinal ileus, abdominal distension, exertional rhabdomyolysis, or both.
  • Hypokalemia-related distal renal tubulopathy is very rarely associated with bulimia nervosa.
  • Xerosis (dry skin) is a common finding in bulimia nervosa, which appears to be related to the chronic dehydration to which persons with bulimia nervosa are often prone.
  • Skin health usually requires an overall healthy nutritional status. Dermatological treatment is ordinarily topical.
  • Patients who chronically overuse and abuse laxatives risk chronic constipation, cathartic colon with pseudo-Hirschsprung syndrome, melanosis coli with increased risk for colon cancer, steatorrhea, and/or protein-losing enteropathy and metabolic consequences of hypophosphatemia and hypomagnesemia.
  • Other potential complications include osteopenia or osteoporosis, menstrual irregularity and infertility, and, less commonly, cognitive changes associated with dehydration and electrolyte and metabolic abnormalities.
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Prognosis

Research to date suggests a variable prognosis. The illness may pursue a long-term, fluctuating course over many years, or may be more episodic, associated with stressful life events and crises. The diagnosis may not be stable over time.[83] In the shorter term, some reports suggest a 50% improvement in binge eating and purging behavior among patients who are able to engage in treatment. In a 12-year outcome study that looked at bulimia nervosa, purging type, 28.2% of the individuals maintained the diagnosis of bulimia nervosa, purging type. Psychiatric comorbidities predicted poor outcome, specifically self-injurious behaviors.[84]

In 2008, a 10-year follow-up study was published that looked at parental psychopathology as a source of predicted outcome. The paper found that substance abuse in fathers and depression in mothers was associated with poor outcome. Obesity in mothers was associated with a better long-term outcome.[85]

Most eating disorders have high recovery in the first 10 years of the disease development. However, bulimia nervosa, as compared to other eating disorders, is the only eating disorder that has increased probability of recovery past 10 years.[86] This is in contrast to those with prolonged anorexia nervosa, whose chance of recovery decreases with increasing length of disease. In another study that examined temporal patterns of recovery in bulimia nervosa, 10% of those with bulimia nervosa met recovery criteria at 10 years. At 15 years, 25% met recovery criteria. The patients had 3 times the rate of recovery at 10-14 years than matched patients with anorexia nervosa.[4] Literature is growing about the long-term outcome of bulimia. In a 5-year longitudinal study, patients with bulimia nervosa had a remission rate of approximately 74% and a relapse rate of approximately 47%. The natural course did not appear to be influenced by personality disorder psychopathology.[87]

Consistent predictors of outcome have not yet been identified. However, the severity of the purging sequelae, negative self-image[88] , childhood maltreatment[89] , childhood obesity/overeating[90] , individual/family eating patterns during childhood/early adolescence[91] , and ADHD[92] may be important indicators of worse prognosis. Depression may also be associated with a worse outcome. Electrolyte imbalances, esophagitis, and hyperamylasemia reflect more severe purging and may predict a poorer outcome.

Lifetime history of anorexia nervosa maybe an important indicator of prognosis in patients with bulimia nervosa. In a 9-year longitudinal study, when compared to women with bulimia nervosa who have no history of anorexia nervosa, patients diagnosed with bulimia nervosa and with a history of anorexia nervosa were more likely to cross back into anorexia nervosa and were less likely to achieve full recovery.[93]

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Patient Education

Table. Self-Help Books and Internet Resources on Eating Disorders (Open Table in a new window)

CBT-oriented workbooksAgras WS, Apple RF: Overcoming Eating Disorders: A Cognitive-Behavioral Treatment for Bulimia Nervosa and Binge-Eating Disorder. New York, Oxford University Press, 1997 (client workbook)
Agras WS, Apple RF: Overcoming Eating Disorders: A Cognitive-Behavioral Treatment for Bulimia Nervosa and Binge-Eating Disorder. New York, Oxford University Press, 1997 (therapist workbook)
Cash TF: The Body Image Workbook: An 8-Step Program for Learning to Like Your Looks. Oakland, CA, New Harbinger, 1997
Fairburn C: Overcoming Binge Eating. New York, Guilford, 1995
Goodman LJ, Villapiano M: Eating Disorders:The Journey to Recovery Workbook. New York, Brunner-Routledge, 2001 (client workbook)
Goodman LJ, Villapiano M: Eating Disorders: Time for Change. Plans, Strategies, and Worksheets. New York, Brunner-Routledge, 2001 (therapist workbook)
Schmidt U, Treasure J: Getting Better Bit(e) by Bit(e): A Survival Kit for Sufferers of Bulimia Nervosa and Binge Eating Disorder. East Sussex, UK, Psychology Press, 1993
Other books reported to be helpful by patients/familiesBulik CM, Taylor N: Runaway Eating: The 8-Point Plan to Conquer Adult Food and Weight Obsessions. New York, Rodale Books, 2005
Ellis A, Abrams M, Dengelegi L: The Art and Science of Rational Eating. Fort Lee, NJ, Barricade Books, 1992
Goodman LJ, Villapiano M: Eating Disorders: The Journey to Recovery Workbook. New York, Brunner-Routledge, 2001 (client workbook)
Hall L: Full Lives: Women Who Have Freed Themselves From Food and Weight Obsessions. Carlsbad, CA, Gürze Books, 1993
Lock J, le Grange D: Help Your Teenager Beat an Eating Disorder. New York, Guilford, 2005
Michel DM, Willard SG: When Dieting Becomes Dangerous. New Haven, CT, Yale University Press, 2003
Walsh BT, Cameron VL: If Your Child Has an Eating Disorder: An Essential Resource for Parents. New York, Guilford, 2005
Zerbe K: The Body Betrayed: A Deeper Understanding of Women, Eating Disorders, and Treatment. Carlsbad, CA, Gürze Books, 1995
Books reported to be helpful for male patientsAndersen AE, Cohn L, Holbrook T: Making Weight: Men's Conflicts With Food, Weight, Shape and Appearance. Carlsbad, CA, Gürze Books, 2000
Internet resources for health care professionalsAcademy for Eating Disorders (http://www.aedweb.org)
Internet resources for patients, families, and professionalsNational Eating Disorders Association (http://www.nationaleatingdisorders.org)National Association of Anorexia Nervosa and Associated Disorders (http://www.anad.org/site/anadweb/)
Eating Disorder Referral and Information Center (http://www.edreferral.com)
Something Fishy (http://www.something-fishy.org; a well-monitored advocacy site)
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Contributor Information and Disclosures
Author

Christine I Osterhout, MD  Resident Physician, Department of Psychiatry and Behavioral Sciences, University of California, Davis Health System

Christine I Osterhout, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Child and Adolescent Psychiatry, American Academy of Psychiatry and the Law, American Medical Association, and American Psychiatric Association

Disclosure: Nothing to disclose.

Coauthor(s)

Lorin M Scher, MD  Health Sciences Assistant Clinical Professor, Department of Psychiatry and Behavioral Sciences, University of California, Davis, School of Medicine

Lorin M Scher, MD is a member of the following medical societies: Academy of Psychosomatic Medicine, Alpha Omega Alpha, American Medical Association, American Psychiatric Association, and Association for Academic Psychiatry

Disclosure: Nothing to disclose.

Donald M Hilty, MD  Professor of Clinical Psychiatry, Vice-Chair of Faculty Development, Department of Psychiatry and Behavioral Sciences, University of California, Davis School of Medicine

Donald M Hilty, MD is a member of the following medical societies: Academy of Psychosomatic Medicine, American Association for Technology in Psychiatry, American Psychiatric Association, and Association for Academic Psychiatry

Disclosure: Nothing to disclose.

Joel Yager  MD, Professor of Psychiatry, University of Colorado Health Sciences Center; Professor of Psychiatry Emeritus, University of California, Los Angeles, David Geffen School of Medicine; Professor of Psychiatry Emeritus, University of New Mexico School of Medicine

Joel Yager is a member of the following medical societies: Alpha Omega Alpha, American Association for the Advancement of Science, American Medical Association, American Psychiatric Association, and Association for Academic Psychiatry

Disclosure: Gurze publishers Salary editing; Massachusetts Medical Society Salary Writing

Specialty Editor Board

Sarah C Aronson, MD  Associate Professor, Departments of Psychiatry and Medicine, Case Western Reserve School of Medicine/University Hospitals of Cleveland

Sarah C Aronson, MD is a member of the following medical societies: American Academy of Family Physicians, American Medical Association, and American Psychiatric Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Harold H Harsch, MD  Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin

Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association

Disclosure: lilly Honoraria Speaking and teaching; Forest Labs None None; Pfizer Grant/research funds Speaking and teaching; Northstar None None; Novartis Grant/research funds research; Pfizer Honoraria Speaking and teaching; Sunovion Speaking and teaching; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research; Merck Honoraria Speaking and teaching

Chief Editor

David Bienenfeld, MD  Professor of Psychiatry, Vice-Chair and Director of Residency Training, Department of Psychiatry, Wright State University, Boonshoft School of Medicine

David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, and Association for Academic Psychiatry

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Gabriel I Uwaifo, MBBS and Robert C Daly, MB, ChB, MPH to the development and writing of this article.

The authors would also like to acknowledge the contributions of Rebecca Davis, Librarian at the University of California (UC), Davis and Dr. Eric Rickin, Director for the Center for Overcoming Problem Eating (COPE) at the Western Psychiatric Institute and Clinic, University of Pittsburgh, Medical Center. Finally, the authors thank the Department of Psychiatry and Behavioral Sciences at UC Davis.

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Parotid hypertrophy. Reprinted with permission from Mandel, L and Siamak, A. Diagnosing bulimia nervosa with parotid gland swelling. J Am Dent Assoc 2004, Vol 135, No 5, 613-616.
Dental caries. Reprinted with permission from Wolcott, RB, Yager, J, Gordon, G. Dental sequelae to the binge-purge syndrome (bulimia): report of cases. JADA. 1984; 109:723-725.
Russell sign. Reprinted with permission from Glorio R, et al. Prevalence of cutaneous manifestations in 200 patients with eating disorders. Int J Derm, 2000, 39(5), 348-353.
This chest radiograph demonstrates pneumomediastinum, which can occur in association with esophageal rupture from forceful vomiting.
Water-soluble contrast esophagram from a patient with esophageal perforation after esophageal dilation shows contrast leak (arrowheads) and normal esophageal lumen (arrows).
Mallory-Weiss tear. Typical longitudinal mucosal tear with overlying fibrinous exudate extending from the distal esophagus to the gastric cardia. Courtesy of C.J. Gostout, MD.
Table. Self-Help Books and Internet Resources on Eating Disorders
CBT-oriented workbooksAgras WS, Apple RF: Overcoming Eating Disorders: A Cognitive-Behavioral Treatment for Bulimia Nervosa and Binge-Eating Disorder. New York, Oxford University Press, 1997 (client workbook)
Agras WS, Apple RF: Overcoming Eating Disorders: A Cognitive-Behavioral Treatment for Bulimia Nervosa and Binge-Eating Disorder. New York, Oxford University Press, 1997 (therapist workbook)
Cash TF: The Body Image Workbook: An 8-Step Program for Learning to Like Your Looks. Oakland, CA, New Harbinger, 1997
Fairburn C: Overcoming Binge Eating. New York, Guilford, 1995
Goodman LJ, Villapiano M: Eating Disorders:The Journey to Recovery Workbook. New York, Brunner-Routledge, 2001 (client workbook)
Goodman LJ, Villapiano M: Eating Disorders: Time for Change. Plans, Strategies, and Worksheets. New York, Brunner-Routledge, 2001 (therapist workbook)
Schmidt U, Treasure J: Getting Better Bit(e) by Bit(e): A Survival Kit for Sufferers of Bulimia Nervosa and Binge Eating Disorder. East Sussex, UK, Psychology Press, 1993
Other books reported to be helpful by patients/familiesBulik CM, Taylor N: Runaway Eating: The 8-Point Plan to Conquer Adult Food and Weight Obsessions. New York, Rodale Books, 2005
Ellis A, Abrams M, Dengelegi L: The Art and Science of Rational Eating. Fort Lee, NJ, Barricade Books, 1992
Goodman LJ, Villapiano M: Eating Disorders: The Journey to Recovery Workbook. New York, Brunner-Routledge, 2001 (client workbook)
Hall L: Full Lives: Women Who Have Freed Themselves From Food and Weight Obsessions. Carlsbad, CA, Gürze Books, 1993
Lock J, le Grange D: Help Your Teenager Beat an Eating Disorder. New York, Guilford, 2005
Michel DM, Willard SG: When Dieting Becomes Dangerous. New Haven, CT, Yale University Press, 2003
Walsh BT, Cameron VL: If Your Child Has an Eating Disorder: An Essential Resource for Parents. New York, Guilford, 2005
Zerbe K: The Body Betrayed: A Deeper Understanding of Women, Eating Disorders, and Treatment. Carlsbad, CA, Gürze Books, 1995
Books reported to be helpful for male patientsAndersen AE, Cohn L, Holbrook T: Making Weight: Men's Conflicts With Food, Weight, Shape and Appearance. Carlsbad, CA, Gürze Books, 2000
Internet resources for health care professionalsAcademy for Eating Disorders (http://www.aedweb.org)
Internet resources for patients, families, and professionalsNational Eating Disorders Association (http://www.nationaleatingdisorders.org)National Association of Anorexia Nervosa and Associated Disorders (http://www.anad.org/site/anadweb/)
Eating Disorder Referral and Information Center (http://www.edreferral.com)
Something Fishy (http://www.something-fishy.org; a well-monitored advocacy site)
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